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A Clinical Study of Pregnancy-Induced Dermatoses

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A Clinical Study of Pregnancy-Induced Dermatoses Journal of Pakistan Association of Dermatologists . 2016; 26 (1):12-20. Original Article A clinical study of pregnancy-induced dermatoses L. Sowmya Kothamasu, Vinma Shetty, Farzana Najmuddin, Pradyumna R Bhandary, Narendra J Shetty Department of Dermatology, A.J. Institute of Medical Sciences, Kuntikana, Mangalore , Karnataka Abstract Objective To document pregnancy-related dermatoses. Methods A hospital-based observational study was conducted in the dermatology outpatient department of a tertiary care institute. A total of 350 pregnant females were included in the study after taking informed consent. Detailed history including demographic data, chief complaints related to skin, presence of itching, skin lesions, onset in relation to duration of pregnancy, jaundice, vaginal discharge, past or family history of similar lesions, exacerbating factors, associated medical or skin disorders etc. was elicited and recorded. Relevant systemic examination and appropriate investigations were done to confirm diagnosis if required. In all cases with history of pruritus related to specific disorders of pregnancy, liver function tests were done. Data was analyzed using SPSS ver. 20. Results Most common physiological skin changes were pigmentary (98%) followed by striae distensae (76%), glandular changes (15.4%) and vascular (10%). Nail changes were observed in 7 (2%) females. 38 (11%) patients had pregnancy-induced dermatoses. Atopic eczema of pregnancy (49.7%) was the most common condition i.e. 19 patients out of 38 which includes eczema (31.5%), prurigo (13%) and pruritic folliculitis (3.1%). followed by polymorphic eruptions (5.2%) was the most common condition followed by atopic eruptions (19.1%),herpes gestationis and intrahepatic cholestasis were observed in one (2.6%) and two (5.3%) females, respectively. Conclusion Pregnant women are prone to suffer from a wide range of dermatological problems apart from the specific dermatoses of pregnancy. These pruritic dermatoses are unique to the gravid state. A detailed history and awareness of clinical presentation facilitate confirmation of the diagnosis and will direct the most appropriate laboratory evaluation in an effort to minimize maternal and fetal morbidity. In addition, monitoring of liver function deserves special consideration. Keywords Atopic eruptions, intrahepatic cholestasis of pregnancy, polymorphic eruptions, pemphigoid gestationis, pregnancy-induced dermatoses. Introduction and vascular changes, which are due to hormonal effects. Along with this, the pre- Pregnancy is characterized by many existing skin conditions may either improve or physiological skin changes like striae exacerbate in pregnancy due to immunological gravidarum, melasma accompanied by hair, nail changes of pregnancy. As cell-mediated immunity is depressed during pregnancy, it Address for correspondence accounts for increased severity and frequency of Dr. L. SowmyaKothamasu skin infections such as candidiasis. There are, Department of Dermatology, A.J. Institute of Medical Sciences, however, few inflammatory skin dermatoses, Kuntikana, Mangalore, Karnataka which are specific to pregnancy and seen only in Email: [email protected] 12 Journal of Pakistan Association of Dermatologists . 2016; 26 (1):12-20. pregnancy. Though most of these skin of pregnancy, jaundice, vaginal discharge, past dermatoses are benign and resolve in postpartum or family history of similar lesions, exacerbating period, a few can risk the fetal life and require factors, associated medical or skin disorders etc. antenatal surveillance.1 was elicited and recorded. Complete skin examination was done in all cases to study all The dermatoses of pregnancy represent a distinct the physiological changes of skin and its heterogeneous group of pruritic skin disorders appendages. If any specific dermatosis of that can be very distressing for the mother. They pregnancy was present, the morphology of skin include polymorphic eruption of pregnancy lesions, distribution and the sites involved were (PEP), formerly known as pruritic urticarial studied. papules and plaques of pregnancy (PUPPP); pemphigoid gestationis (PG), formerly known as Relevant systemic examination was carried out. herpes gestationis; intrahepatic cholestasis of If any pre-existing skin disease was present, any pregnancy (ICP); and atopic eruption of evidence of exacerbation or remission was pregnancy (AEP).AEP includes eczema of recorded. Appropriate investigations were done pregnancy(EP), prurigo of pregnancy(PP) and to confirm diagnosis if required. Bedside pruritic folliculitis(PF). Whereas PEP and AEP laboratory procedures like Tzanck smear, KOH can be associated with severe pruritus and