Skin Disorders in pregnancy

Dr. Furqan
Physiological skin changes in pregnancy:
Many physiological changes affect skin during pregnancy:
• Melasma: brown, clearly defined patches on the face,
typically on the cheekbones and forehead.
• Darkening of the nipples and external genitals (pubic area).
• Linea nigra: a dark line that appears on the abdomen, running
straight down from the umbilicus. Hyperpigmentation is due to
increased melanocyte stimulating hormone levels
• Striae gravidarum
• Acne can worsen
•Increased pigmentation, especially on the face, areolae, axillae
and abdominal midline, is common.
•Spider naevi affect the face, arms and upper torso, and broad
pink linear striae (striae gravidarum) frequently appear over
the lower abdomen and thighs.
Pruritus without rash affects up to 20% of normal pregnancies,
but liver function tests should always be performed to exclude
obstetric cholestasis.

Pre-existing skin disease:

Some pre-existing skin conditions:
*such as eczema or acne worsen in pregnancy. Atopic eczema
is a common pruritic skin condition affecting 1–5% of the
general population and causes the commonest pregnancy rash.
It can be treated with emollients and bath additives. Hand and
nipple eczema are common postpartum.
*Acne usually improves in pregnancy, but can flare in the third
trimester and acne rosacea often worsens. Oral or topical
erythromycin can be used, but retinoids are contraindicated.
*Psoriasis affects 2% of the population and during pregnancy it
remains unchanged in around 40% of patients, improves in
another 40% and worsens in around 20%. Topical steroids can
still be used, while methotrexate is contraindicated.

Specific dermatoses of pregnancy:

Pemphigoid gestationis: Pemphigoid gestationis (PG) is a
rare pruritic autoimmune bullous disorder. It most commonly
presents in the late second or third trimester with lesions
beginning on the abdomen 50% of the time and progressing to
widespread clustered blisters, sparing the face. Diagnosis is
made by the clinical appearance and by direct
immunofluorescence. Skin biopsy shows complement (C3)
deposition in basement membrane. Once established, the
disease runs a complex course with exacerbations and
remissions, and flares postpartum in 75% of cases. Possible
increased risk of adverse perinatal outcome - monitor fetal
growth and well-being.
Management aims to relieve pruritus and prevent new blister
formation, and is achieved through the use of potent topical
steroids and/or oral prednisolone. There is some association
with preterm delivery and small for gestational age births, but
no increase in pregnancy loss has been reported. PG recurs in
most subsequent pregnancies.
Polymorphic eruption of pregnancy: Polymorphic eruption
of pregnancy (PEP) is a self-limiting pruritic inflammatory
disorder that usually presents in the third trimester and/or
immediately postpartum. PEP often begins on the lower
abdomen involving pregnancy striae, and extends to thighs,
buttocks, legs and arms, while sparing the mucous membranes,
scalp, face, palms, soles and umbilicus. In 70% of patients the
lesions become confluent and widespread, resembling a toxic
erythema. Symptomatic treatment is sufficient and pregnancies
appear to be otherwise unaffected, with no tendency to recur.
Prurigo of pregnancy: Prurigo of pregnancy is a common
pruritic disorder presents as excoriated papules on extensor
limbs, abdomen and shoulders. It is more common in women
with a history of atopy. Prurigo usually starts at around 25–30
weeks of pregnancy and resolves after delivery, with no effect
on the mother or baby. Treatment is symptomatic with topical
steroids and emollients.
Pruritic folliculitis of pregnancy: Pruritic folliculitis (PF) is a
pruritic follicular eruption, with papules and pustules that
mainly affect the trunk, but can involve the limbs. It is similar in
appearance to acne lesions and is sometimes considered a type
of hormonally-induced acne. Its onset is usually in the second
and third trimester, and it resolves weeks after delivery. Topical
steroid treatment is effective.