KEY POINTS
• The skin is significantly affected by the profound endocrine, metabolic, psychological, and immunologic changes that occur with pregnancy.
• A thorough review of all the dermatologic complications of pregnancy would be beyond the scope of this chapter. This is a summary of the most common and important conditions.
• Four broad categories of pregnancy-related skin changes are reviewed:
• Physiologic skin changes of pregnancy
• Skin diseases specifically related to pregnancy
• Cutaneous tumors and dermatoses influenced by pregnancy
• Infections affecting pregnancy
PHYSIOLOGIC SKIN CHANGES OF PREGNANCY
Pigmentation Changes
Background
• Localized hyperpigmentation is a common skin finding in pregnancy, occurring in up to 90% of pregnant women (1).
• Common manifestations are darkening of the nipples, areolae, linea alba, inner thighs, and external genitalia.
• Nevi, freckles, and recent scars may darken during pregnancy.
• Pigmentary change is related to elevated levels of melanocyte-stimulating hormone, estrogen, and possibly progesterone.
• Most of these pigment changes regress postpartum, rarely requiring treatment.
Melasma
Background
• Melasma (also known as chloasma or the mask of pregnancy) is an acquired, symmetric, hypermelanosis of the forehead, cheeks, and sometimes the upper lip.
• Melasma is an extremely common condition, having been reported in up to 70% of pregnant women (2). It is also associated with the use of oral contraceptives.
• Increased levels of serum estrogen, progesterone, and melanocyte-stimulating hormone are thought to be responsible for this condition.
• The hyperpigmentation usually fades after delivery in lightly pigmented individuals, but dyspigmentation may persist for darker complected women (3). Continued exposure to the UVB rays may allow the condition to persist following pregnancy.
Treatment
• Sun avoidance and the judicious use of sunscreens are essential not only to successful treatment of this condition but also for maintenance of remission.
• Bleaching agents such as hydroquinone and topical retinoids have been shown to be efficacious in treating this condition. Both classes of medications are pregnancy category C and should be avoided until parturition (4).
Hair
Background
• The physiologic state of pregnancy affects hair by prolonging the anagen (growing) phase. In some people, this results in excessive hair growth, predominantly on the face, and less often on the arms, legs, and back.
Treatment
• Excessive hair growth usually spontaneously resolves after delivery.
• An additional effect of prolonging the anagen phase during pregnancy is delaying the telogen (resting) phase of the hair. As a result, 3 months following pregnancy, the major portion of the scalp hair is cycled into the telogen phase often leading to mass shedding called telogen effluvium. This resolves in 1 to 5 months but can last for as long as 15 months postpartum (1).
• If severe hirsutism occurs, the possibility of androgen-secreting tumors of the ovary, lutein cysts, luteomas, or polycystic ovary disease should be investigated.
Nails
• Nail changes in pregnancy include brittleness, transverse grooving, and distal onycholysis. The pathogenesis behind these changes is not clear.
VASCULAR CHANGES
Palmar Erythema
• Palmar erythema appears on the palms in a diffuse or localized distribution generally between the 2nd and 5th months of pregnancy. There are no symptoms, and resolution is generally seen within 3 months following delivery. This condition is often seen in conjunction with spider telangiectasias.
Spider Telangiectasias
• Spider telangiectasias appear as a red papule with multiple radiating vessels emerging from the central papule, approximately 2 to 10 mm in diameter.
• They are seen in approximately two-thirds of pregnant women, most often in areas drained by the superior vena cava such as the periocular region. Resolution without treatment often occurs within 3 months following delivery; however, 20% to 50% of these lesions persist.
• Treatment is not necessary, but electrosurgical destruction and laser therapy are viable options.
Striae Distensae
• Striae distensae or “stretch marks,” appear in up to 90% of pregnant women (2). Initially, they are slightly erythematous, linear, atrophic bands appearing most commonly in the breasts, abdomen, and hips. Following pregnancy, the erythema fades, but the lesions persist.
• Striae are thought to be a risk factor for lacerations during vaginal delivery and for the development of pelvic relaxation and clinical prolapse (5,6).
• No uniformly satisfactory treatment of striae exists; however, treatment with topical tretinoin and/or laser may help improve the appearance.
SKIN DISEASES SPECIFICALLY RELATED TO PREGNANCY
Intrahepatic Cholestasis of Pregnancy
Background
• Intrahepatic cholestasis of pregnancy (ICP) is characterized by pruritus in the absence of preceding skin lesions. Skin lesions are caused by scratching. The disease commonly presents itself in the third trimester of pregnancy (7).
Etiology
• The cause is multifactorial including hormonal, genetic, environmental, and likely alimentary factors. Estrogens inhibit glucuronyl transferase, which produces a cholestatic effect by reducing bile acid uptake into hepatocytes (8). This results in increased levels of circulating bile acids.
• Some evidence exists for a genetic predisposition to this condition, with several gene mutations linked to ICP risk.
