Skin manifestations during pregnancy are common and diversified. This review will focus on the most important entities to be recognized by obstetricians. These are, on the one hand, physiological changes, where unnecessary investigations should be avoided, and on the other, the specific dermatoses of pregnancy. These develop electively in pregnancy, and they are currently grouped into three disorders: polymorphic eruption of pregnancy, atopic eczema of pregnancy, and pemphigoid gestationis. Arguments for recognition of these are presented including detection of anti-BP180 antibodies. Follow-up and treatment depend on the precise diagnosis. Risks in fetal prognosis may occur in rare pemphigoid gestationis cases.
Highlights
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In pregnancy, skin presents physiological changes that regress after delivery.
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Polymorphic eruption, atopic eruption and pemphigoid are specific to pregnancy.
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Pemphigoid gestationis usually starts as a tense blistering rash in the umbilicus.
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Pemphigoid gestationis may be associated with prematurity and low birth weight.
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Potent or ultrapotent topical steroids can control specific dermatoses of pregnancy.
Skin disease in pregnancy
Dermatological manifestations associated with pregnancy can be grouped into five categories: (i) physiological changes, (ii) pregnancy-specific dermatoses, (iii) cutaneous infections affecting fetal outcome, (iv) various intercurrent dermatoses affected by or affecting pregnancy, and (v) side effects of topical cutaneous treatments and fetal risk of such treatments. These manifestations, mainly physiologic changes and specific dermatoses, will be the focus of this review. They are important to recognize as diagnostic studies and monitoring are mandatory in some disorders while workup is unnecessary in others.
Cutaneous physiological changes during pregnancy
During pregnancy, the following three main precipitating factors induce the development of skin changes: (i) the increase in the level of circulating hormones, (ii) the intravascular volume expansion, and (iii) the compression from the enlarging uterus.
In the skin, almost all cell types such as keratinocytes, melanocytes, fibroblasts, inflammatory cells, and components such as pilosebaceous units, sweat glands, and blood vessels express receptors to the various previously cited secreted molecules. The main subsequent modifications result in an increase in keratinocyte proliferation, angiogenesis, melanogenesis, collagen synthesis, and an increase in T helper 2 (Th2) lymphocytes and regulatory T cells.
According to the cell type targeted, the modifications of the skin are divided into pigmentary, vascular, structural, and adnexal changes. These changes are called physiological due to the following reasons: they correspond to the expected consequences of the new hormonal, metabolic, immune, and vascular status of a pregnant woman; they affect the majority of these women; they commonly appear early on in the period of pregnancy; and they tend to resolve spontaneously after delivery.
Pigmentary changes
Hyperpigmentation is the most frequent skin modification found in pregnancy. Estrogens and progesterone synergistically stimulate melanogenesis. In addition, the increased levels of melanocyte-stimulating hormone have a direct effect on the skin. Hyperpigmentation manifests early in the first trimester, mainly affecting women with darker complexion and body areas of normally darker pigmentation. After delivery, it fades variably from one patient to another. The most commonly affected sites are the areolae and/or nipples, the periumbilical area and the linea nigra, the anogenital region, the axillae, and the thighs . Naevi, freckles, and recent scars also may darken.
Facial hyperpigmentation, or melasma, most commonly manifests on the forehead, the cheeks, the upper lip, and the chin, consisting of grey–brown plaques. Many risks factors are clearly associated with melasma including dark skin type, Amerindian ancestry, chronic sun exposure, hormonal stimuli, and antidepressant/anxiolytic use . It begins after the third month; it usually regresses in the postpartum period, but it can recur for years after with sun exposure, oral contraception, or future pregnancies. Treatment of melasma is preferred after the end of lactation as some molecules used such as hydroquinone and tretinoin can be teratogenic. Meanwhile, preventive measures including mainly sun avoidance and sunscreen protection are the most effective .
Vascular changes
During pregnancy, there is activation of endothelium and decreased vascular smooth muscle tone leading to reduced peripheral vascular resistance. At the same time, intravascular volume expansion and compression from the enlarging gravid uterus cause venous congestion. All these factors explain the different vascular changes of skin during pregnancy.
Spider telangiectasias (spider angiomas)
These lesions typically begin, at the end of the first trimester, in the area of skin drained by the superior vena cava (face, neck, arms, and hands). They present as a punctiform central redness (corresponding to a dilated afferent arteriole) with radiating capillaries and surrounding erythema. These lesions increase in number through pregnancy especially in women with lighter complexions . If the number of spider angiomas increases abnormally, the liver status should be checked as estrogen catabolism decreases in liver diseases. Spider telangiectasias often disappear within weeks after delivery. Persistent lesions can be effectively treated with fine-needle cautery, pulsed dye laser, or intense pulse light system.
