Journal of Pakistan Association of Dermatologists. 2014;24 (1):46-50.

Original Article Dermatoses in : Specific dermatoses vis-a-vis others, in a tertiary hospital in Kolkata Sudip Das, Sayantani Chakraborty, Suchibrata Das, Joyeeta Choudhury, Loknath Ghosal

Department of , N R S Medical College, Kolkata

Abstract Objective To document the frequency of specific and other dermatoses in pregnancy.

Methods Two hundred and twenty five consecutive pregnant patients irrespective of the duration of pregnancy and gravidity reporting to our skin OPD were enrolled in the study. Out of them, 218 patients who gave consent were included in the study.

Results The specific dermatoses of pregnancy were subclassified into four main groups - atopic eruption of pregnancy (AEP), polymorphic eruption of pregnancy (syn. pruritic urticarial papules and plaques of pregnancy) [PEP], pemphigoid gestationis (PG), intrahepatic cholestasis of pregnancy (ICP). 39 (68.4%) patients belonged to AEP, 14 (24.5%) to PEP, and 1 (1.8%) to PG and 3 (5.2%) to ICP. About half of the patients with AEP were found to have raised IgE level. Five STD patients were reported in the first trimester, 2 in second and 7 in third trimester. Patients reported with molluscum contagiosum (4), genital herpes (4), condyloma acuminata (3), primary chancre (1) and condyloma lata (1). One patient with molluscum contagiosum was HIV positive. Among the non STD other dermatoses in pregnancy, scabies topped the list affecting in all trimesters. Fungal infections (tinea and pityriasis versicolor) was a close second. One case each of pompholyx, psoriasis, and leprosy reported to us.

Conclusion Early diagnosis of specific dermatosis of pregnancy may prevent harmful effect on mother and .

Key words Pregnancy, sexually transmitted disease, dermatoses.

Introduction retrospective two-centre study on more than 500 pregnant patients, a rationalized The specific dermatoses of pregnancy classification of these dermatoses has recently represent a heterogeneous group of pruritic been proposed that includes the following skin diseases that have been classified as diseases: pemphigoid (herpes) gestationis pemphigoid gestationis (PG), polymorphic (PG), polymorphic eruption of pregnancy eruption of pregnancy (syn. pruritic urticarial (PEP: synonymous with pruritic urticarial papules and plaques of pregnancy) (PUPPP), papules and plaques of pregnancy), intrahepatic cholestasis of pregnancy (ICP), intrahepatic cholestasis of pregnancy (ICP) and atopic eruption of pregnancy (AEP). The and atopic eruption of pregnancy (AEP).1 pathogenesis of these diseases is yet unknown, While some dermatoses, such as PEP and and there is limited literature on their clinical AEP, are distressing only to the mother characteristics. Based on the results of a because of severe pruritus, PG may be associated with small-for-date babies, while Address for correspondence ICP poses an increased risk of , Dr. Sudip Das, Associate Professor, Department of Dermatology, prematurity and . Familiarity with the N R S Medical College, clinical presentation of these diseases is 138, AJC Bose Road, essential, as unequivocal diagnostic tests are Kolkata-70014, India E-mail: [email protected] available only for PG and ICP, and a pregnant

