CLINICAL REVIEW An overview of 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 . 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, , 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) 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 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  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  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: 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 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 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 prescribed in pregnancy. Even topical that this condition is harmless, will for mild disease, progressing to retinoids should be used with caution cause no adverse effect to the foetus phototherapy for moderate disease, in women of child-bearing age (as in or neonate, and usually resolves within and then consideration of systemic a recent meta-analysis (Kaplan et al, a few weeks of delivery (Vaughan- or biologic drugs for severe disease 2015) and are not recommended. Jones et al, 2014). Topical emollients, if appropriate (Bae et al, 2012). A systemic antihistamines and a short rare form of psoriasis known as Due to their effect on foetal course of moderately potent topical generalised pustular psoriasis of bone and teeth development, oral can be used safely to pregnancy (or ) tetracyclines are contraindicated treat PEP (Vaughan-Jones et al, 2014). (Roth, 2011) presents with pustules after the fi rst trimester (Vaughan- predominantly in the fl exures with Jones, 2016) when oral erythromycin Atopic eruption of pregnancy associated hypocalcaemia, fevers and can be considered instead. Oral The more recent term ‘atopic eruption tetany (Vaughan-Jones et al, 2014). corticosteroids may be required for of pregnancy’ (AEP) encompasses It is a more serious condition that the more severe cases of rosacea the conditions previously known as may require systemic treatment with fulminans (acne conglobata) (Vaughan- eczema of pregnancy, pruritic folliculitis corticosteroids (Bae et al, 2012). Jones, 2016). Further management of pregnancy and prurigo of pregnancy of infl ammatory skin diseases in (Ambros-Rudolph et al, 2006). AEP is Acne vulgaris tends to improve in pregnancy will appear in Part II of this the skin complaint in pregnancy most early pregnancy but once maternal article, due for publication later this frequently seen (Ambros-Rudolph et androgen levels rise in the third year (2016). al, 2006), occurring in between 1 in

26 Dermatological Nursing, 2016, Vol 15, No 1 www.bdng.org.uk

24-30_PregnancymjjpC.indd 28 26/02/2016 12:41 CLINICAL REVIEW

Figure 4a Figure 4b DERMQUEST.COM/GALDERMA Pemphigoid gestationis demonstrating (4a) involvement of the umbilicus and (4b) erythema multiforme-style lesions.

5 and 1 in 20 pregnancies (Ambros- as menthol or urea) and the addition IgG autoantibodies against the NC16a Rudolph et al, 2012). The exact of systemic antihistamines (Vaughan- terminus of BP180 (Powell et al, 2005; aetiology of AEP is not clear but it is Jones et al, 2014). Mild to moderately Tani et al, 2015). There seems to be likely to be related to the reduction potent topical corticosteroids can a close association with the HLA of Th1 cytokine production, which be used safely in pregnancy without subtypes DR3 and DR4. The condition allows maternal tolerance of the causing harm to the foetus (Chi et is characterised by intense pruritus foetus, and an increase in Th2 cytokine al, 2011). Patients with AEP have with urticated plaques that most production, which can worsen pre- a good prognosis but, due to the frequently start in the periumbilical existing autoimmune diseases and underlying atopic tendency, AEP can area and can rapidly progress to cause may act as a trigger for AEP (García- recur in subsequent pregnancies, and widespread blistering (Chi et al, 2009) González et al, 1999). (Figures 4a and 4b). An erythema- Patients with pemphigoid multiforme-like clinical appearance Atopic eruption of pregnancy is can precede the small, tense blisters either seen as the fi rst presentation gestationis should be (Tani et al, 2015). It is uncommon for of an eczematous or papular skin considered at higher PG to affect the face or the mucous problem in an atopic patient; or as risk and therefore membranes (Tani et al, 2015). PG can a result of an exacerbation of pre- close communication occur at any stage of pregnancy but existing eczematous skin disease between dermatologists, it is most common in the second and (Ambros-Rudolph et al, 2012). It tends obstetricians, midwives and third trimesters. In a recent systematic to occur earlier in the pregnancy than study, multigravidae developed PG the other specifi c dermatoses with nursing staff is essential. at a signifi cantly (P < 0.01) earlier 75% of eczematous plaques or papules stage of pregnancy (21.1 weeks) than developing before the third trimester infants may have an increased risk of primigravidae (31.3 weeks) (Tani et al, (Ambros-Rudolph et al, 2006). There subsequent atopic disease. 2015). are two subclasses of AEP often referred to as the ‘E-type’ (which Pemphigoid gestationis Patients with PG should be includes those patients who develop Pemphigoid gestationis (PG) is a rare considered at higher risk and therefore eczematous plaques on the face, neck blistering condition in pregnancy with close communication between and fl exural surfaces of the limbs) and an incidence of between 1 in 1700 dermatologists, obstetricians, midwives the ‘P-type’, in which patients develop (Roger et al, 1994) and 1 in 50,000 and nursing staff is essential. This is papules and nodular prurigo on the (Shornick et al 1983) pregnancies. One a result of evidence suggesting that lower limbs (Ambros-Rudolph et al, study carried out at a tertiary referral patients with PG tend to have pre- 2006). These fi ndings are combined centre reported an incidence of PG in term births and low-birth weight with a generalised xerosis. The 4.2% of 505 pregnancies over 10 years babies, correlated with earlier onset of treatment of AEP should focus on the (Ambros-Rudolph et al, 2006). PG is the condition and disease severity (Chi liberal application of emollients with an autoimmune sub-epidermal bullous et al, 2009). It has been suggested that or without antipruritic additives (such condition that results in predominantly a mild chronic placental failure occurs

