FAST FACTS FOR BOARD REVIEW

Series Editor: William W. Huang, MD, MPH

Dermatoses of Dr. Pichardo-Geisinger is Associate Professor of Dermatology, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina. Rita Pichardo-Geisinger, MD The author reports no conflict of interest.

Clinical Features and Condition Associations Management Other Features

Atopic eruption of Pruritus presenting with -type Topical steroids Increase in TH2-dominant pregnancy (eczema lesions on the trunk, arms, and legs; and emollients humoral immune of pregnancy) onset before the third trimester; response 20% of patients may have exacerbation of preexisting atopic , but 80% experience skin manifestations for the first time during pregnancy Cholestasis of Generalized pruritus is a prominent First-line treatment Degree of fetal risk is pregnancy (jaundice feature, no primary lesions, jaundice in is ursodeoxycholic controversial; meconium of pregnancy, prurigo 20% of cases; onset in the third trimes- acid, cholestyramine staining and premature gravidarum, obstetric ter of pregnancy, usually resolves or phenobarbital for labor in 45% of cases; cholestasis, intrahe- 1–2 d after delivery; associated with modest elevation of , , patic cholestasis of multiple gestations, underlying genetic bile acids, UVB pho- mortality as high as 13%; pregnancy) predisposition, increased risk for choleli- totherapy, oral guar recurrence in subsequent thiasis or gallbladder disease gum, and vitamin K and with if deficient; rest and use of oral contraceptives; low-fat diet elevation of serum bile acid levels Urticarial papules and plaques in the Systemic corticoste- Subepidermal vesicles (pemphigoid gestationis, periumbilical region that progress to a roids are the main- and perivascular infiltrate herpes gestationis) generalized pemphigoidlike eruption; stay of treatment of lymphocytes and rarely involves mucous membranes; (eg, prednisone eosinophils, showing typically develops during the second or 0.5 mg/kg/d), topical identical histopathologic third trimester or immediately postpar- corticosteroids findings to BP; antibod- tum; spontaneous remission over weeks and antihistamines ies (C3 and IgG) on the to months following delivery usually is usually are ineffec- epidermal side on IIF seen; associated findings include severe tive; no known clini- salt-split skin; antibodies pruritus, hydatidiform moles and cho- cal trials have been to BPAg2 (collagen XVII); riocarcinomas, recurrence with menses completed increased frequency of and use of oral contraceptives, autoim- HLA-DR3 and HLA-DR4; mune diseases such as Graves disease; serum eosinophilia neonates are affected in 10% of cases; increased incidence of preterm delivery and SGA neonates; flares with delivery in up to 75% of patients; not present in each pregnancy in 5%

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Clinical Features Condition and Associations Management Other Features

Impetigo gestationis Rare disease; not pruritic, erythematous Systemic Placental insufficiency, (pustular psoriasis of plaques with rings of pustules; plaques corticosteroids fetal growth restriction, pregnancy) enlarge from the periphery as the center (eg, prednisolone ; pathology is the becomes eroded and crusted; lesions 60–80 mg/d, same as pustular psoriasis first manifest in intertriginous areas; low-dose in nonpregnant patients trunk, arms, and legs are affected cyclosporine while hands, feet, and face usually (2–3 mg/kg/d) may are spared; onycholysis and pitting; help patients who fail can occur anytime during pregnancy to respond to oral and remits in the ; corticosteroids hormonal changes (progesterone), hypocalcemia, and hypoparathyroidism may be inciting factors Prurigo of pregnancy Pruritus presenting with discrete excori- Topical cortico- Recurrence during (prurigo gestationis, ated papules on the extensor surfaces of steroids, benzoyl subsequent pregnancies; Besnier prurigo, Nurse the arms, legs, and abdomen; pustules peroxide, UVB light elevation in serum early-onset prurigo of or follicular pustules may be seen; therapy IgE levels; no fetal risk pregnancy, Spangler reported in all trimesters of pregnancy; papular dermatitis of disease may last for weeks to months pregnancy postpartum; may be associated with ; possible overlap with cholestasis of pregnancy Pruritic urticarial Most common pregnancy-related Potent topical Typically does not papules and plaques dermatosis; pruritic urticarial papules corticosteroids, recur with subsequent of pregnancy (PUPPP) classically located within the abdominal oral antihistamines, pregnancies, no fetal risk, (polymorphic eruption striae with periumbilical sparing; can and systemic DIF is negative of pregnancy, toxic spread in days, usually sparing the face, corticosteroids erythema of pregnancy) palms, and soles; onset usually is in primigravidas in the latter part of the third trimester or immediately postpartum; resolution generally occurs within 7–10 d of delivery; associated with increased maternal weight gain; increased incidence in multiple gestation pregnancies; diagnosis of exclusion; liver function panel, serum hCG, and cortisol levels generally are normal

Abbreviations: TH2, helper T cell type 2; SGA, small for gestational age; BP, bullous pemphigoid; IIF, indirect immunofluorescence; BPAg2, bullous pemphigoid antigen 2; hCG, human chorionic gonadotropin; DIF, direct immunofluorescence.

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Practice Questions

1. Which dermatosis of pregnancy occurs during the third trimester and is associated with multiple gestation pregnancies? a. atopic eruption of pregnancy b. gestational pemphigoid c. intrahepatic cholestasis of pregnancy d. prurigo of pregnancy e. pruritic urticarial papules and plaques of pregnancy

2. Which dermatosis of pregnancy frequently flares after delivery? a. atopic eruption of pregnancy b. gestational pemphigoid c. polymorphic eruption of pregnancy d. prurigo gravidarum e. prurigo of pregnancy

3. Which dermatosis of pregnancy has lesions that have a predilection for the abdominal striae? a. cholestasis of pregnancy b. gestational pemphigoid c. prurigo gestationis d. prurigo of pregnancy e. pruritic urticarial papules and plaques of pregnancy

4. Which dermatosis of pregnancy has a risk for the development of hydatidiform moles and choriocarcinomas? a. atopic eruption of pregnancy b. cholestasis of pregnancy c. gestational pemphigoid d. pruritic urticarial papules and plaques of pregnancy e. toxic erythema of pregnancy

5. Intrahepatic cholestasis of pregnancy has been associated with: a. fetal mortality as high as 13% b. jaundice in 20% of cases c. onset in the third trimester of pregnancy d. recurrence in subsequent pregnancies e. all of the above

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