PEER REVIEWED FEATURE 2 CPD POINTS Managing the skin in pregnancy Part 1. Pregnancy-related skin concerns NINA WINES BSc, MB BS, DRANZCOG, FACD Pregnancy-associated skin concerns range from regnant women with skin concerns usually present first common benign conditions such as stretch marks to their GPs, who play a major role in their diagnosis, and skin pigmentation to rarer specific dermatoses management and timely referral when required. Skin of pregnancy, some of which are associated with concerns in pregnant women can be broadly divided Pinto benign conditions related to the pregnancy, potentially more maternal and fetal risk. Management requires knowledge of which treatments are safe and serious pregnancy-specific skin rashes and pre-existing or practical while a woman is pregnant or incident skin diseases that require management during preg- nancy. Postpartum, women may also present to their GP with breastfeeding. skin concerns. Management of these conditions requires knowl- edge of which treatments are safe and practical while a woman is pregnant or breastfeeding. KEY POINTS This is the first article in a short series that discusses the • Benign pregnancy-related skin concerns are common and management of skin conditions during pregnancy and are mostly treatable either during the pregnancy or, if they breastfeeding. This article focuses on the management of persist, after the birth. pregnancy-related skin concerns, including benign conditions • Specific dermatoses of pregnancy such as intrahepatic such as stretch marks and pigmentation and more severe cholestasis of pregnancy and pemphigoid gestationis are pregnancy- specific skin rashes, some of which pose fetal and associated with maternal and fetal risk. maternal risk. It also summarises the safety during pregnancy • Topical medications are usually the first-line choice for and breastfeeding of topical and systemic medications used to treatment of most skin conditions during pregnancy treat skin conditions. Future articles in the series will discuss (estimated percutaneous absorption 4 to 25%). the management of pre-existing skin diseases, such as acne, • Selected systemic medications may be used after consideration of their safety and the high-risk periods psoriasis and atopic dermatitis, and skin cancer during preg- during pregnancy. nancy, as well as common postpartum skin problems. • Referral to a dermatologist is recommended when the diagnosis is unclear or the condition does not respond to treatment or is associated with potential fetal or maternal MedicineToday 2016; 17(7): 25-34 risk. Dr Wines is Principal Consultant Dermatologist at Northern Sydney JPC-PROD/SHUTTERSTOCK © Dermatology; and a Visiting Medical Officer at The Skin Hospital, Sydney, NSW. MedicineToday JULY 2016, VOLUME 17, NUMBER 7 25 Downloaded for personal use only. No other uses permitted without permission. © MedicineToday 2016. MANAGING THE SKIN IN PREGNANCY continued when used on a small surface area.2 Sun protection is important as all hyper- pigmenting conditions are exacerbated by sun exposure. GPs are involved in the early treatment of melasma. Daily sun avoidance and sun protection should be recommended, as well as avoidance of rubbing, abrasive treatments or scrubs, friction, perfumed products or any product that stings, as Figures 1a and b. Stretch marks. a (left). Early stretch marks (red stage). These respond well to vascular laser therapy. b (right). Old stretch marks leave white or silvery lines. These irritation can encourage pigmentation. respond well to fractionated laser therapy. The importance of avoiding waxing affected areas should be explained as waxing promotes inflammation and Benign pregnancy-related skin After pregnancy, the best time to treat worsens melasma. Topical azelaic acid is concerns stretch marks is when they are still red. safe to use during pregnancy and has a Stretch marks Once the lesions are white or silver, frac- gradual lightening effect.2 Superficial peels Stretch marks occur when the skin is tional laser therapy can be effective. Referral containing low concentrations of salicylic subjected to continuous and progressive to a dermatologist with experience in laser acid or glycolic acid are likely to be safe stretching. They are more frequent in management can be helpful for manage- during pregnancy.2 Referral to an experi- women with large babies in comparison ment of both early and old stretch marks. enced dermatologist may be beneficial if with their size, multiple pregnancies or There is evidence that topical retinoids may this resource is not available. obesity. Common locations for stretch also help.1 However, in practice I have found Women should be reassured that marks in pregnant women include the them only partially effective. melasma is not permanent and in most abdomen, breasts and thighs. At their cases fades gradually over six to 12 months onset the skin initially becomes pink, Skin pigmentation after the birth. To hasten postpartum occasionally itchy and then purple. Over Darkening of the skin around the nipples, resolution, an additional