28 Dermatological Nursing, 2016, Vol 15, No 1 www.bdng.org.uk

24-30_PregnancymjjpC.indd 30 26/02/2016 12:41 CLINICAL REVIEW

due to the circulating autoantibodies attacking the placenta (Huilaja et Pruritus in pregnancy: an aid to initial diagnosis al, 2008). Ten percent of neonates born to mothers with PG will have transient blistering due to passive transfer of maternal antibodies across the placenta (Ambros-Rudolph et al, 2012). Milder forms or pre-bullous Yes No stage PG can be managed with potent topical corticosteroids and emollients. However, in established bullous disease systemic corticosteroids are generally required, for example, oral prednisolone 0.5-1.0mg/kg per day  Check LFTs (Vaughan-Jones et al, 2014). Due to  Check serum bile acids the placental enzyme 11-hydroxsteroid  Ensure close obstetric dehydrogenase type 2, prednisolone is monitoring mostly all inactivated prior to reaching the foetal circulation, making it a safe option to use in pregnancy (Jackson et al, 2007). A post-partum fl are is often seen (75% of cases) and patients  Biopsy skin, send for DIF Figure 5 should be warned that PG can fl are  Check TFTs when menses re-commence and/or LFT: liver function test; DIF: direct immunofl uorescence;  Ensure close obstetric if hormonal contraception is started. TFT: thyroid function test monitoring PG will often recur in subsequent (Adapted from Ambros-Rudolph et al, 2006) pregnancies (Vaughan-Jones et al, 2014). It is important to check thyroid 2014). The treatment goal for ICP is function in patients who have had Whenever reviewing a to reduce levels of serum bile acids PG as there is a strong association pregnant woman with with ursodeoxycholic acid, which in with other autoimmune diseases, pruritus, a useful place to turn alleviates the pruritus and leads particularly Grave’s disease (Jenkins start is to perform some to a more favourable foetal outcome et al, 1999). One paper demonstrated blood tests to screen for (Kondrackiene et al, 2005). In addition, a high incidence of Grave’s disease in common causes of itching frequent application of emollients women with PG — 10.7% compared (with or without antipruritic agents to 0.4% in the normal population (for example, anaemia). such as menthol or urea) can provide (Jenkins et al, 1999). some relief, as symptoms will often intense scratching (Sävervall et al, persist until delivery, after which Intrahepatic cholestasis of pregnancy 2015). The aetiology of ICP seems spontaneous resolution normally Intrahepatic cholestasis of pregnancy to be multifactorial. As one review occurs within a few days. (ICP) is not a primary skin dermatosis, article reported, ICP seems to be however it is classifi ed as a specifi c caused by a combination of hormonal Dermatoses in pregnancy and the nurse’s role dermatosis of pregnancy (Ambros- infl uence (particularly high levels of A number of different skin diseases Rudolph et al, 2006). It is an oestrogen), a genetic predisposition that can occur in pregnancy have been important disease to exclude in (as demonstrated by familial clustering outlined in this article. Pregnancy is women presenting with pruritus in and a high prevalence of the condition a time when any change in women’s pregnancy. ICP was previously referred in Scandinavia and South America), health can cause anxiety about to as ‘pruritus gravidarum’. In ICP and likely other exogenous factors the potential effect on the unborn important clinical distinctions help to (Lammert et al, 2000). child. Whether it be a harmless distinguish it from other conditions, physiological change in the skin or namely that pruritus presents later in In all pruritic pregnant women a more serious pregnancy-specifi c the third trimester, often localises to liver function tests and serum bile dermatosis, as health professionals the palms and soles, and is typically acid levels should be mandatory it is vital that evidence-based advice worse at night (Lammert et al, 2000). (Lammert et al, 2000). Due to the is given. The algorithm in Figure 5 is The pruritus will usually progress risk of stillbirth, early delivery and helpful with initial diagnosis. Whenever to become generalised and patients foetal distress, patients with ICP reviewing a pregnant woman with develop secondary excoriations or should be closely monitored under pruritus, a useful place to start is to even prurigo nodules as a result of an obstetric team (Williamson et al, perform some blood tests to screen