Palmar erythema
This sign also appears during the first trimester, more frequently in white women, and fades within 1 week post partum. The following two patterns are distinguished: (a) diffuse mottled erythema of the entire palms, and (b) erythema restricted to the thenar and hypothenar eminences, the metacarpophalangeal joints, and the finger pads. Palmar erythema is attributed to venous engorgement, but hyperthyroidism, cirrhosis, lupus, and salbutamol intake are differential diagnoses that should be kept in mind .
Vasomotor instability
During pregnancy, women frequently experience episodes of pallor, facial flushing, hot-and-cold sensations, and cutis marmorata (reticulate bluish erythema of the lower legs when exposed to cold).
Venous congestion signs
Varicosities appear in 40% of pregnant women starting from the second month . Additional precipitating factors are genetic predisposition and prolonged standing. Leg raising and elastic stockings are effective methods of prevention.
- –
Those localized on the legs, the pelvis, and the perineum may have a small risk of thrombosis . They usually regress post partum. Lesions persisting 3 months post partum may be treated with sclerosing agents and laser.
- –
Hemorrhoids with pain and bleeding occur in 40% of patients, mainly associated with constipation, high birth weight of the newborn, and prolonged straining during delivery. Hemorrhoids are common during the last trimester of pregnancy and the first month post partum . Preventing constipation with laxatives and fibers has a beneficial effect .
- –
The Jacquemier sign (varicosities of the vestibule and vagina) and the Chadwick sign (bluish tint of the mucosa) are two early diagnostic signs of pregnancy .
Nonpitting edema of the legs but also possibly of the face and the eyelids is due to fluid leakage in the extracellular milieu when the venous hydrostatic pressure increases. It is very frequent in the morning during the last few months of pregnancy . It should be noted that persistent edema of the face and the hands may be indicative of preeclampsia.
Purpura of the legs is also possible in the second half of pregnancy due to excessive fragility of skin capillaries induced by venous hypertension in lower limbs. Purpura should always warrant a check of the platelet count, as it is an unusual physiological sign of pregnancy.
Vascular proliferation signs
Hyperplasia of the interdental papillae of the gingival mucosa is frequently observed during the third trimester of pregnancy . It can be mild and asymptomatic or severe with intense pain and bleeding. Poor dental hygiene, periodontal disease, local irritants, and nutritional deficiencies are triggering factors. Healing is progressive in the postpartum period.
Epulis gravidarum, misnamed pyogenic granulomas, represents asymptomatic erythematous fragile nodules of the gingival mucosa corresponding to hyperplasia of mucosal capillaries and fibroblasts or of the skin itself. Triggers are physical trauma and irritation (plaque deposits and gingivitis). Epulis regresses within months after delivery and recurs in later pregnancies. Considerable bleeding allows surgical excision.
Structural changes
Striae distensae
In the third trimester, striae begin as linear red to purple bands. They develop on the abdomen, the breasts, the thighs, the inguinal folds, and the arms. They fade gradually and leave white atrophic bands. Risk factors in primiparous women are young maternal age, elevated maternal body mass index (BMI), excessive maternal weight gain, macrosomia, and personal and familial history of striae. Causes seem multiple including mechanical stretching of the skin and hormonal reduction of elastic fibers through steroids, estrogens, and relaxin. A recent genome-wide association study (GWAS) suggested an association with mutations of genes encoding for elastic microfibrils . All preventive measures have been failures . The appearance of recent purplish striae may improve with pulsed dye laser or 0.1% tretinoin cream, two treatments reserved for at least 3 months post partum .
Acrochordons
Skin tags grow during the second half of pregnancy. They correspond to small pedunculate lightly pigmented polyps on the neck, the axillary, the inframammary, and the inguinal folds. They have no malignant potential. They often shrink after delivery. Otherwise, removal is simple with snipping, cryotherapy, or cautery.
Adnexal changes
Hair
During pregnancy, fewer anagen (growing) hair follicles enter the telogen (shedding) phase. Scalp and body hair will increase in number, thickness, and brightness, especially on the face, the arms, and the legs. This pattern reverses within 6 months post partum .
Two to four weeks after delivery, the scalp hair enters a prolonged telogen phase and sheds profusely (telogen effluvium) during 3–4 months. Later on, hair completely grows within 6–15 months . However, anemia, iron deficiency, and thyroid dysfunction should be evaluated if any doubt is present.
Nails
Nails grow faster and become brittle. Other manifestations are uncommon and reversible (subungual thickening, longitudinal melanonychia (brown pigmentation arranged lengthwise along the nail unit), transversal grooves (linear narrow depressions of the nail), and distal onycholysis) .