bleaching agent time the stretch marks become white or genitalia and in a line from the umbilicus can be commenced. Many formulas are silvery (Figures 1a and b). to the pubis (linea nigra) is common and reported to be effective. In my clinical Unfortunately, there are no truly effec- normal in pregnancy, especially in women practice, I have found a compounded tive ways of preventing stretch marks in with dark skin (Figure 2). Scars may also formula containing hydroquinone 2 to 4%, those who are vulnerable to them. There darken. tretinoin 0.5%, hydrocortisone 1% in aque- is no evidence that topical agents or Melasma (also known as chloasma) is a ous delivers the best results. Hydroquinone moisturising oils prevent them, but oils distressing form of facial pigmentation that and tretinoin are considered moderately may relieve the itch that can sometimes affects many pregnant women (Figure 3). safe in lactation on a small surface area.2 be present. Daily massage with olive oil Conventional lightening products such as I advise using a pea-sized amount with a possibly helps. Control of excessive weight hydroquinone and tretinoin are contra- moisturiser initially every alternate night, gain may assist in preventing their indicated in pregnancy, although they are gradually working up to daily application development. likely to be safe during breastfeeding to help avoid irritation. Avoid using hydro- quinone in high concentrations for long periods as this may result in permanent bluish discolouration of the skin. Laser therapy has been reported to be helpful for melasma, but in practice I find this delivers disappointing results and sometimes worsens the condition. In addition, there is little point advising patients to make a large investment in treat- ment if they plan to have more children, as Figure 2. Linea nigra. Figure 3. Melasma. melasma will probably recur in subsequent pregnancies. 26 MedicineToday JULY 2016, VOLUME 17, NUMBER 7 Downloaded for personal use only. No other uses permitted without permission. © MedicineToday 2016. Skin tags Skin tags (fibroma pendulum) are small skin growths that appear in areas of fric- tion, such as under the arms and breasts. Most resolve spontaneously after the pregnancy. If they persist and bother the patient, I offer a variety of treatments, such as liquid nitrogen spray, snip excision, electrodesiccation or shave excision. The choice of treatment depends on the size of the skin tag and the thickness of its base. If the tag and its base are tiny then snip Figures 4a and b. A pyogenic granuloma in a pregnant patient (a, left) before curettage and excision using spring scissors with or with- (b, right) two weeks after curettage. out local anaesthesia is helpful and easy. (Snip excision of a tiny skin tag typically screen investigating for anaemia, iron defi- referral to a dermatologist experienced in causes less pain than local anaesthesia.) If ciency and thyroid abnormality is benefi- laser therapy may be helpful. Patients should the base is larger, I tend to infiltrate a local cial. Reassurance that the hair should be be instructed not to wax or pluck for six anaesthetic and then use forceps to assist back to normal by the baby’s first birthday weeks before laser therapy as the shaft of shave excision. Cryotherapy is quick but is important. Simple measures, such as the hair bulb is needed as a target for the can leave residual surrounding post- using a thickening shampoo, avoiding laser. Patients should shave in the lead up inflammatory pig menta tion or erythema, aggressive treatments to the hair and avoid- to laser. This can seem foreign to patients, and multiple treatments are sometimes ing tight hair styling may be helpful. In especially on the face. Multiple laser treat- required. addition, microfibre treatments are safe, ments (approximately four depending on relatively inexpensive and effective in giving the location of the hair) are required at six Hair and pregnancy the appearance of thicker hair. A healthy to eight-week intervals. Darker, thicker hair Hair thinning balanced diet and stress reduction strategies responds best to laser therapy, whereas Scalp hair continuously goes through may also prevent ongoing shedding. white or blonde hair does not respond. If growth, resting and shedding cycles. If hair loss continues after 12 months the patient cannot access laser therapy then Throughout pregnancy more hair follicles postpartum then referral to a dermatol- waxing and electrolysis are options during stay in the growth and resting phase, so that ogist is warranted for investigation and breastfeeding. hair shedding is reduced and the hair feels consideration of systemic therapy. thicker. Postpartum, the hair cycle returns Spider veins to normal, and approximately three months Hirsutism Spider veins are common during preg- after the birth hair shedding is temporarily Pregnant women may experience excessive nancy and are found predominantly on increased. This phenomenon is termed hair growth in locations such as the lip, the chest, face and neck and occasionally ‘telogen effluvium gravidarum’.