An Overview of Pregnancy Dermatoses
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CLINICAL REVIEW An overview of pregnancy dermatoses Ella McNulty-Brown, Samantha Vaughan-Jones A number of changes can occur in the skin during pregnancy. Benign changes seen are largely due to physiological alterations to the mother’s body in pregnancy; these alterations in turn can have an effect on pre-existing skin diseases such as eczema, psoriasis and acne. There are also a number of pregnancy- specific dermatoses. Pruritus is a common symptom in pregnancy and it is important to distinguish between physiological and pathological itch. Treating pregnant women requires a multi-disciplinary approach in order to care for the mother while considering the safety of her unborn child. Citation: McNulty-Brown EL, Vaughan-Jones S (2016) An overview of pregnancy dermatoses. Dermatological Nursing 15(1): 24-30 Introduction Pregnancy is a unique time when a number of changes can occur in the maternal skin as a result of complex hormonal, metabolic and immunologic interactions to ensure foetal tolerance (Ambros-Rudolph, 2011; García-González et al, 1999). Benign changes occur in pigmentation (for example, melasma, changing naevi, linea nigra); vasculature (for example Figure 1 telangiectasia, pyogenic granulomas); DERMQUEST.COM/GALDERMA hair (for example, telogen effl uvium Telogen effl uvium is one of the physiological changes that can occur during pregnancy. post-partum, Figure 1), and nails (for example, ridging, splitting) (Vaughan- third trimester) and psoriasis vulgaris pregnancy and prurigo of pregnancy), Jones et al, 2014; García-González (commonly improving in pregnancy) pemphigoid gestationis (syn herpes et al, 1999). In addition, pre-existing (Vaughan-Jones et al, 2014). gestationis) and intrahepatic infl ammatory skin diseases can cholestasis of pregnancy (syn obstetric fl uctuate in severity throughout the Skin complaints occurring only cholestasis) (Ambros-Rudolph et prenatal and post-partum period, for in pregnancy are referred to as the al, 2006). These dermatoses are a example, acne vulgaris (improving in pregnancy-specifi c dermatoses and group of intensely pruritic conditions early pregnancy and worsening in the were re-classifi ed in 2006 to include that occur during pregnancy and/or polymorphic eruption of pregnancy the immediate post-partum period Dr Ella L McNulty-Brown is a Dermatology (syn pruritic urticarial papules and (Ambros-Rudolph, 2011). Polymorphic Registrar at Worthing Hospital. Dr Samantha plaques of pregnancy ‘PUPPP’), atopic eruption of pregnancy (PEP) usually Vaughan-Jones is a Consultant Dermatologist eruption of pregnancy (syn eczema develops as pruritic urticated plaques at St Peter’s Hospital, Chertsey, Surrey of pregnancy, pruritic folliculitis of within the striae distensae of the 24 Dermatological Nursing, 2016, Vol 15, No 1 www.bdng.org.uk 24-30_PregnancymjjpC.indd 26 26/02/2016 12:41 CLINICAL REVIEW Table 1. Key features and investigations for the four pregnancy-specific dermatoses. Polymorphic eruption Intrahepatic cholestasis of Atopic eruption of pregnancy Pemphigoid gestationis of pregnancy pregnancy Estimated incidence 1:5 - 1:20 1:160 1:50 - 1:5000 1:1700 - 1:50,000 Common skin signs Pruritus Pruritus Nocturnal pruritus Pruritus Eczematous plaques Urticaria Excoriations Urticarial plaques Papules Sparing of umbilicus Targetoid lesions Tense blisters Common anatomical site ‘E-type’ on face, neck, Striae distensae Palms and soles Periumbilical fl exures Lower abdomen Extremities Abdomen ‘P-type’ on lower limbs Thighs Extremities Investigations Serum IgE levels may be Negative DIF Elevated ALT Linear C3 DIF (BP180) elevated Elevated total serum bile acids Usual trimester of pregnancy of onset 1st - 2nd 3rd 3rd 2nd - 3rd Post-partum Resolution Resolution Resolution Can fl are post-partum Risk to foetus No risks No risks Foetal distress Prematurity Pre-term delivery Foetal growth restriction Stillbirth Neonate No harm but increased risk of No harm No harm Transient blisters seen in 10% atopic disease Recurrence Can recur due to No risk Risk of recurrence in Recurrence is common in subsequent underlying atopic tendency subsequent pregnancies pregnancies Can occur on combined oral Can fl are when menses or hormonal contraceptive pill contraception recommences Adapted from Huilaja et al, 2014. IgE: serum immunoglobulin DIF: direct immunofl uorescence ALT: alanine transaminase BP180: bullous pemphigoid 180 lower abdomen in the third trimester cholestasis of pregnancy (ICP) is not a and resolves rapidly post-partum primary dermatosis (as itching results (Rudolph et al, 2006). Atopic eruption in secondary excoriations only), but of pregnancy (AEP) is a common skin is an important diagnosis to exclude complaint in pregnancy