Dermatoses of Pregnancy

What is Dermatoses of Pregnancy ?

Pregnant women often experience skin changes due to three main factors: changes in hormone levels, an increase in the amount of blood in their veins, and pressure on the skin from the growing baby. Examples of common skin changes include dark spots (melasma), spider veins, redness of the hands, and stretch marks.

That being said, there are also several specific skin conditions that can happen during pregnancy or after childbirth. These can range from minor, temporary issues to more serious, long-lasting conditions. These skin issues can cause discomfort or stress, and might also carry risks for both the mother and her growing baby.

These specific pregnancy-related skin conditions include Pemphigoid gestationis (PG), Polymorphic eruption of pregnancy (PEP), Intrahepatic cholestasis of pregnancy (ICP), Atopic eruption of pregnancy (AEP), and Pustular psoriasis of pregnancy (PPP).

What Causes Dermatoses of Pregnancy ?

Pemphigoid gestationis (PG) is a condition where the body mistakenly creates antibodies against specific skin proteins. It starts with an immune response in the placenta, causing the body to produce antibodies against unusual placental proteins. These antibodies also attach to proteins in the skin’s lower layer, leading to inflammation and subsequently the separation of the skin’s layers. This results in the formation of tight skin blisters, a key characteristic of pemphigoid gestationis.

Polymorphic eruption of pregnancy (PEP), previously known as pruritic urticarial papules and plaques of pregnancy (PUPPP) is a skin rash that usually starts in the stretch marks on the belly. What exactly causes it isn’t well-known, but it might be related to damage to the skin’s collagen due to the stretching of the abdomen. This triggers an inflammatory response that could spread to collagen in other body areas. PEP often appears in women with multiple pregnancies or those who gained substantial weight during pregnancy. Another theory suggests that it could be the woman’s immune response to the fetus’s proteins in her bloodstream.

Intrahepatic cholestasis of pregnancy (ICP) happens due to the accumulation of bile salts within the liver cells leading to high levels of these salts in the blood. Though not fully understood, it is thought to be due to a combination of genetic, environmental, and hormonal factors. Genetic factors could include mutations in proteins that transport bile, while environmental factors could be low vitamin D levels and selenium intake. Hormonal factors include high levels of estrogen and progesterone during pregnancy, which can interfere with bile movement in and out of liver cells.

Atopic eruption of pregnancy (AEP) commonly appears in pregnant women with a history of atopy, a group of allergic conditions that includes hay fever, asthma, and eczema. It most likely happens because of changes in the maternal immune response during pregnancy. There’s a reduction in cell-mediated immune function and an increase in antibody production. This shift in immune response, specific to pregnancy, worsens the existing imbalance in people with atopy, leading to the itching and skin rashes typical of atopic eruption of pregnancy.

Last but not least, Pustular psoriasis of pregnancy (PPP), also known as impetigo herpetiformus, is thought to be a variant of pustular psoriasis that occurs outside of pregnancy.

Risk Factors and Frequency for Dermatoses of Pregnancy

There are several skin conditions that can develop during pregnancy, and they’re seen in women of childbearing age all around the world. Here’s what you should know about these conditions:

Pemphigoid gestationis (PG) is quite rare, affecting 1 in 50,000 to 1 in 60,000 pregnancies. The biggest risk factor for PG is having had the condition in a previous pregnancy.
Polymorphic eruption of pregnancy (PEP) affects 1 in 200 pregnancies. It usually develops in the third trimester, particularly in women having their first child, and can also show up after childbirth. This condition is more common when the baby is a boy.
Intrahepatic cholestasis of pregnancy (ICP) varies in frequency depending on your ethnic background. It’s most common in Araucanian Indian women from Chili (28%). In Europe, it occurs in less than 1.5% of pregnancies, and in the United States, it ranges from 0.32% in white groups up to 5.6% in Hispanic groups. Risk factors for ICP include personal or family history of ICP, liver and gallbladder diseases, and older maternal age.
Atopic eruption of pregnancy (AEP) is the most frequently reported skin disorder during pregnancy, making up half of all such conditions. Most AEP cases appear early on, in the first trimester.
Pustular psoriasis of pregnancy (PPP) or impetigo herpetiformus is very rare and usually seen in the third trimester, especially in women having their first child.

