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Common Dermatoses of Pregnancy

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Common Dermatoses of Pregnancy Common Dermatoses of Pregnancy Ramsay S. Farah, M.D. Associate Professor of Medicine and Pathology Farah Dermatology and Cosmetics, LLC Upstate Medical University Common Dermatoses of Pregnancy • Pregnancy is a time of significant and complex physiologic changes • Some of these changes are due to the de novo production of a variety of protein and steroid hormones by the fetoplacental unit as well as by increased activity of the maternal pituitary, thyroid, and adrenal glands Common Dermatoses of Pregnancy • The chemistry, function, and metabolism of these hormones is quite complex. • The levels of these hormones are of diagnostic significance in certain obstetric conditions and complications, but their exact impact on cutaneous physiology as well as their influence on the immunology of the skin remains essentially unknown. Common Dermatoses of Pregnancy Well defined eruptions: -PUPP (pruritic urticarial papules and plaques of pregnancy) -Pemphigoid (herpes) gestationis -Impetigo Herpetiformis -Recurrent cholestasis of Pregnancy Poorly defined eruptions: -Prurigo gestationis -Papular dermatitis of pregnancy -Follicular eruption of pregnancy -Autoimmune progesterone dermatitis Pruritic Urticarial Papules and Plaques of Pregnancy (PUPP) • Otherwise known as polymorphic eruption of pregnancy • The most common gestational dermatoses with an incidence of 1 in 160 pregnancies • Seen most frequently in the late trimester or occasionally in the early postpartum period Pruritic Urticarial Papules and Plaques of Pregnancy (PUPP) • The mean duration is 6 weeks, but the rash is not severe for more than one week. • Unlike urticaria, the eruption remains fixed and increases in intensity, clearing in most cases before or within one week of delivery • Recurrences with future pregnancies is unusual Pruritic Urticarial Papules and Plaques of Pregnancy (PUPP) • There are no fetal or maternal complications • Infants do not develop the eruption • Etiology is unknown. It has been associated with increased maternal-fetal weight gain and twin pregnancy, and so it was postulated to be related to abdominal distention. Pruritic Urticarial Papules and Plaques of Pregnancy (PUPP) • The eruption begins suddenly, developing first on the abdomen in 90% of patients • The initial lesions maybe confined to the striae Pruritic Urticarial Papules and Plaques of Pregnancy (PUPP) • The eruption begins suddenly, developing first on the abdomen in 90% of patients • The initial lesions maybe confined to the striae Pruritic Urticarial Papules and Plaques of Pregnancy (PUPP) • The initial lesions begin as red papules that are often surrounded by a narrow, pale halo Pruritic Urticarial Papules and Plaques of Pregnancy (PUPP) • Early in the course, the lesions often predominate in the periumbilical area with sparing of the umbilicus Pruritic Urticarial Papules and Plaques of Pregnancy (PUPP) • The lesions then increase in number and may become confluent, resulting in broad areas of erythema that spread to involve the buttocks and thighs. • The papules maybe discrete at this point. Pruritic Urticarial Papules and Plaques of Pregnancy (PUPP) • The lesions then increase in number and may become confluent, resulting in broad areas of erythema that spread to involve the buttocks and thighs. • The papules maybe discrete at this point. Pruritic Urticarial Papules and Plaques of Pregnancy (PUPP) • In other instance the lesions may develop into erythema multiforme like lesions or lesions that look like herpes gestationis Pruritic Urticarial Papules and Plaques of Pregnancy (PUPP) • Histologic features include a superficial perivascular infiltrate of lymphocytes, monocytes and eosinophils • Variable dermal edema • Variable epidermal spongiosis Pruritic Urticarial Papules and Plaques of Pregnancy (PUPP) • Direct immunofluorescence of lesional or peri- lesional skin is negative • This can be used as a distinction with herpes gestationis Pruritic Urticarial Papules and Plaques of Pregnancy (PUPP) • Direct immunofluorescence of lesional or peri- lesional skin is negative • This can be used as a distinction with herpes gestationis Pruritic Urticarial Papules and Plaques of Pregancy (PUPP) • Treatment: The goal of treatment is to relieve pruritus, halt progression of the eruption, and hasten its resolution. • Most patients respond to frequent (5-6 times per day) application of potent topical steroids. • Once the eruptions is controlled, one can taper to less potent topical steroids Pruritic Urticarial Papules and Plaques of Pregancy (PUPP) • Patients with extensive eruptions or those refractory to treatment respond to a tapering course of systemic steroids (starting at 40mg/day and tapering by 5 mg every 2-3 