www.bdng.org.uk Dermatological Nursing, 2016, Vol 15, No 1 29

24-30_PregnancymjjpC.indd 31 26/02/2016 12:41 CLINICAL REVIEW

for common causes of itching (for urticarial papules and plaques of pregnancy: Kondrackiene J, Beuers U, Kupcinskas L example, anaemia). This would often current status. Australas J Dermatol 46(2): (2005) Effi cacy and safety of ursodeoxycholic include a full blood count, ferritin, urea 53-8; quiz 59 acid versus cholestyramine in intrahepatic cholestasis of pregnancy. Gastroenterology and electrolytes, liver function tests, Ambros-Rudolph CM, Müllegger RR, Vaughan-Jones SA, Kerl H, Black MM 129(3): 894-901 and thyroid function. It is important (2006) The specifi c Lammert F, Marschall HU, Glantz A, Matern S to keep in mind that haemodilution revisited and reclassifi ed: results of a (2000) Intrahepatic cholestasis of pregnancy: in pregnancy leads to a physiological retrospective two-center study on 505 molecular pathogenesis, diagnosis and reduction in haemoglobin levels and pregnant patients. J Am Acad Dermatol 54(3): management. J Hepatol 33(6): 1012-21 therefore a diagnosis of anaemia 395-404 Murase JE, Chan KK, Garite TJ, Cooper DM, should be interpreted in this context. Ambros-Rudolph CM (2011) Dermatoses of Weinstein GD (2005) Hormonal effect on psoriasis in pregnancy and post partum. Serum bile acids should always be pregnancy — clues to diagnosis, fetal risk Arch and therapy. Ann Dermatol 23(3): 265-75 Dermatol 141(5): 601-6 requested alongside liver function tests Ambros-Rudolph CM, Shornick J (2012) Murase JE, Heller MM, Butler DC (2014) to check for intrahepatic cholestasis Pregnancy Dermatoses. In: Bolognia J, Jorizzo Safety of dermatologic medications in of pregnancy. A skin biopsy should be J, Schaffer J (Eds) Dermatology. 3rd edn. pregnancy and lactation: Part I. Pregnancy. J considered, particularly if pemphigoid Elsevier Saunders Am Acad Dermatol 70(3): 401.e1-14 gestationis is suspected, when histology Bae YS, Van Voorhees AS, Hsu S, Korman NJ, Powell AM, Sakuma-Oyama Y, Oyama N, and direct immunofl uorescence should Lebwohl MG, Young Me, et al (2012) Review Albert S, Bhogal B, Kaneko F, et al (2005) both be analysed. of treatment options for psoriasis in pregnant Usefulness of BP180 NC16a enzyme-linked or lactating women: from the Medical Board immunosorbent assay in the serodiagnosis of of the National Psoriasis Foundation. J Am pemphigoid gestationis and in differentiating Detailed management Acad Dermatol 67(3): 459-477 between pemphigoid gestationis and pruritic recommendations for the dermatoses Chi CC, Wang S-H, Mayon-White R, urticarial papules and plaques of pregnancy. in pregnancy are beyond the remit Wojnarowska F (2013) Pregnancy Arch Dermatol 141(6): 705-10 of this article but some simple advice outcomes after maternal exposure to topical Roger D, Vaillant L, Fignon A, Pierre F, Bacq is summarised here. When topical corticosteroids. A UK population-based Y, Grangeponte MC, et al (1994) Specifi c treatments are prescribed, women cohort study. JAMA Dermatol 149: 1274-80 pruritic diseases of pregnancy. A prospective study of 3192 pregnant women. Arch should be educated on how to Chi CC, Kirtschig G, Aberer W, Gabbud JP, Lipozencic J, Kárpáti S, et al (2011) Dermatol 130(6): 734-9 apply these safely and in the correct Evidence-based (S3) guideline on topical Roth MM (2011) Pregnancy dermatoses: quantity. This is important to limit corticosteroids in pregnancy. Br J Dermatol diagnosis, management, and controversies. toxicity both to the foetus and also 165(5): 