Signs and Symptoms of Dermatoses of Pregnancy

If you notice a new rash during your pregnancy, it’s important to get it checked out. A doctor will need to examine you to determine if the rash poses any risks to you or your baby. This checkup usually involves a medical history review, including information about previous pregnancies and any family health issues. The doctor may also ask specific questions about the rash, such as when it first appeared and if you’re experiencing any other symptoms. They might do a detailed examination of your skin and may even do a skin biopsy. Depending on what the doctor finds, they may also need to do some lab tests.

There are several types of rashes that can occur during pregnancy:

Pemphigoid Gestationis (PG): This is a rash that usually appears during the second or third trimester of pregnancy. The main symptom is severe itching. You may notice small raised bumps and more solid areas of skin, called plaques, on your abdomen and back. The rash often begins around your belly button and can spread to your trunk and limbs. Luckily, your face and the inside of your mouth are usually not affected. The time between when the rash appears and when fluid-filled bumps, or bullae, form can range from a few days to 4 weeks. These bumps typically go away on their own a few weeks before you give birth. However, they can come back once you’ve delivered. A minor percentage of patients might experience a recurrence during future pregnancies or while on birth control pills.
Polymorphic Eruption of Pregnancy (PEP): This rash often shows up during the third trimester. It’s characterized by itchy skin changes that involve the streak-like lines on the belly, or ‘striae.’ This rash spares the area around the belly button. The irritated skin may be surrounded by lighter skin areas, giving them a bull’s-eye appearance.
Intrahepatic Cholestasis of Pregnancy (ICP): ICP often appears in the second or third trimester. Its main symptom is itching, which may be worse at night and often starts on the palms and soles of the hands and feet. Rather than a visible rash, you might see secondary skin changes like scratch marks, raw areas, and scabs. In some cases, patients may also experience yellowing of the skin and eyes (jaundice), pale stools, and fatty, foul-smelling stools (steatorrhea). ICP is known to repeat in subsequent pregnancies.
Atopic Eruption of Pregnancy (AEP): AEP can appear in the first or second trimester and is associated with severe itching. If you have this condition, you might notice small groups of red bumps or breakouts on your limbs and trunk. You can also have eczema-like breakouts on your face, neck, upper chest, and the insides of your limbs. In many cases, patients with AEP have a personal or family history of allergies or asthma.
Pustular Psoriasis of Pregnancy (PPP): This condition is not common, but when it does arise, it is usually seen in the third trimester of pregnancy. It presents as itchy, red, raised skin patches that eventually develop pus-filled blisters along their edges. These occur primarily in skin folds, although it may spread to affect the trunk and limbs. Other symptoms can occur as well, such as nausea, vomiting, diarrhea, fever, loss of appetite, swollen glands, fatigue, and in severe cases, seizures.

Remember, if you notice anything unusual happening to your skin during your pregnancy, be sure to get in touch with a healthcare professional.

Testing for Dermatoses of Pregnancy

Pemphigoid gestationis (PG), a skin condition during pregnancy, is typically diagnosed by taking a piece of the skin for testing – a procedure known as biopsy. Sometimes, a method called enzyme-linked immunoassay, which detects certain antibodies in a mother’s blood, can be utilized as well.

Another skin condition during pregnancy, Polymorphic eruption of pregnancy (PEP), is usually diagnosed based on its symptoms and the patient’s overall history. In rare cases, a skin biopsy might be needed. PEP doesn’t present with fluid-filled blisters on the skin, unlike some other skin conditions.

It can be challenging to distinguish between PG and PEP due to their similar appearances. Despite this, it’s crucial to tell them apart as PEP doesn’t cause complications in pregnancy, whereas PG could potentially lead to an inefficient placenta. In locations lacking certain testing methods, a scoring system could help distinguish these two conditions.

Intrahepatic cholestasis of pregnancy (ICP), a liver condition that happens during pregnancy, is connected to increased levels of certain components in the blood called total bile acids. If these acids exceed a certain level, the condition is considered severe. Other tests may also show abnormal levels of certain substances like bilirubin and liver enzymes. An ultrasound of the liver can help rule out other causes of these abnormal blood levels.

Atopic eruption of pregnancy (AEP) is a skin condition that is often diagnosed based on its symptoms. However, a skin biopsy could be performed to rule out other conditions. Unfortunately, there are no definitive criteria for identifying AEP.

Pustular psoriasis of pregnancy (PPP), another skin condition, is often diagnosed by means of a skin biopsy. The biopsy will generally show specific types of lesions and blisters formed by a particular type of white blood cell known as neutrophils. The condition typically affects about 56% of the skin surface.