46 Journal of Pakistan Association of Dermatologists. 2014;24 (1):46-50. patient with pruritus needs information on her They were classified as pregnancy specific condition, as well as the associated fetal risks. dermatoses (group I), STD (group II), non Our purpose was to find out the proportion of STD other dermatoses (group III). Fifty seven specific pregnancy dermatoses along with (26.1%) patients belonged to group I, 14 other dermatoses amongst all the enrolled patients (6.4%) to group II, 147 patients pregnant patients presenting with skin (67.5%) to group III. manifestations. Based on clinical history, clinical examination Methods and relevant histology, 57 patients with specific dermatoses of pregnancy were Two hundred and twenty five consecutive subclassified into four main groups - AEP, pregnant patients irrespective of the duration PEP, PG and ICP. 39 (68.4%) patients of pregnancy and gravidity reporting to our belonged to AEP, 14 (24.5%) to PEP, 3 (5.2%) skin OPD were enrolled in the study. Out of to ICP and 1 (1.8%) to PG. About half of the them, 218 patients who gave a written consent patients with AEP were found to have raised were included in the study. A comprehensive IgE level. Most of them (63%) presented in the set of clinical and obstetric parameters were late second trimester. About 15% of the obtained including demographic parameters, patients with AEP had history of suffering gestation, parity, chief complaints related to from adult atopic (AD) with skin, presence of itching, onset in relation to exacerbation during pregnancy. Out of the 14 duration of pregnancy, jaundice, vaginal patients who were diagnosed with PEP, 2 of discharge, past or family history of similar them had multiple pregnancy, 1 had lesions, exacerbating factors, associated while others had no such medical or skin disorders, history of similar association. Majority of them presented in the skin changes in previous , third trimester. Four of them had raised IgE localization, and morphology of skin lesions, level. after obtaining informed consent from the patient. Relevant systemic examination was Out of the 3 patients with ICP, 2 had mildly carried out. If any preexisting skin disease was raised conjugated bilirubin with subtle rise in present, evidence of exacerbation or remission liver enzymes while the third one had mild was recorded. Liver function tests were done clinical jaundice with pruritus. One of these in relevant patients. Simple dermatological patients with ICP, gave birth to the baby at 35th tests like scraping for KOH smear, gram stain, week while the rest did not have any adverse were done. Patients were classified into three fetal out come. The patient with PG presented groups - true pregnancy dermatoses (group I), in the mid-third trimester but there was no sexually transmitted diseases [STD] (group II), complication related with the fetus. She was non-STD other dermatoses (group III). treated with topical and systemic corticosteroids with fair control of the disease. Results Among the STD patient (Table 2), 5 reported Of the 218 patients recruited in the study 122 in the first trimester, 2 in second, 7 in third (56%) were primigravida and 96 (44%) were trimester. Patients reported with molluscum multigravida with age ranging from 16 to 42 contagiosum (4), genital herpes (4), years with a mean of 24 years. Most of them condyloma acuminata (3), primary chancre presented in the second 98 (45%) and third (1), condyloma lata (1) and HIV positive (1). trimester 76 (34%).

47 Journal of Pakistan Association of Dermatologists. 2014;24 (1):46-50.

Table 1 Specific dermatoses in pregnancy (n=57). Discussion Dermatosis N (%) Atopiform eruption of pregnancy 39 (68.5) Dermatoses related to pregnancy or the Polymorphic eruption of pregnancy 14 (24.5) Intrahepatic cholestasis of 3 (5.2) are known as the specific pregnancy dermatoses of pregnancy. Some aspects Pemphigoid gestationis 1 (1.8) regarding the etiology and the nosologic

