SAN FRANCISCO — Many women experience minor skin conditions such as pruritus, stretch marks, and melasma during pregnancy, but several serious skin diseases can emerge.
When it comes to treating skin conditions in pregnant women, it is important to remember that there is a great deal of variation in how these patients experience symptoms, Dr. Kristin M. Leiferman explained at a meeting sponsored by Skin Disease Education Foundation.
Many mothers-to-be will endure some degree of skin discomfort such as itching, rather than take medications, she said. “But pregnant women need to be monitored closely for secondary problems associated with skin disorders, including cutaneous infection, fluid balance problems, excessive blistering or erosion, and lack of sleep due to discomfort from itching.”
Dr. Kristin M. Leiferman of the University of Utah, Salt Lake City, reviewed several dermatoses of pregnancy, including:
▸ Polymorphic eruption of pregnancy/pruritic urticarial papules and plaques of pregnancy (PEP/PUPPP). The pathogenesis of PEP/PUPPP remains unknown but many theories persist, including those citing the role of hormones, fetal DNA, and placental factors, Dr. Leiferman said. The condition has a nonspecific inflammatory pattern, and there may be perivascular lymphocytic infiltration in the upper and middle dermis.
The differential diagnosis for PEP/PUPPP should start by ruling out scabies, Dr. Leiferman noted. Once scabies is ruled out, a dermatologist's differential should include pemphigoid gestationis, atopic eruption of pregnancy, contact dermatitis, drug eruption, erythema multiforme, and pityriasis rosea, she said.
▸ Pemphigoid gestationis. This condition is an autoimmune disorder that typically begins with urticaria or blistering around the umbilicus, Dr. Leiferman noted. Until or unless blistering occurs, this condition may be difficult to distinguish from PEP/PUPPP, she said, although PEP/PUPPP does not usually involve the area immediately around the umbilicus.
Pemphigoid gestationis may occur during or immediately after pregnancy, or it can occur with hormone use. The condition can present with urticarial, arch-shaped plaques in addition to dermatitis and blisters. The current evidence suggests that pemphigoid gestationis occurs when the protection of a fetus from the mother's immune response breaks down. When diagnosing pemphigoid gestationis, be sure to rule out varicella and pemphigus vulgaris, Dr. Leiferman emphasized.
▸ Cholestasis of pregnancy. This condition is characterized by a sudden onset of itching, first on the palms and soles, and then the itching becomes generalized. Cholestasis of pregnancy does not include primary skin lesions, but it can have serious effects for both mother and fetus. It may cause gallstones or jaundice in the mother, and increased levels of serum bile salts can enter the fetal circulation and cause a reduction in the level of oxygen in the placenta. The oxygen dip can lead to cardiac depression and increase the risk of prematurity, fetal distress, and stillbirth.
▸ Atopic eruption of pregnancy. This condition encompasses three previously recognized distinct skin conditions—prurigo of pregnancy, pruritic folliculitis of pregnancy, and eczema of pregnancy, Dr. Leiferman explained. Most patients have atopic dermatitis, from which the name derives. Studies suggest that approximately half of these patients have signs of eczema and approximately one-third have signs of papules and prurigo.
The histology of atopic eruption of pregnancy is nonspecific, and debate continues as to whether the condition should be considered a distinct dermatosis of pregnancy or an exacerbation of a skin disease with pregnancy, said Dr. Leiferman.
▸ Impetigo herpetiformis. Another disorder previously thought to be a dermatosis of pregnancy is impetigo herpetiformis, now generally regarded as a variant of pustular psoriasis, Dr. Leiferman stated. It rapidly resolves after delivery, but recurrences in subsequent pregnancies are common and are more severe with earlier onset. Neonatal death or stillbirth may result from placental insufficiency. Recurrences with menses can occur for years, she said.
With pregnancy-associated dermatoses, “treatment should be tailored to the symptoms and to the disease with the least amount [of] and least potentially toxic medications that will keep the mother comfortable and the baby safe,” Dr. Leiferman said in an interview.
“Certain pregnancy-associated dermatoses may respond to skin care that helps reduce itching, and to topical medications from which little is absorbed internally,” she explained. By contrast, when the skin is blistered or eroded, more aggressive treatments are needed.
Systemic glucocorticoids, such as prednisone, are the main therapy for pemphigoid gestationis and other severe pregnancy-related skin problems, said Dr. Leiferman. “Their use in pregnancy is well studied, and they generally are tolerated, but they may be associated with placental calcifications and low-birth-weight infants.”
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