Sebaceous glands
As an early sign of pregnancy, sebaceous glands enlarge on the areola and appear as multiple brown papules (Montgomery’s glands), starting from the sixth week of gestation. They regress spontaneously after delivery .
Facial skin may become greasy in the third trimester due to increased sebaceous glands activity. Acne frequently develops during pregnancy. The diagnosis is easy but the treatment should exclude cyclins and retinoids. Erythromycin and benzoyl peroxide can be prescribed.
Sudoral glands
Eccrine sweat gland activity increases through pregnancy with subsequent hyperhidrosis and miliaria (pruriginous inflammation of the glands) . Apocrine gland activity seems to decrease.
Cutaneous physiological changes during pregnancy
During pregnancy, the following three main precipitating factors induce the development of skin changes: (i) the increase in the level of circulating hormones, (ii) the intravascular volume expansion, and (iii) the compression from the enlarging uterus.
In the skin, almost all cell types such as keratinocytes, melanocytes, fibroblasts, inflammatory cells, and components such as pilosebaceous units, sweat glands, and blood vessels express receptors to the various previously cited secreted molecules. The main subsequent modifications result in an increase in keratinocyte proliferation, angiogenesis, melanogenesis, collagen synthesis, and an increase in T helper 2 (Th2) lymphocytes and regulatory T cells.
According to the cell type targeted, the modifications of the skin are divided into pigmentary, vascular, structural, and adnexal changes. These changes are called physiological due to the following reasons: they correspond to the expected consequences of the new hormonal, metabolic, immune, and vascular status of a pregnant woman; they affect the majority of these women; they commonly appear early on in the period of pregnancy; and they tend to resolve spontaneously after delivery.
Pigmentary changes
Hyperpigmentation is the most frequent skin modification found in pregnancy. Estrogens and progesterone synergistically stimulate melanogenesis. In addition, the increased levels of melanocyte-stimulating hormone have a direct effect on the skin. Hyperpigmentation manifests early in the first trimester, mainly affecting women with darker complexion and body areas of normally darker pigmentation. After delivery, it fades variably from one patient to another. The most commonly affected sites are the areolae and/or nipples, the periumbilical area and the linea nigra, the anogenital region, the axillae, and the thighs . Naevi, freckles, and recent scars also may darken.
Facial hyperpigmentation, or melasma, most commonly manifests on the forehead, the cheeks, the upper lip, and the chin, consisting of grey–brown plaques. Many risks factors are clearly associated with melasma including dark skin type, Amerindian ancestry, chronic sun exposure, hormonal stimuli, and antidepressant/anxiolytic use . It begins after the third month; it usually regresses in the postpartum period, but it can recur for years after with sun exposure, oral contraception, or future pregnancies. Treatment of melasma is preferred after the end of lactation as some molecules used such as hydroquinone and tretinoin can be teratogenic. Meanwhile, preventive measures including mainly sun avoidance and sunscreen protection are the most effective .
Vascular changes
During pregnancy, there is activation of endothelium and decreased vascular smooth muscle tone leading to reduced peripheral vascular resistance. At the same time, intravascular volume expansion and compression from the enlarging gravid uterus cause venous congestion. All these factors explain the different vascular changes of skin during pregnancy.
Spider telangiectasias (spider angiomas)
These lesions typically begin, at the end of the first trimester, in the area of skin drained by the superior vena cava (face, neck, arms, and hands). They present as a punctiform central redness (corresponding to a dilated afferent arteriole) with radiating capillaries and surrounding erythema. These lesions increase in number through pregnancy especially in women with lighter complexions . If the number of spider angiomas increases abnormally, the liver status should be checked as estrogen catabolism decreases in liver diseases. Spider telangiectasias often disappear within weeks after delivery. Persistent lesions can be effectively treated with fine-needle cautery, pulsed dye laser, or intense pulse light system.
Palmar erythema
This sign also appears during the first trimester, more frequently in white women, and fades within 1 week post partum. The following two patterns are distinguished: (a) diffuse mottled erythema of the entire palms, and (b) erythema restricted to the thenar and hypothenar eminences, the metacarpophalangeal joints, and the finger pads. Palmar erythema is attributed to venous engorgement, but hyperthyroidism, cirrhosis, lupus, and salbutamol intake are differential diagnoses that should be kept in mind .
Vasomotor instability
During pregnancy, women frequently experience episodes of pallor, facial flushing, hot-and-cold sensations, and cutis marmorata (reticulate bluish erythema of the lower legs when exposed to cold).