Currently, only cholestasis of pregnancy and pemphigoid gestationis have specific diagnostic tests available.

Treatment Options for Dermatoses of Pregnancy

Pemphigoid gestationis (PG): The main aim of treating PG is to lessen itching and reduce blister formation. The go-to treatment involves topical steroid creams such as fluocinonide 0.05% or clobetasol propionate 0.05%. Oral antihistamines, for example, 10 mg of loratadine daily, may help to alleviate itching. If creams don’t give the desired result, systemic corticosteroids may be required. Other treatments that have been used include intravenous immune globulin, azathioprine, and dapsone. Rituximab is also utilized for treating postpartum flares.

Polymorphic eruption of pregnancy (PEP): The main goal with PEP is to alleviate itching. These skin lesions often clear up on their own in 4 to 6 weeks. Topical steroids and oral antihistamines are typically used for treatment. If topical treatments aren’t satisfactory, a short course of systemic corticosteroids may be used.

Intrahepatic cholestasis of pregnancy (ICP): Ursodeoxycholic acid (UDCA) is currently the most effective treatment for ICP, and it significantly improves itching for mothers. Other treatment options are oral antihistamines, S-adenosyl-l-methionine, and rifampin. If the bile acid levels reach higher than 100 micromoles/L, delivery is recommended at 36 weeks of pregnancy due to the increased risk of stillbirth.

Atopic eruption of pregnancy (AEP): Initial treatments include topical therapies to reduce itching and relieve dryness. Topical steroids may be used and oral corticosteroids may be needed if initial treatments aren’t successful. The use of light therapy and medication like cyclosporin A and azathioprine can be considered if the benefits outweigh the possible risk to the baby.

Pustular psoriasis of pregnancy (PPP): Typically, PPP is treated with prednisolone, a systemic corticosteroid, 15 mg to 30 mg daily. If necessary, the dose can be increased. Other medications such as dapsone, H1-receptor antagonists, and colchicine have also been tested. Delivery is curing, so it can be considered, especially when the due date is close and the disease doesn’t respond to other treatments.

If a pregnant woman develops a skin condition, it’s crucial to correctly identify the problem to provide appropriate treatment. Here are some possible skin issues the doctor might need to consider:

Acute urticaria (Hives)
Contact dermatitis (Skin irritation caused by contact with certain substances)
Chronic urticaria (Long-lasting hives)
Drug eruptions (Rashes triggered by a medication)
Erythema multiforme (A rare skin disorder with circular patches)
Insect bites
Gallstones
Problems with the gallbladder such as cholecystitis (inflammation of the gallbladder) or cholangitis (inflammation of the bile ducts)
Hepatitis (Inflammation of the liver)
Acute fatty liver of pregnancy (A serious liver condition that can occur during pregnancy)
Atopic dermatitis (Eczema)
Scabies (A contagious skin condition caused by mites)
Folliculitis (Inflammation of the hair follicles)

Doctors use this list when diagnosing a patient to ensure they make the right diagnosis and can provide the most effective treatment.

What to expect with Dermatoses of Pregnancy

Pemphigoid gestationis, commonly known as PG, often reappears in future pregnancies. Around half to 70% of women experience this, and it usually starts earlier and is more severe the second time around. Although rare, it can potentially lead to premature birth and slow fetal growth. It tends to go away after childbirth, but there is a high chance (75%-85%) of it coming back during postpartum.[1]

Pruritic eruption of pregnancy, also known as PEP, typically stays for about 3 to 6 weeks after the baby is born.[1]

Intrahepatic cholestasis of pregnancy, or ICP, is a condition only witnessed during pregnancy, which usually gets better on its own after childbirth. However, it can potentially pose some risks to the newborn, including premature birth and in severe cases, even death.[11]

Atopic eruption of pregnancy (AEP) doesn’t lead to harmful effects on the mother or the baby. It’s primarily characterized by uncomfortable and potentially disruptive itching.

Pustular psoriasis of pregnancy, known as PPP, may increase the risk of fetal death due to a reduction in blood flow to the placenta. In mothers, it may cause convulsions due to high calcium levels. If it reoccurs in later pregnancies, it may start earlier each time. It’s also worth noting that the use of birth control pills may trigger a flare-up of this condition.[1]

Possible Complications When Diagnosed with Dermatoses of Pregnancy

Pemphigoid gestationis (PG) is a condition that can affect pregnancy. It has been linked to slow fetal growth and early birth. PG can also appear in newborns, showing up in about 10-13% of cases. When this happens, the infant typically shows mild blisters that clear up on their own within a few weeks after birth.

