- Pruritus gravidarum (also called obstetric cholestasis)
- Obstetric cholestasis (Pruritus gravidarum)
- Herpes gestationis (or pemphigoid gestationis)
- Pruritic urticarial papules and plagues of pregnancy (PUPPP)
- Striae distensae
- Physiological skin changes related to pregnancy
- Dermatoses modified by pregnancy
- Dermatoses caused by pregnancy
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Skin and Pregnancy
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Mild hirsutism. Increased sebum production with acne . Topical treatment like adapalene gel, or benzoyl peroxide 5 - 10% cream. Brittle nails. Increased tendency of sweating with miliaria rubra on trunk. Topical low-potency steroids and/or calamine lotion. Small hemangiomas, vascular spiders . Laser treatment or electro-coagulation. Varicose veins of legs and risk of haemorrhoids . Compressive stockings Edema of face, hands and feet - most pronounced in the morning Gingivial oedema and redness (in up to 80% of pregnant women) Prevented by good oral hygiene Increase of skin infections because of reduction in cell-mediated immunity Candidiasis clotrimazole or miconazole in a cream bases Trichomoniasis metronidazol. Condyloma acuminata never treat with podofyllin; physical removal Herpes simplex topical or systemic treatment Pityrosporum folliculitis on trunk ketoconazole shampoo Scabies permethrin cream Dermatophytosis - treat with topical therapy only - econozale, ketoconazole, lamisil Atopic eczema has a variable course during pregnancy, but the mother often fights eczema of the nipples during breast-feeding and irritant hand eczema postpartum due to increased skin irritation. Topical steroid therapy during pregnancy for eczema, psoriasis or other diseases does not give any risks for the child even though small amounts of the steroids are absorbed. Tacrolimus and pimecrolimus (topical calcineurin-inhibitors used for treatment of atopic eczema) should not be used as no experience exists. However, they are not absorbed and will likely not influence the pregnancy. Dermatoses caused by pregnancy Itching - or pruritus - affects up to 1/5 of pregnant women. An underlying skin disease should be considered including eczema, urticaria, psoriasis, scabies, drug eruptions. Therapy will be according to an eventual diagnosis. Anti-histamines can be tried and do not increase the risk for the child. They are of course most effective for urticarial pruritus. Intrahepatic cholestadid of pregnancy (Pruritus gravidarum) (also called obstetric cholestasis) Between 0.02-2.4% of pregnancies develop itching in the third trimester beginning on the abdomen, but can become widespread. There are no evident cutaneous changes. Liver enzymes often slightly elevated and the patients can be mildly icteric. In one study on 693 women no complication were seen with bile acid level < 40 micromol/L. The pathophysiology is considered to be a mind cholestasis. If present, during several pregnancies it is associated with increased risks of cholelithiasis. Obstetric cholestasis (Pruritus gravidarum) The incidence is higher in Scandinavia, Chile and China, family history in 35 %. Starts in the second half of pregnancy usually in the third trimester.
Pruritus without rash, worse at palms of hands and soles of feet. Mild elevated transaminase < 3 fold very seldom up to 10 fold. Alkaline phosphatates slight increase. Raised gamma-glutamyl transpeptidase (yGT) (about 20 % of cases) Bilirubin mild elevation (less common) Increased (10 to 100 folds) serum bile acid (but normally nok available). Differential Diagnosis: Hepatitis, primary biliary cirrhosis, sclerosing cholangitis, gall stones. Eventually rule out by liver ultrasound, viral serology (for hepatitis A, B and C, EBV, CMV) Liver autoantibodies (for pre-existing liver disease, anti-smooth muscle antibody/chronic active hepatitis, antimitochondrial antibodies/primary/ biliary cirrhosis). Maternal Risk: Postpartum bleeding caused by Vitamin K deficiency Fetal Risk: Stillbirth, risk increases towards term, but does not correlate with maternal symptoms or transaminase levels. Preterm labor and fetal distress, intracranial. Management: Mother counseled concerning possible risk to the fetus and the need for closer surveillance (fetall movements, fetal growth, CTG, liquor volume Doppler), but fetal death seems to be sudden. Regular liver function test including Prothrombin time. Early delivery at 37-38 weeks but in over 1.500 active managed pregnancies 13 of 18 stillbirth happens before 37 weeks. In sever cases such as jaundice delivery should be considered at 36 weeks. Vitamin K 10 mg orally from 32 weeks to reduce the risk of fetal and maternal bleeding, K vitamin to the infant. Treatment: Antihistamine may provide some sedation at wight but no significantly have an impact on pruntus. Topical options: Diprobase ®, Balnium ®, Calamine lotion, cream with mental may provide some relief. Ursodeoxycholic acid (UDCA) (Cholorectiv agent) reduce serum bile acids 1,000 to 1,500 mg daily in 2-3 divided doses. Dexamethasone 12 mg orally daily (few studies). S-adenosylmethionine intravenously (few studies) (not recommended by RCOG). Is rare affecting 1 : 150 000 pregnancies, but well-known because of very severe itching, urticarial or vesiculo-bullous skin lesions (resembling herpes) and linear band of IgG at the basal membrane in the skin - like bullous pemphigoid. It normally starts in the second trimester and will resolve postpartum although this may take several weeks. Topical potent steroid cream combined with antihistamines is the treatment of choice, but may be insufficient so a low dose of systemic steroid is necessary. Pruritic urticarial papules and plagues of pregnancy (PUPPP) This condition is by some regarding as three different diseases (polymorphic eruption of pregnancy, prurigo of pregnancy and pruritic follculitis of pregnancy). However, they do have overlapping clinical symptoms and can for therapeutical reasons be lumped. What is important is that immnofluorescence investigation of a skin biopsy is negative. The condition is common, 1 in 240 pregnancies. The itching starts in third trimester and often in primigravidae, but it can start in the second, too. Clinically there are urticaria, papules and eventually plagues. In some patients a more follicular pattern is prominent. Initial symptoms are on the abdomen, but they can spread to the extremities. Topical steroids and anti-histamines should be tried first. The condition may be related to abnormal weight gains and claimed that the excessive weight gain stretches the abdominal skin leading to the irritation. Striae distensae This is a common phenomenon. There is no good prophylaxis, but routine usage of emollients with a gentle massage of the skin may delay and diminish their development. There is no cure although the use of excimer laser is claimed to promote fibroblast activity. Well-conducted studies are lacking. References: (1) Rook, Wickensson, Ebling. Textbook of Dermatology Ed. 1998. Blackwell. (2) Obstetric Cholestasis. Royal College of Obstrecians and Gynecologists Guideline 43. January 2006 (3) Nielsen Piercy C. Handbook of Obstetric Medicine 2002. Martin Daniel Ltd.
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