and is the in the pruritic pregnant woman. It result of either the fi rst eczematous usually presents in the third trimester episode in a previously known atopic with pruritus that is intense, often patient or a fl are of symptoms in localising to the palms and soles and pre-existing eczematous disease typically worse at night (Lammert et (Ambros-Rudolph et al, 2012). PEP al, 2000). Like in PG, ICP patients need and AEP are not known to cause close monitoring due to the risk of any adverse outcomes to the foetus pre-term delivery, foetal distress and or neonate. In contrast, pemphigoid stillbirth (Williamson et al, 2014). The gestationis (PG) is a rare condition key features and investigations for the that presents with urticated plaques four pregnancy-specifi c dermatoses often starting in the periumbilical area, are discussed in more detail below and then spreading to cause widespread summarised in Table 1. blistering (Chi et al, 2009). Pregnancies Figure 2 affected by PG are considered high Benign naevi versus malignant melanoma in DERMQUEST.COM/GALDERMA risk due to the association with both pregnancy Linea nigra, a dark vertical line that appears pre-term birth and low-birth weight A number of benign changes on the abdomen, is a common pigmentary change babies (Chi et al, 2009). Intrahepatic occur in the skin during pregnancy. that occurs during pregnancy. www.bdng.org.uk Dermatological Nursing, 2016, Vol 15, No 1 25 24-30_PregnancymjjpC.indd 27 26/02/2016 12:41 CLINICAL REVIEW Patients will often report a change Polymorphic eruption of pregnancy in pigmentation including linea nigra Polymorphic eruption of pregnancy (Figure 2), melasma or a change to (PEP), previously known as pruritic a naevus. Melanocyte stimulating urticarial papules and plaques of hormone is secreted by the placenta pregnancy (PUPPP), is a condition (García-González et al, 1999) and that usually occurs in the late third raised levels of this hormone can trimester or immediately post- result in deepening of pigmentation partum in primigravidae (Figure 3). in pre-existing naevi. However, this It is a common pregnancy-specifi c can also be a warning sign and early dermatosis, with an incidence of excision biopsy should be considered Figure 3 DERMQUEST.COM/GALDERMA approximately 1 in 160 deliveries in all pregnant women presenting PEP (polymorphic eruption of pregnancy) is (Rudolph et al, 2006) that typically with changing naevi, to exclude a condition that usually occurs in the late does not recur in subsequent the possibility of early malignant third trimester or immediately post-partum in pregnancies (apart from multiple melanoma. primigravidae. pregnancy). The pruritic urticarial papules often start on the abdomen Infl ammatory skin disease in pregnancy within the striae distensae and A number of infl ammatory skin Treatment of acne and commonly also affect the proximal conditions can either present, improve rosacea in pregnancy thighs and buttocks. It is important to or become exacerbated throughout can be diffi cult as many note that the umbilicus is spared in the prenatal and post-partum period. of the usual treatments PEP and the face, palms and soles One study observed that 50% of are contraindicated. For are also rarely involved (Rudolph et women seen in a specialised pregnancy al, 2006). clinic presented with an infl ammatory example, systemic retinoids skin condition such as acne or psoriasis are teratogenic and must The exact cause of PEP is unknown (Ambros-Rudolph et al, 2006). Eczema not be prescribed. but literature suggests that the of pregnancy is now included within condition presents more commonly atopic eruption of pregnancy (as trimester women can experience a in association with excessive maternal discussed below). fl are in symptoms (Vaughan-Jones weight gain and multiple pregnancy et al, 2014). Rosacea is sensitive to (Vaughan-Jones et al, 2014). One Due to hormonal infl uences on increasing levels of oestrogen and theory suggests that stretching of immune function, psoriasis vulgaris can worsen throughout pregnancy abdominal skin could possibly cause tends to improve during pregnancy (Vaughan-Jones, 2016). Treatment disruption to collagen within the striae and can worsen post-partum of acne and rosacea in pregnancy and an allergic-type reaction is elicited (Murase et al, 2005). Safe treatment can be diffi cult as many of the usual (Ahmadi et al, 2005). Other authors of psoriasis in pregnancy depends treatments are contraindicated. have suggested a possible hormonal on the severity of disease, starting For example, systemic retinoids aetiology but this remains unclear. It with emollients and mild/moderate are teratogenic and must not be is important to reassure the patient potency topical corticosteroids prescribed in pregnancy. Even topical that