Pruritic eruption of pregnancy (PEP) is a condition that causes itchy skin during pregnancy. It is not associated with any negative effects on the mother or the baby, and it usually doesn’t appear again in future pregnancies.

Intrahepatic cholestasis of pregnancy (ICP) is a liver condition which can lead to poor outcomes for the baby. Some of the risks to the baby with ICP include premature birth, breathing difficulties, and stained amniotic fluid. The risk of stillbirth increases, particularly when bile acid levels in the mother are above 100 micromoles per liter.

Atopic eruption of pregnancy (AEP) often occurs during multiple pregnancies. There are no associated risks to either the mother or the baby.

Pustular psoriasis of pregnancy (PPP) is associated with:

Low maternal calcium levels, which may cause confusion, seizures, or muscle spasms
Fluid loss and dehydration
Increased likelihood of infections, which can lead to bloodstream infections

PPP may appear again in future pregnancies, usually at an earlier stage and with more severity. It can also come back during menstruation or when taking birth control pills. Other complications linked to PPP include early labor, fetal death, slowed growth in the fetus, early rupture of the amniotic sac, and fetal death due to insufficient blood flow to the placenta.

Preventing Dermatoses of Pregnancy

The first steps to ensuring the best possible results for patients with certain skin conditions during pregnancy include identifying the condition, getting the correct diagnosis, and providing effective treatment for the symptoms. Enhancing symptom relief and educating patients about their particular diagnosis can lead to better results for those dealing with these pregnancy-related skin conditions. Consulting with a skin doctor (dermatologist) can offer a further expert review to refine treatment methods and outcomes. It’s essential to apply the right treatment methods to reduce and prevent intense itching and possible risks to pregnancy and newborn health. Educating patients about the chances of these conditions reoccurring in future pregnancies can aid in family planning decisions.

Frequently asked questions

Dermatoses of Pregnancy refers to a range of specific skin conditions that can occur during pregnancy or after childbirth. These conditions can vary in severity and duration, and may cause discomfort or stress for the mother. Some examples of dermatoses of pregnancy include Pemphigoid gestationis (PG), Polymorphic eruption of pregnancy (PEP), Intrahepatic cholestasis of pregnancy (ICP), Atopic eruption of pregnancy (AEP), and Pustular psoriasis of pregnancy (PPP).

Dermatoses of Pregnancy is quite common, affecting 1 in 200 pregnancies for Polymorphic eruption of pregnancy (PEP), and varying in frequency depending on ethnic background for Intrahepatic cholestasis of pregnancy (ICP).

The signs and symptoms of Dermatoses of Pregnancy include: - Severe itching - Small raised bumps and solid areas of skin (plaques) on the abdomen and back - Rash starting around the belly button and spreading to the trunk and limbs - Fluid-filled bumps (bullae) forming on the skin - Itchy skin changes involving streak-like lines on the belly (PEP) - Lighter skin areas surrounding irritated skin, giving a bull's-eye appearance (PEP) - Itching starting on the palms and soles of the hands and feet (ICP) - Secondary skin changes like scratch marks, raw areas, and scabs (ICP) - Yellowing of the skin and eyes (jaundice), pale stools, and fatty, foul-smelling stools (ICP) - Small groups of red bumps or breakouts on the limbs and trunk (AEP) - Eczema-like breakouts on the face, neck, upper chest, and insides of the limbs (AEP) - Itchy, red, raised skin patches with pus-filled blisters along the edges (PPP) - Other symptoms of PPP can include nausea, vomiting, diarrhea, fever, loss of appetite, swollen glands, fatigue, and in severe cases, seizures. If any unusual skin changes occur during pregnancy, it is important to consult a healthcare professional for proper evaluation and diagnosis.

The doctor needs to rule out the following conditions when diagnosing Dermatoses of Pregnancy: - Acute urticaria (Hives) - Contact dermatitis (Skin irritation caused by contact with certain substances) - Chronic urticaria (Long-lasting hives) - Drug eruptions (Rashes triggered by a medication) - Erythema multiforme (A rare skin disorder with circular patches) - Insect bites - Gallstones - Problems with the gallbladder such as cholecystitis (inflammation of the gallbladder) or cholangitis (inflammation of the bile ducts) - Hepatitis (Inflammation of the liver) - Acute fatty liver of pregnancy (A serious liver condition that can occur during pregnancy) - Atopic dermatitis (Eczema) - Scabies (A contagious skin condition caused by mites) - Folliculitis (Inflammation of the hair follicles)