Venous congestion signs
Varicosities appear in 40% of pregnant women starting from the second month . Additional precipitating factors are genetic predisposition and prolonged standing. Leg raising and elastic stockings are effective methods of prevention.
- –
Those localized on the legs, the pelvis, and the perineum may have a small risk of thrombosis . They usually regress post partum. Lesions persisting 3 months post partum may be treated with sclerosing agents and laser.
- –
Hemorrhoids with pain and bleeding occur in 40% of patients, mainly associated with constipation, high birth weight of the newborn, and prolonged straining during delivery. Hemorrhoids are common during the last trimester of pregnancy and the first month post partum . Preventing constipation with laxatives and fibers has a beneficial effect .
- –
The Jacquemier sign (varicosities of the vestibule and vagina) and the Chadwick sign (bluish tint of the mucosa) are two early diagnostic signs of pregnancy .
Nonpitting edema of the legs but also possibly of the face and the eyelids is due to fluid leakage in the extracellular milieu when the venous hydrostatic pressure increases. It is very frequent in the morning during the last few months of pregnancy . It should be noted that persistent edema of the face and the hands may be indicative of preeclampsia.
Purpura of the legs is also possible in the second half of pregnancy due to excessive fragility of skin capillaries induced by venous hypertension in lower limbs. Purpura should always warrant a check of the platelet count, as it is an unusual physiological sign of pregnancy.
Vascular proliferation signs
Hyperplasia of the interdental papillae of the gingival mucosa is frequently observed during the third trimester of pregnancy . It can be mild and asymptomatic or severe with intense pain and bleeding. Poor dental hygiene, periodontal disease, local irritants, and nutritional deficiencies are triggering factors. Healing is progressive in the postpartum period.
Epulis gravidarum, misnamed pyogenic granulomas, represents asymptomatic erythematous fragile nodules of the gingival mucosa corresponding to hyperplasia of mucosal capillaries and fibroblasts or of the skin itself. Triggers are physical trauma and irritation (plaque deposits and gingivitis). Epulis regresses within months after delivery and recurs in later pregnancies. Considerable bleeding allows surgical excision.
Structural changes
Striae distensae
In the third trimester, striae begin as linear red to purple bands. They develop on the abdomen, the breasts, the thighs, the inguinal folds, and the arms. They fade gradually and leave white atrophic bands. Risk factors in primiparous women are young maternal age, elevated maternal body mass index (BMI), excessive maternal weight gain, macrosomia, and personal and familial history of striae. Causes seem multiple including mechanical stretching of the skin and hormonal reduction of elastic fibers through steroids, estrogens, and relaxin. A recent genome-wide association study (GWAS) suggested an association with mutations of genes encoding for elastic microfibrils . All preventive measures have been failures . The appearance of recent purplish striae may improve with pulsed dye laser or 0.1% tretinoin cream, two treatments reserved for at least 3 months post partum .
Acrochordons
Skin tags grow during the second half of pregnancy. They correspond to small pedunculate lightly pigmented polyps on the neck, the axillary, the inframammary, and the inguinal folds. They have no malignant potential. They often shrink after delivery. Otherwise, removal is simple with snipping, cryotherapy, or cautery.
Adnexal changes
Hair
During pregnancy, fewer anagen (growing) hair follicles enter the telogen (shedding) phase. Scalp and body hair will increase in number, thickness, and brightness, especially on the face, the arms, and the legs. This pattern reverses within 6 months post partum .
Two to four weeks after delivery, the scalp hair enters a prolonged telogen phase and sheds profusely (telogen effluvium) during 3–4 months. Later on, hair completely grows within 6–15 months . However, anemia, iron deficiency, and thyroid dysfunction should be evaluated if any doubt is present.
Nails
Nails grow faster and become brittle. Other manifestations are uncommon and reversible (subungual thickening, longitudinal melanonychia (brown pigmentation arranged lengthwise along the nail unit), transversal grooves (linear narrow depressions of the nail), and distal onycholysis) .
Sebaceous glands
As an early sign of pregnancy, sebaceous glands enlarge on the areola and appear as multiple brown papules (Montgomery’s glands), starting from the sixth week of gestation. They regress spontaneously after delivery .
Facial skin may become greasy in the third trimester due to increased sebaceous glands activity. Acne frequently develops during pregnancy. The diagnosis is easy but the treatment should exclude cyclins and retinoids. Erythromycin and benzoyl peroxide can be prescribed.
Sudoral glands
Eccrine sweat gland activity increases through pregnancy with subsequent hyperhidrosis and miliaria (pruriginous inflammation of the glands) . Apocrine gland activity seems to decrease.
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