boards’ fodder Dermatoses Kelly K. Park, MD, MSL & Monika Kanizewska, MD, MS

Risk Fetal Dermatosis Description Timing Location Factors Treatment Pathology Involvement Pemphigoid Pruritic Classically Abdomen, HLA-DR3, Self-limited; Subepidermal ↑ risk of gestationis vesiculobullous late pregnancy, umbilicus, HLA-DR4 topical and vesicle mixed prematurity, eruption but can occur can systemic cor- infiltrate with small-for- Herpes in any generalize May flare or ticosteroids, eosinophils gestational age gestationis* Spontaneously trimester, or have recur- antihista- neonates, remits weeks immediately Spares to months after postpartum mucous rence with mines DIF: Linear C3 neonatal delivery membranes menses, oral + IgG along pemphigoid Commonly contraceptives BMZ gestationis recurs in subsequent [Note: Indirect IF: IgG Patients are autoantibodies at ↑ risk against BMZ for Grave’s Disease] Salt-split skin test: Epidermal Polymorphic Pruritic End of third Within Primipara, Self-limited; Non-specific, None eruption of erythematous trimester, abdominal maternal resolves negative IF pregnancy and edematous immediately striae, can weight gain, within 4 and ELISA (PEP) papules and postpartum generalize multiple weeks, plaques that gestation topical Pruritic may become Spares urticarial vesicular, umbilicus, pregnancy corticosteroids, papules and targetoid, face, palms, antihistamines plaques of eczematous soles pregnancy, PUPPP*

Atopic erup- Flare or Commonly Can be in Atopic Topical Variable, but None tion of preg- new onset prior to third a flexural diathesis corticosteroids, commonly nancy (AEP) eczematous or trimester distribution ultraviolet B spongiosis, papular eruption (UVB) acanthosis, in atopics Commonly phototherapy lymphocytic recurs in May have serum subsequent and IgE elevation pregnancies eosinophilic infiltrate Kelly K. Park, MD, MSL, is a PGY-3 resident at Loyola University Medical Center in Maywood, Pruritic fol- Follicular-based After first Trunk > Atopy Post-partum Sterile None Illinois. liculitis of papules and trimester extremities has been resolution folliculitis pregnancy† pustules suggested May recur in subsequent May be pregnancies a variant of Atopic Eruption of Pregnancy

Prurigo of Prurigo nodules After first Extremities > Atopy has Resolves Varies None pregnancy† trimester abdomen been post-partum May have serum suggested Monika Kaniszewska, IgE elevation May recur in MD, MS, is a PGY- subsequent May be pregnancies 4 dermatology resident a variant at Loyola University of Atopic Medical Center in Eruption of Maywood, Illinois. Pregnancy

irinections D­Residency p. 4 • Fall 2014 boards’ fodder Pregnancy Dermatoses (cont.) Kelly K. Park, MD, MSL & Monika Kanizewska, MD, MS

Risk Fetal Boards’ Dermatosis Description Timing Location Factors Treatment Pathology Involvement Fodder Intrahepatic Pruritus, may Late second Starts on Endemic Resolves Nonspecific ↑ risk of cholestasis have secondary trimester, palms clusters, within days premature In addition to this of pregnancy lesions third trimester and soles, positive family of delivery; labor, fetal issue’s Boards’ (ICP) (excoriations, spreads to history, ursodeoxy- distress, prurigo); Recurrence in extensor Fodder, Pregnancy multiple- cholic acid Cholestasis jaundice subsequent extremities, Dermatoses, don’t gestation (UDCA) of pregnancy, pregnancies abdomen, forget to download obstetric Elevated serum buttocks pregnancies, cholestasis bile acids ABCB4 muta- the new Board’s (OC)‡ tion, hepatitis Fodder online C virus (HCV) exclusive from infection, www.aad.org/ selenium deficiency, ↑ DIR, where a new intestinal chart is published permeability each quarter. The Fall 2014 online May have Boards’ Fodder is recurrence with oral Autoinflammatory contraceptives syndromes by Sailesh Konda, MD Autoimmune Progesterone Varies Varies None Symptomatic, Dependent on Spontaneous progesterone hypersensitivity reported can include morphology has and Sasank Konda, characterized by antihistamines, been reported BA. (AIPD) a cyclical topical and eruption related oral corti- to menses To view, download, costeroids, or print every May worsen or epinephrine Boards’ Fodder improve during prn pregnancy ever published, both in print and online, check Generalized Pustules on Third Flexural Unclear, Systemic Pustular Low birth out the com- pustular erythematous trimester surfaces may include cortico- psoriasis: weight, plete archives at psoriasis of patches that (inguinal), hypocalcemia, steroids; spongiform intrauterine pregnancy form polycyclic Recurs with spread to hypovitaminosis resolves pustules, growth www.aad.org/ erythematous subsequent trunk and D, stress, postpartum neutrophils, restriction, BFarchives. Impetigo patches and pregnancies proximal herpetiformis plaques with extremities bacterial superficial premature (IH) ‡ peripheral infections perivascular rupture of pustules lymphocytic membranes, and neutro- stillbirth, philic infiltrate neonatal death

* historical nomenclature † may be considered as under the classification of AEP ‡ synonym(s)

Physiologic cutaneous changes in pregnancy

Mucosal: Chadwick’s sign (blue-to-violaceous discoloration of mucous membranes of cervix, vagina, vulva) First Trimester Vascular: gingival hyperemia and , palmar erythema, spider angiomas Glandular: hypertrophy of Montgomery tubercles, ↑ sweating

Pigmentary changes Second Trimester Pruritus (late)

Pruritus (early) Hair and nail changes Third Trimester Connective tissue changes Vascular: edema, purpura, petechiae

References 1. Kroumpouzos G, ed. Text Atlas of Obstetric Dermatology. Philadelphia, PA: Lippincott, Williams & Wilkins; 2014. 2. Bolognia JL, Jorizzo J, Schaffer JV, ed. Dermatology, Third Edition: Elsevier Limited; 2012. 3. Ambros-Rudolph CM, Mullegger RR, Vaughan-Jones SA, Kerl H, Black MM. The specific dermatoses of pregnancy revisited and reclassified: results of a retrospective two-center study on 505 pregnant patients. Journal of the American Academy of Dermatology 2006;54:395-404. irinections www.aad.org/DIR Fall 2014 • p. 5 D­Residency