Table 2 Sexually transmitted diseases in pregnancy classification of various pregnancy dermatoses (n=14). are highly controversial. The first Diseases N (%) classification of dermatoses of pregnancy was Molluscum contagiosum 4 (28.6%) Genital herpes 4 (28.6%) proposed by Holmes and Black in 1983 and Condyloma acuminata 3 (21.5%) included four skin conditions: 1. pemphigoid Primary chancre 1 (7.1%) gestationis (PG, syn. herpes gestationis) 2. Condyloma lata 1 (7.1%) HIV positive 1 (7.1%) polymorphic eruption of pregnancy (PEP) (syn. pruritic urticarial papules and plaques of Table 3 Non-sexually transmitted diseases pregnancy [PUPP]) 3. prurigo of pregnancy (n=148). (PP) and 4. pruritic folliculitis of pregnancy Diseases N (%) 2 Scabies 48 (32.4%) (PF). A second classification, proposed by Pyoderma 22 (14.8%) Shornick in 1998, included intrahepatic Tinea 21 (14.2%) cholestasis of pregnancy (ICP) in addition to 17 (11.6%) 3 Allergic contact dermatitis 14 (9.5%) PG, PEP and PP, PG. The most recent Pediculosis 8 (5.4%) rationalized classification was proposed by Verruca vulgaris 7 (4.7%) Ambros-Rudolph et al.1 in 2006 which is as Chickenpox 5 (3.4%) Psoriasis 3 (2%) follows: 1. atopic eruption of pregnancy, 2. Pompholyx 1 (.6%) polymorphic eruption of pregnancy, 3. Leprosy 1 (.6%) pemphigoid gestationis and 4. intrahepatic cholestasis of pregnancy, described as specific One patient with molluscum contagiosum was dermatoses of pregnancy.1 According to a HIV positive. study with 3192 subjects, the incidence of true pregnancy dermatoses has been found to be Among the non-STD other dermatoses in 0.5% to 3.0%.4 In an Indian study by Thapa et pregnancy, scabies topped the list in all al.5 the incidence of pregnancy specific trimesters, fungal infections (tinea and dermatoses has been found to be 3.6%. Out of pityriasis versicolor) was a close second. One 218 patients, 26.14% patients presented with case each of pompholyx, psoriasis, and leprosy true pregnancy dermatoses. This, however, reported to us. does not reflect the actual incidence as we have included only those patients who were Pruritus was noted in 124 (56%) patients and referred to us for some dermatological or STD was mostly attributed to nonspecific related complaint. dermatoses (54%) followed by the specific dermatoses of pregnancy. Nonspecific vulval During gestation a woman can develop any pruritus was found in 8.9% cases while kind of skin disorder. Pruritus represents the pruritus with white discharge was encountered leading symptom in the majority of dermatoses in 24% cases. Vaginal candidiasis was found of pregnancy. In an Indian study, Shivakumar in 16 (30%) cases suffering from pruritus with and Madhavamurthy6 found pruritus to be the vaginal discharge. commonest symptom (58.82%). We found the incidence of pruritus in our study to be 56%

48 Journal of Pakistan Association of Dermatologists. 2014;24 (1):46-50. out of which most were due to nonspecific incidence of PEP is about 1:160 pregnancies dermatoses. and it is considered as the second most common skin dermatosis in pregnancy after The identification of the most of the types of atopic eczema.10 pregnancy dermatoses is based mainly on clinical criteria whereas specific diagnostic In our study, 14 patients out of 218 patients tests such as histopathology, included in the study were diagnosed to have immunofluorescence or laboratory PEP. Though this does not reflect the actual investigation help in confirming the diagnosis incidence, as we had included only those for PG, ICP and . In our patients who were referred to us for some study, out of the 3 patients who were dermatological or STD related complaint. A diagnosed to have ICP, 2 had mildly raised recent retrospective study involving 181 conjugated bilirubin with subtle rise in liver patients with PEP revealed a high frequency of enzymes while the third one had mild clinical atopy among patients (55%).10 We found 4 jaundice with pruritus. The patient who had patients diagnosed with PEP to have raised bullous eruption, was subjected to skin biopsy IgE level. for histopathology and DIF, to be diagnosed as pemphigoid gestationis on the basis of this. AEP presents as benign pregnancy specific dermatoses that is characterised by intense Conditions like PG and AEP tend to recur in itching and eczematous or papular eruption subsequent pregnancies usually with an earlier with a personal and/or family history of atopy onset and increased severity. and/or elevated total IgE levels AEP typically recurs in subsequent pregnancies due to the ICP usually starts in the third trimester of atopic background. pregnancy but in about 25% of cases it may appear as early as the late second trimester of In the present study, AEP constituted the main pregnancy, or even much earlier, in the first pregnancy specific dermatoses with an trimester of pregnancy (in 10% of cases).7,8 incidence of 68.4% in patients presenting with pregnancy specific dermatoses. According to Pruritus is the commonest manifestation in Ambros-Rudolf,1 AEP has an incidence of at ICP, skin involvement in the form of least 50%. Though we found about half of the excoriated papules, scratch marks, nodules of patients diagnosed with AEP had raised IgE prurigo being secondary to pruritus. Jaundice, level but this cannot be considered as the sole found only in 10% of cases due to concomitant indicator of atopy, history and clinical extrahepatic cholestasis,9 complicates the most manifestations have to be taken into account. severe and prolonged episodes. Among the STDs, viral infections i.e. PEP (also called pruritic urticarial papules and molluscum contagiosum, herpes simplex and plaques of pregnancy) is a benign, self-limited, condyloma acuminata were the most common. pruritic, papulo-urticarial inflammatory One patient was HIV positive. Shivkumar and disorder that usually affects the primigravida Madhavmurty6 also found condyloma in the last trimester of pregnancy or immediate acuminata to be the most common STD in postpartum period. It is generally accepted that their study. PEP and pruritic urticarial papules and plaques of pregnancy are identical disorders, which are Among patients with pruritus and vaginal exclusively related to pregnancy. The discharge, vaginal candidiasis was the most

