Expert Commentary

6 skin disorders of pregnancy: A management guide

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You can handle most of these dermatoses, but some require referral


 

References

The dermatoses of pregnancy are a poorly understood group of conditions. Their only common feature is a tendency to appear during pregnancy.

Only three of these conditions are considered unique to pregnancy, however; the others are probably exacerbations of preexisting conditions triggered by pregnancy. There isn’t even complete agreement on what to call them. To make management even more complex, two patients—mother and fetus—need to be considered in decisions about care.

Who manages these patients is another matter. These conditions fall into overlapping areas of health care, where family physicians, obstetricians, and dermatologists all might have some share in responsibility for diagnosis and treatment. You need to be sufficiently familiar with these conditions so that you can differentiate those that can be treated symptomatically and those that require referral to a specialist. This review and the handy TABLE, will help you toward that end.

TABLE

Skin disorders of pregnancy: What you’ll see, how to treat

DisorderLesionsDiagnosis and sequelaeTreatmentRecurrence
Pemphigoid gestationis3,5Erythematous papules that progress to vesicles and bullae, in a periumbilical distribution that spares the face, palms, and soles
  • Mean onset at 21 weeks; postpartum in 20% of cases
  • Direct immunofluorescence microscopy shows linear C3 deposition
  • Newborn may be small for gestational age, but no associated morbidity or mortality
  • Oral corticosteroids, 20–60 mg/d OR
  • Intravenous immunoglobulin OR
  • Cyclosporine in refractory cases
Frequent; skips a pregnancy 8% of the time
Pruritic urticarial papules and plaques of pregnancy8-10Urticarial papules and plaques on the abdomen, legs, arms, buttocks, chest, and back
  • Usually presents after 34th week but can present at any stage
  • Diagnosis is clinical
  • No increase in fetal morbidity or mortality
Topical corticosteroids and antihistaminesUncommon
Intrahepatic cholestasis of pregnancy14,17,19-22No primary lesions; secondary excoriations in any area that the patient can reach
  • Onset after 30th week in 80% of patients
  • Strongly indicated by serum bile acid level >11 µmol/L
  • Increased fetal mortality
Ursodeoxycholic acid, 450-1,200 mg/dFrequent
Eczema of pregnancy/pruritus of pregnancy4,10,24Grouped, crusted erythematous papules, patches, and plaques, most often on extensor surfaces of the arms and legs or on the abdomen
  • Onset at any point in pregnancy
  • Clinical diagnosis
  • No increase in fetal morbidity or mortality
Symptomatic treatment with topical corticosteroids or antihistaminesFrequent
Acute pustular psoriasis of pregnancy26-28Erythematous plaques and pustules that start on the inner thighs and groin and spread to the trunk and extremities
  • Onset at any point in pregnancy
  • Clinical diagnosis by appearance of lesions and association with systemic illness
  • Increased incidence of miscarriage, stillbirth, and maternal mortality
  • Prednisone, 15–60 mg/d OR
  • Cyclosporine, 100 mg twice daily, in refractory cases
Management of associated hypocalcemia
Unknown
Pruritic folliculitis of pregnancy24,28Papules and pustules concentrated around hair follicles, often beginning on the abdomen and spreading to the extremities
  • Onset most often in third trimester
  • Clinical diagnosis
  • No associated fetal morbidity or mortality
Topical corticosteroidsUnknown

DERMATOSES UNIQUE TO PREGNANCY

1. Pemphigoid gestationis

Years ago, this disorder was referred to as herpes gestationis, because the lesions are herpetiform. Pemphigoid gestationis (PG) has an incidence of approximately 1 in 10,000 pregnancies.1,2 Time of onset is usually about the 21st week of gestation, although, in about 20% of cases, the eruption appears immediately postpartum.3

Presentation. The disease usually begins with urticarial papules and plaques around the umbilicus and extremities. Bullous lesions tend to develop as the disease progresses, and are often not present on first presentation (FIGURE 1). Lesions of PG tend to spare the face, palms, and soles. Mucosal surfaces are involved in fewer than 20% of cases. In about 75% of cases, PG flares around the time of delivery, regressing spontaneously after the baby is born.4


FIGURE 1 Pemphigoid gestationis

As the disease progresses, bullous lesions tend to develop.

Pathophysiology. The pathophysiology of PG is nearly identical to that of bullous pemphigoid, a blistering skin disorder seen more often in elderly patients.5 Pemphigoid disorders are immune processes, involving an immunoglobulin G (IgG) immune response directed at a 180-kDa hemidesmosome transmembrane glycoprotein. This protein is the common target in several subepidermal blistering diseases.

Differential diagnosis. Disorders that may have some of the same features as PG include pruritic urticarial papules and plaques of pregnancy (PUPPP), erythema multiforme, intrahepatic cholestasis of pregnancy (ICP), contact dermatitis, and drug reactions.

Diagnosis. A biopsy is necessary for definitive diagnosis. Direct immunofluorescence (DIF) microscopy of a sample of perilesional skin can show tissue-bound immunoreactants. Linear deposition of the complement component protein C3 along the basement membrane zone is diagnostic for PG. IgG is also deposited about 40% of the time.3

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