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PREGNANCY

DERMATOSES

Name of the Doctor :-

Dr. Sankalp Awasthi

� In Pregnancy more than 90% women have significant and complex skin changes

� Pregnancy is associated with complex of

endocrinological, immunological, metabolic, and vascular changes that may influence the skin.

The skin changes in pregnancy can be -

Physiologica

l (endocrinal changes)

Changes in

pre-existing skin

diseases Specific

dermatosesof Pregnancy

Physiological changes

Hormonal changes(↑ MSH, estrogen, progesterone)

• Hair

• Nail

• Vascular

• Pigmentation

• Connective tissue

PIGMENTARY CHANGES

• Melasma

• Hyperpigmentation around areolae

• Linea nigra on abdomen

• Darkening of nevi

VASCULAR CHANGES

• Spider angiomas

• Palmar erythema

• Varicosities

• Non-pitting edema

• Pyogenic granulom

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NAIL CHANGES

• Onycholysis

• Brittleness

HAIR CHANGES

• Hypertrichosis (prolongation of anagen phase)

• Postpartum telogen effluvium (synchronized transition into telogen phase)

• Androgenetic alopecia

CONNECTIVE TISSUE

• Striae gravidarum

Pregnancy-specific skin dermatoses include an ill-defined heterogeneous group of pruritic skin eruptions

which are seen only in pregnancy.

Classification of pregnancy specific

dermatoses

Ambros-Rudolph et al, 2006

� Atopic eruption of pregnancy

� Eczema in pregnancy

� Prurigo of pregnancy

� Pruritic folliculitis of pregnancy

� Polymorphic eruption of pregnancy

� Pemphigoid gestationis

� Intrahepatic cholestasis of pregnancy

Atopic Eruption of Pregnancy

� Most common specific dermatoses in pregnancy

� Starts early in 75% before the third trimester

� Tends to recur in subsequent pregnancies.

� Patients with a personal and/or family history of atopyand/or elevated IgE levels .

� Benign pruritic disorder of pregnancy which includes

eczematous and/or papular lesions .

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2/3rd present with widespread eczematous changes (so-called E-type AEP) often affecting typical atopic sites such

as face, neck, upper chest, and the flexural surfaces of the extremities

1/3rd have papular lesions (P-type AEP).

Eczema in

pregnancy

Prurigo of

pregnancy/prurigo

gestationis

Pruritic

folliculitis

DIAGNOSIS AND SEQUALAE

• Diagnosis – Clinical

• No increase in fetal morbidity or mortality

� Symptomatic treatment• Topical corticosteroids

• Antihistamines

� Severe cases

• Short course of systemic corticosteroids and

antihistamines

• Phototherapy (UVB) is a helpful additional measure and considered safe in pregnancy

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Polymorphic Eruption Of Pregnancy

� Benign, self-limited pruritic inflammatory disorder

� Last weeks of pregnancy or immediately postpartum.

� The rash usually resolves within 4 to 6 weeks.

� It starts on the abdomen, within striae distensae, with

severely pruritic urticarial papules that coalesce into plaques, spreading to the buttocks and proximal thighs.

� Can quickly generalize in severe cases sparing umbilical region.

DIAGNOSIS AND SEQUALAE

• Resolves with delivery; recurrence uncommon

• No increase in fetal morbidity or mortality

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� Treatment-

• Symptomatic treatment with topical CS and emolients

• Antihistamines

• Severe cases may need short course systemic CS

Pemphigoid Gestationis

� Rare, self-limited autoimmune bullous disorder.

� Presents mainly in late pregnancy or the immediate postpartum period. May flare at the time of delivery or

postpartum. Complete resolution- weeks to months after postpartum

� Clinically PG presents with intense pruritic erythematous urticarial papules and plaques

develops typically on the abdomen. Followed by development of bullae.

� The umbilical region is almost always involved.

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DIAGNOSIS AND SEQUALAE

• Clinical

• Histopathology

• Direct and indirect immunofluorescence

Histology: papillary dermal edema resulting in subepidermalbulla with eosinophils.

• DIF: linear C3 deposition ± IgG at basement membrane

• IIF: Indirect Ishows circulating IgG antibody against

BPag2 in patients serum detected in 30-100% cases.

� In about 75% of cases, PG flares around the time of delivery, regressing spontaneously after the baby is

born.

� Recurrence in future pregnancies: 8%

� Newborn may be small for gestational age, but no associated morbidity or mortality

� Treatment-depends on the age and severity of disease,

� aims to control pruritis and prevent blister formation.

� Topical CS with oral antihistamines maybe sufficient in mild cases,severe cases are started with oral

corticosteroids.

� Unresponsive patients may benefit from third line-Azathioprine ,Plasma Exchange, IVIG

Intrahepatic Cholestasis of Pregnancy

� Obstetric cholestasis is manifested by pruritus in pregnancy with or without laboratory evidence of

cholestasis.

� Incidence is 1 in 50 to 5,000 pregnancies.

� Genetically linked oestrogen-dependent condition, which results in cholestasis with or without jaundice.

� Usually begins in the latter half of pregnancy

� Recurrence in subsequent pregnancy occurs in 60-70% of cases

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� Typically presents with sudden onset of severe pruritus that may start on the palms and soles but

quickly becomes generalized

� It is not associated with primary skin lesions.

� Secondary skin lesions develop due to scratching that range from subtle excoriations to severe prurigonodules.

� Symptoms are worsened at night.

� Jaundice, clay colored stools, dark urine seen in 10% of

patients.

DIAGNOSIS AND SEQUALAE

• Gold standard: serum bile acid level >11 µmol/L

• Steatorrhea often noted by the patient, followed by vitamin K deficiency

• Resolves after delivery . Sometimes associated with PPH.

• Recurs with subsequent pregnancies

• Increased fetal mortality – premature birth, fetal distress, still birth

Treatment: UDCA is tt of choice.

� Though pruritus is the principal cutaneous symptom in pregnancy, itching in itself is not diagnostically helpful.

� Therefore, a full clinical history and a thorough clinical

examination are essential to confirm, or exclude, the possibility of any coexisting dermatosis or infestation.

History & clinical examination

1. Gravida

2. Week of pregnancy

3. Symptoms

4. Skin lesions - onset – Acute or chronic , progression,

duration , distribution, morphology.

5. H/o similar symptoms in previous pregnancy

6. H/o abortions or congenital abnormalities in previous

pregnancy

7. History of drug intake

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PRURITIS

Related to

PregnancyPregnancy

Unrelated To

Pregnancy

Withou

t Rash

With

Rash

Early

Onset(before 3rd trimester

Late

trimester)

Late

Onset(>3rd

trimester)

InfectionsInfections

Drugs InflammatoryAutoimmune

Others

Intrahepati

c Cholestasi

s of

PregnancyAtopic

Pregnancy

Atopic

Eruption Of Pregnancy

Polymorphic

Eruption Of Pregnancy

Pemphigoid Gestationis

Take home message

� Pregnancy presents with a variety of skin changes.

� Though, most of them are benign and require only symptomatic treatment (Atopic eruptions ,

polymorphic eruption of pregnancy)

� A small proportion of them present with relatively disabling symptoms to the mother , and possible poor outcomes in the neonate. Conditions like intrahepatic

cholestasis , pemphigoid gestationis, require regular

monitoring and care.

� It is important for a cinician to distinguish between physiological and pathological conditions associated

with pregnancy so that proper care and reassurance along with the treatment wherever necessary can be

given to the patient.

THANKYOU..