943-52 Am J Clin Dermatol 12(1): 25-41 to the neonate during breastfeeding Chi CC, Wang SH, Charles-Holmes R, Rudolph CM, Al-Fares S, Vaughan-Jones if topical treatment is applied directly Ambros-Rudolph C, Powell J, Jenkins R, et al SA, Mullegger RR, Kerl H, Black MM, et al to the skin on the breast (Murase (2009) Pemphigoid gestationis: early onset (2006) Polymorphic eruption of pregnancy: et al, 2014). Mild/moderate potency and formation are associated with clinicopathology and potential trigger factors adverse pregnancy outcomes. Br J Dermatol in 181 patients. Br J Dermatol 154: 54-60 topical corticosteroids are safe to 160(6): 1222-8 Sävervall C, Sand FL, Thomsen SF (2015) use in pregnancy and have not been García-González E, Ahued-Ahued R, Arroyo Dermatological diseases associated with found to have any association with E, Montes-De-Oca D, Granados J (1999) pregnancy: pemphigoid gestationis, the development of orofacial clefts, Immunology of the cutaneous disorders of polymorphic eruption of pregnancy, pre-term delivery or foetal death (Chi pregnancy. Int J Dermatol 38(10): 721-9 intrahepatic cholestasis of pregnancy, et al, 2011). If potent or ultrapotent Huilaja L, Mäkikallio K, Tasanen K (2014) and atopic eruption of pregnancy. Dermatol Res Pract 2015:979635. doi: topical corticosteroids are required, Gestational pemphigoid. Orphanet J Rare Dis 9: 136 10.1155/2015/979635 their use should be limited (<200g Shornick JK, Bangert JL, Freeman RG, for the duration of the pregnancy) Huilaja L, Hurskainen T, Autio-Harmainen H, Hofmann SC, Sormunen R, Rasanen J, et al Gilliam JN (1983) Herpes gestationis: clinical to minimise the risk of foetal growth (2008) Pemphigoid gestationis autoantigen, and histologic features of twenty-eight cases. restriction (Chi et al, 2013). Giving transmembrane collagen XVII, promotes J Am Acad Dermatol 8(2): 214-24 appropriate reassurance and education the migration of cytotrophoblastic cells of Tani N, Kimura Y, Koga H, Kawakami T, about treatments will help to reduce placenta and is a structural component of Ohata C, Ishii N, et al (2015) Clinical and anxiety and improve compliance. As fetal membranes. Matrix Biol 27(3): 190-200 immunological profi les of 25 patients with pemphigoid gestationis. Br J Dermatol stated earlier, a second article on Jackson S, Gilchrist H, Nesbitt LT (2007) Update on the dermatologic use of systemic 172(1): 120-9 ‘Treating skin conditions in pregnancy’ glucocorticosteroids. J Dermatol Ther 20(4): Vaughan-Jones S, Ambros-Rudolph C, will be published in a forthcoming 187-205 Nelson-Piercy C (2014) Skin disease in edition of Dermatological Nursing and Jenkins RE, Hern S, Black MM (1999) pregnancy. BMJ 348:g3489 will expand on these important issues Clinical features and management of 87 Vaughan-Jones (2016) Dermatoses of for women and how dermatology patients with pemphigoid gestationis. Clin Pregnancy. In: Griffi ths C, Barker J, Chalmers nurses can advise and support. DN Exp Dermatol 24(4): 255-9 R, Bleiker T, Creamer D (Eds). Rook’s Kaplan YC, Ozsarfati J, Etwel F, Nickel Textbook of Dermatology. 9th edn. Wiley C, Nulman I, Koren G (2015) Pregnancy Blackwell outcomes following fi rst-trimester exposure Williamson C1, Geenes V (2014) Intrahepatic References to topical retinoids: a systematic review and cholestasis of pregnancy. Obstet Gynecol Ahmadi S, Powell FC (2005) Pruritic meta-analysis. Br J Dermatol 173(5): 1132-41 124(1): 120-33

30 Dermatological Nursing, 2016, Vol 15, No 1 www.bdng.org.uk

24-30_PregnancymjjpC.indd 32 26/02/2016 12:41