Epidemiology
• The incidence of ICP varies from 2% to 28% of pregnancies depending on ethnicity (9).
Evaluation
Laboratory Findings
• Fasting serum bile acid elevation is the most sensitive marker of ICP, and liver function abnormalities are commonly found (8).
• Jaundice is rare but can be complicated by steatorrhea and subsequent vitamin K deficiency and prolonged prothrombin time (8).
• Skin biopsy is nonspecific (10).
Treatment
• Mild ICP may respond to symptomatic treatment with emollients and topical antipruritics.
• Ursodeoxycholic acid is the mainstay of treatment of ICP (8).
Complications
• ICP is associated with preterm birth in 20% to 60% of patients, fetal distress in 20% to 30% of cases, and fetal death in 1% to 2% of patients (11).
Polymorphic Eruption of Pregnancy
Background
Definition
• Polymorphic eruption of pregnancy (PEP) (previously known as pruritic and urticarial papules and plaques of pregnancy or PUPP) is a dermatosis, most commonly of primigravid women, consisting of pruritic papules and plaques that develop suddenly over the abdomen. PEP generally occurs in the third trimester of pregnancy (12).
Epidemiology
• PEP is the most common gestational dermatosis, affecting between 1 in 130 and 1 in 300 pregnancies (13).
Evaluation
Clinical Manifestations
• PEP is a polymorphous eruption but usually consists of small 1 to 2 mm juicy erythematous papules that coalesce to form urticarial plaques.
• The initial lesions appear in the abdominal striae distensae in half the patients. Subsequently, the eruption generally becomes widespread, involving the trunk, proximal extremities, and infrequently the hands and feet. Periumbilical sparing is a classic finding (9).
• Despite extreme pruritus, excoriations are rarely found.
Laboratory Findings
• No distinct abnormalities have been found.
• Biopsy is often nonspecific (8).
Treatment
Management
• Treatment is symptomatic with topical emollients, antihistamines, and corticosteroids. • Severe cases may require systemic corticosteroids and, rarely, early delivery.
Course and Prognosis
• Most lesions resolve about 4 to 6 weeks after initial onset (14).
• Fetal morbidity and mortality have not been reported, and there is usually no recurrence in subsequent pregnancies (10).
Pemphigoid Gestations (PG)
Background
Definition
• Pemphigoid gestation (PG) is the rarest but most well-defined dermatosis of pregnancy. PG is more common in multigravid women in the third trimester.
Etiology
• The blistering is initiated by the presence of immunoglobulin (IgG1) directed against an epidermal basal lamina protein.
• This is the same immunoglobulin that causes the disease bullous pemphigoid (11).
• Although rare, transplacental transfer of these antibodies can occur, causing fetal disease.
• PG has also been associated with autoimmune diseases, particularly Graves disease.
• The disease typically regresses postpartum, but recurrence may occur in subsequent pregnancies, with menses or with use of oral contraceptives.
Epidemiology
• The incidence is estimated to be between 1 in 10,000 to 1 in 50,000 pregnancies (8).
Evaluation
Clinical Presentation
• Skin disease presents with pruritic urticarial plaques, which become annular or polycyclic, and subsequently develops into vesicles or bulla located on the extremities, abdomen, and buttocks.
• The face, mucous membranes, palms, and soles are generally spared.
Laboratory Tests
• A biopsy is generally helpful, revealing a subepidermal vesicle with perivascular lymphocytes and eosinophils.
• Direct immunofluorescence of perilesional skin reveals a linear deposition of C3 with or without IgG at the basement membrane zone.
• Serum ELISA reveals circulating IgG antibodies against NC16A domain of BP180 (8).
Treatment
Management
• Mild cases may respond to treatment with oral antihistamines and topical steroids.
• Most patients will require oral prednisone, responding to doses of 0.5 mg/kg/d.
• Doses above 80 mg/d are rarely necessary.
• Due to the frequent postpartum flare, it is recommended that steroids be continue until after delivery, tapering as the disease allows.
Course and Prognosis
• Resolution usually occurs within 3 months following delivery.
• Exacerbation at delivery or immediately postpartum occurs in approximately 75% of cases (1).
• There are no maternal medical risks associated with PG.
• Immunoglobulin may cross the placental barrier causing mild, self-limited disease in the fetus.
• Studies have shown a tendency for small-for-gestational-age infants as well as prematurity, neither of which is altered by the use of systemic steroids. Despite this, there is no increase in fetal morbidity or mortality.
• PG tends to recur during subsequent pregnancies, generally presenting with an earlier onset and more severe manifestations.
Impetigo Herpetiformis (IH)
Background
• Impetigo herpetiformis (IH) is a rare variant of pustular psoriasis. Women usually have no family or personal history of psoriasis. IH can present at any time during pregnancy; however, the onset is typically in the last trimester (2).
Evaluation
Clinical Manifestations
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