days) • Antihistamines may also be used for the control of pruritus Pruritic Urticarial Papules and Plaques of Pregancy (PUPP) • Differential Diagnosis: • Erythema Multiforme • Drug eruptions • Contact dermatitis • Insect bites • Scabies • Urticaria • Herpes Gestationis Pruritic Urticarial Papules and Plaques of Pregancy (PUPP) Pruritic Urticarial Papules and Plaques of Pregancy (PUPP) Pruritic Urticarial Papules and Plaques of Pregancy (PUPP) Pruritic Urticarial Papules and Plaques of Pregancy (PUPP) Pruritic Urticarial Papules and Plaques of Pregancy (PUPP) Pruritic Urticarial Papules and Plaques of Pregancy (PUPP) Herpes Gestationis (Pemphigoid Gestationis) • An extremely pruritic polymorphic inflammatory, subepidermal bullous eruption of pregnancy and the postpartum period • Occurs in fewer than 1 in 50,000 pregnancies • Definitive diagnosis can be made with specific immunopathologic studies. Herpes Gestationis (Pemphigoid Gestationis) • Usually begins from the fourth to seventh month of pregnancy, but the onset has been reported during the first trimester and in the immediate postpartum period • Postpartum exacerbations as well as flares with the first few postpartum menstrual periods are common • May or may not recur in subsequent pregnancies; if it does, it is likely to begin earlier Herpes Gestationis (Pemphigoid Gestationis) • Many authors are calling this disease pemphigoid gestationis because it has 1) Immunologic similarities to bullous pemphigoid and 2) No relationship with herpes virus infections. Herpes Gestationis (Pemphigoid Gestationis) • Lesions vary from erythematous, edematous papules to large, tense bullae with many intermediate forms including small vesicles, confluent papules and vesicles and urticarial like plaques; with and without grouping, bullae, erosions and crusts Herpes Gestationis (Pemphigoid Gestationis) • Involves the abdomen usually, but may involve other areas as well (including palms, soles, chest, back and face) • Begins as edematous plaques occurring in crops on the abdomen and extremities • Mucous membrane involvement is rare Herpes Gestationis (Pemphigoid Gestationis) • These then coalesce into bizarre polycyclic rings covering wide areas of the skin Herpes Gestationis (Pemphigoid Gestationis) • These then coalesce into bizarre polycyclic rings covering wide areas of the skin Herpes Gestationis (Pemphigoid Gestationis) • Widespread urticarial plaques characterized by round shape and by polycyclic outlines. Herpes Gestationis (Pemphigoid Gestationis) • These then coalesce into bizarre polycyclic rings covering wide areas of the skin Herpes Gestationis (Pemphigoid Gestationis) • As with bullous pemphigod, within days to weeks the tense blisters evolve from the urticarial like plaques, rupture and leave slowly healing, denuded areas that heal without scarring Herpes Gestationis (Pemphigoid Gestationis) • It may leave postinflammatory hyperpigmentation. • Spontaneous clearing may be seen in the latter parts of the pregnancy, but flares are seen at the time of delivery in 75- 80% of cases • Mild recurrences may occur with menses or with the use of oral contraceptives Herpes Gestationis (Pemphigoid Gestationis) • Etiology: It is postulated that IgG antibodies are initiated in response to an antigenic stimulus peculiar to pregnancy • These antibodies have a specificity for a 180 kDa antigen (BPAG2 or type XVII collagen) that is a hemidesmosomal protein in the basement membrane Herpes Gestationis (Pemphigoid Gestationis) • Once deposited in the BM zone, these antibodies activate the complement cascade • The IgG antibody can in most cases, cross the placenta, hence the occasional genesis of transient blistering in the infant Herpes Gestationis (Pemphigoid Gestationis) Herpes Gestationis (Pemphigoid Gestationis) Herpes Gestationis (Pemphigoid Gestationis) • Treatment: is designed to suppress blister formation and to relieve the intense pruritus. • Achieved by giving 20-40mg of prednisone in divided doses daily. • Exacerbation of the pruritus and blistering commonly occur at parturition and may then require and increase in predinisone – this is then gradually tapered in the postpartum period. Herpes Gestationis (Pemphigoid Gestationis) • Exacerbations at the time of menses may require a temporary increase in dosage • A few patients do not require systemic prednisone and can be managed with antihistamines and topical steroids or emollients • At other extremes, some individuals after parturition require azathioprine in addition to prednisone to control their disease Herpes Gestationis (Pemphigoid Gestationis) • Alternatives to steroids or adjuvants (dapsone, MTX,Gold, Cyclophosphamide, plasmapheresis) are anecdotal and the experience is variable • No compelling argument for inducing delivery has been made. • The cutaneous lesions noted in infants
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