mount and Gram’s stain were carried out. To discomfort for the mother, PG and ICP are confirm diagnosis skin biopsy and DIF were associated with increased fetal complications. done in a few cases. In all cases with history of The diagnosis and management of these pruritus related to specific disorders of pregnancy-specific disorders can be challenging pregnancy, liver function tests were done. due to their variation in clinical presentation and Results were tabulated and analyzed using SPSS lack of definitive diagnostic tests. Early ver. 20. recognition of these disorders is critical to provide symptomatic care for the mother and Results avoid potential increased fetal risk if the diagnosis is delayed.2 Most common physiological skin changes were pigmentary (98%) followed by striae distensae Methods (76%), glandular changes (15.4%) and vascular (10%). Nail changes were observed in 7 (2%) This hospital-based observationalstudy was females. In pigmentary conditions linea nigra conducted in the dermatology outpatient (86.6%), secondary areola (74.3%) and melasma department of A.J. Institute of Medical Sciences, (44%) were most common. Acne was observed Kuntikana. Ethical Committee clearance was in 38 (11%) while nonpitting edema was present obtained. in 5.7% females ( Table 1 ). Consecutive sampling method was followed and 38 (11%) patients had pregnancy-induced a total of 350 pregnant females, referred from dermatoses. Atopic eruption of pregnancy was obstetrics and gynecology OPD were included in the most common condition seen in 19 patients the study after taking written informed consent. out of(50%) which included eczema (31.5%), Detailed history including demographic data, prurigo (13%) and pruritic folliculitis (3.1%); chief complaints related to skin, presence of followed by polymorphic eruptionin 16 (42.1%) itching, skin lesions, onset in relation to duration patients.Pemphigoid gestationis and intrahepatic 13 Journal of Pakistan Association of Dermatologists . 2016; 26 (1):12-20. Table 1 Distribution of subjects based on Discussion physiological changes in pregnancy (n-350). Physiological changes N (%) Pregnancy is associated with significant Pigmentation 343 (98) Linea nigra 303 (86.6) cutaneous changes, which may range from Secondary areola 260 (74.3) physiological changes of skin to common skin Melasma 154 (44) diseases occurring coincidently with pregnancy, Naevi darkening 1 (0.3) to eruptions seen only during pregnancy or Pigmentary demarcation line 1 (0.3) Striae distensae 266 (76) postpartum period. Complex endocrinologic, Glandular changes 54 (15.4) immunologic, metabolic and vascular changes Acne 38 (10.9) associated with pregnancy influence the skin in Montogmery's tubercule 18 (5.1) various ways. 3 Miliaria 5 (1.4) Vascular changes 35 (10.0) Nonpitting edema of feet 20 (5.7) Physiological cutaneous changes may be seen in Palmar erythema 11 (3.1) almost all the pregnant females. Physiologic skin Spider telangectesia 5 (1.4) changes in pregnancy include changes in Varicosities of legs 1 (0.3) Nail Changes 7 (2.0) pigmentation (in the form of melasma, linea nigra, secondary areola, localized or generalized Table 2 Distribution of subjects based on specific hyperpigmentation), vascular system (such as dermatoses of pregnancy (n=38). palmar erythema, spider angiomas, varicosities), Specific dermatoses of pregnancy N (%) Atopic eruption of pregnancy 19 (50.0) striae distensae and endocrine function, as well Eczema 12 (31.6) as, changes in hair and nails. Prurigo 5 (13.1) Pruritic folliculitis 2 (5.3) Pigmentary alteration was seen in up to 90% of Polymorphic eruption 16 (42.1) 4 Intrahepatic cholestasis of pregnancy 2 (5.3) pregnant women in one of the study. In our Pemphigoid gestationis 1 (2.6) study, pigmentary changes were seen in 98% of cases, of which linea nigra was the most Table 3 Distribution of subjects based on associated common, seen in 86% of cases followed by dermatological disorders (n=38). secondary areola seen in 74% of cases. Kumari Specific dermatoses of pregnancy N (%) et al. 5 Scabies 9 (2.6) reported linea nigra, and secondary areola Acne vulgaris 5 (1.4) in 91.4% and 78.4% of their cases, respectively, Acute urticaria 3 (0.9) which is comparable to our study. Polymorphic light eruption 3 (0.9) Hyperpigmentation is due to elevated serum Discoid eczema 2 (0.6) Herpes simplex 2 (0.6) levels of MSH, estrogen or progesterone. Contact dermatitis 2 (0.6) Estrogen increases the output of melanin by the Psoriasis 1 (0.3) melanocytes and effect of estrogen is augmented Molluscum contagiosum 1 (0.3) by progesterone, resulted from melanin deposition into epidermal and dermal cholestasis of pregnancy were observed in 2 macrophages. (5.3%) and 1 (2.6%) females, respectively (Table 2 ). Melasma was seen in 44% of cases in our study. In most of the cases onset was in
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