The types of tests needed for Dermatoses of Pregnancy include: 1. Biopsy: A skin biopsy is often performed to diagnose conditions like pemphigoid gestationis (PG) and pustular psoriasis of pregnancy (PPP). This involves taking a piece of the skin for testing. 2. Enzyme-linked immunoassay: This method can be utilized to detect certain antibodies in a mother's blood, which can help diagnose pemphigoid gestationis (PG). 3. Scoring system: In locations lacking certain testing methods, a scoring system can be used to help distinguish between different dermatoses of pregnancy. 4. Blood tests: For conditions like intrahepatic cholestasis of pregnancy (ICP), blood tests are performed to measure levels of total bile acids, bilirubin, and liver enzymes. 5. Ultrasound: An ultrasound of the liver may be done to rule out other causes of abnormal blood levels in cases of intrahepatic cholestasis of pregnancy (ICP). It's important to note that not all dermatoses of pregnancy require specific diagnostic tests, and some conditions may be diagnosed based on symptoms and patient history.

Dermatoses of Pregnancy are treated based on the specific condition. Pemphigoid gestationis (PG) is typically treated with topical steroid creams and oral antihistamines, with systemic corticosteroids as a possible option. Polymorphic eruption of pregnancy (PEP) is usually treated with topical steroids and oral antihistamines, with systemic corticosteroids as a secondary option. Intrahepatic cholestasis of pregnancy (ICP) is treated with Ursodeoxycholic acid (UDCA) as the most effective treatment, along with other options such as oral antihistamines. Atopic eruption of pregnancy (AEP) is initially treated with topical therapies and topical steroids, with oral corticosteroids and other medications considered if necessary. Pustular psoriasis of pregnancy (PPP) is typically treated with prednisolone, with other medications also tested. Delivery can be considered for PPP when the due date is close and other treatments are not effective.

When treating Dermatoses of Pregnancy, there can be potential side effects associated with the different treatment options. Here are some possible side effects: - Topical steroid creams (fluocinonide 0.05% or clobetasol propionate 0.05%): Potential side effects include skin thinning, discoloration, and stretch marks. - Oral antihistamines (loratadine): Possible side effects may include drowsiness, dry mouth, and dizziness. - Systemic corticosteroids: Side effects can include weight gain, increased blood sugar levels, mood changes, and increased risk of infection. - Intravenous immune globulin: Possible side effects may include headache, fever, and allergic reactions. - Azathioprine: Potential side effects include nausea, vomiting, and increased risk of infection. - Dapsone: Side effects can include anemia, liver problems, and skin discoloration. - Rituximab: Possible side effects may include infusion reactions, infections, and low blood cell counts. - Ursodeoxycholic acid (UDCA): Potential side effects include diarrhea, nausea, and abdominal pain. - S-adenosyl-l-methionine: Side effects can include gastrointestinal upset and allergic reactions. - Rifampin: Possible side effects may include nausea, vomiting, and liver problems. - Cyclosporin A: Potential side effects include high blood pressure, kidney problems, and increased risk of infection. - Prednisolone: Side effects can include weight gain, increased appetite, and mood changes. - Dapsone, H1-receptor antagonists, and colchicine: Possible side effects may include gastrointestinal upset, headache, and allergic reactions. It is important to note that the benefits of these treatments should be weighed against the potential risks to the mother and baby. It is recommended to consult with a healthcare professional for personalized advice and monitoring during treatment.

The prognosis for dermatoses of pregnancy varies depending on the specific condition: - Pemphigoid gestationis (PG): It often reappears in future pregnancies and can potentially lead to premature birth and slow fetal growth. It tends to go away after childbirth, but there is a high chance of it coming back during postpartum. - Polymorphic eruption of pregnancy (PEP): Typically stays for about 3 to 6 weeks after the baby is born. - Intrahepatic cholestasis of pregnancy (ICP): Usually gets better on its own after childbirth, but it can potentially pose risks to the newborn, including premature birth and, in severe cases, even death. - Atopic eruption of pregnancy (AEP): Doesn't lead to harmful effects on the mother or the baby, but it can cause uncomfortable and potentially disruptive itching. - Pustular psoriasis of pregnancy (PPP): May increase the risk of fetal death and can cause convulsions in mothers. If it reoccurs in later pregnancies, it may start earlier each time.

A dermatologist.

Pregnancy Skin Problems And Treatments