49 Journal of Pakistan Association of Dermatologists. 2014;24 (1):46-50. common (30%). Vaginal candidiasis ranged up References to 30% according to several literatures.1,5,6 1. Ambros-Rudolph CM, Mullegger RR, Scabies was the most common non STD other Vaughan-Jones SA et al. The specific dermatoses of pregnancy revisited and dermatoses in a study by Shivkumar and reclassified: Results of a retrospective Madhavmurty.6 Our study also supported this two-center study on 505 pregnant patients. finding. This, as suggested, was due to the J Am Acad Dermatol. 2006;54:395-404. 2. Holmes RC, Black MM. The specific poor socio-economic status of the patients dermatoses of pregnancy. J Am Acad attending the out-patient department. Dermatol. 1983;8:405-12. 3. Shornick JK. Dermatoses of pregnancy. Semin Cutan Med Surg. 1998;17:172-81. Pregnancy may bring about a wide range of 4. Roger D, Vaillant L, Fignon A et al . physiological and non-physiological changes. Specific pruritic dermatoses of pregnancy: In our study we have emphasised mainly on A prospective study of 3192 women. Arch the dermatoses specific to pregnancy, Dermatol. 1994;130:734-9 5. Kumari R, Jaisankar TJ, DM. A clinical dermatoses associated with pregnancy which study of skin changes in pregnancy. Indian include STDs and non STD other dermatoses. J Dermatol Venereol Leprol. 2007;73:141. Pruritus represents the leading symptom in the 6. Shivakumar V, Madhavamurthy P. Skin in pregnancy. Indian J Dermatol Venereol majority of dermatoses of pregnancy and it Leprol. 1999;65:23-5. should never be ignored or neglected. It is very 7. Kroumpouzos G. Intrahepatic cholestasis important for the physician to identify the of pregnancy. J Eur Acad Dermatol Venereol. 2002;16:316-8. causes of pruritus in pregnancy and also the 8. Ambros-Rudolph C. Intrahepatic STDs missed out in routine serological cholestasis of pregnancy. In: Black MM, screening during pregnancy. As some of the Ambros-Rudolph C, Edwards L et al., editors. Obstetric and Gynaecologic pregnancy specific dermatoses are associated Dermatology. 3rd ed. London: Mosby, with poor fetal prognosis they need to be 2008. P.57-63. identified by the clinician to take adequate 9. Riosecco AJ, Ivankovic MB, Manzur A et al. Intrahepatic cholestasis of pregnancy: a precaution to avoid any catastrophe. Only one retrospective case-control study of patient included in our study had premature perinatal outcome. Am J Obstet Gynecol. labour at thirty-five weeks of pregnancy. The 1994:170:890-5. 10. Rudolph C, Al-Fares S, Vaughan-Jones S patient should be alerted regarding the et al. Polymorphic eruption of pregnancy: recurrence of diseases like PG, ICP and clinicopathology and potential trigger impetigo herpetiformis in subsequent factors in 181 patients. Br J Dermatol. 2006;154:54-60. pregnancies.

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