Pregnancy dermatosis

Specific skin conditions of pregnancy

• heterogeneous group of pruritic inflammatory dermatoses that occur
exclusively during pregnancy and/or in the immediate postpartum
period. These include the following conditions :
1. Pemphigoid gestationis
2. Polymorphic eruption of pregnancy (pruritic urticarial papules and
plaques of pregnancy [PUPPP])
3. Atopic eruption of pregnancy (eczema in pregnancy, prurigo of
pregnancy, pruritic folliculitis of pregnancy)
4. Intrahepatic cholestasis of pregnancy
5. Pustular psoriasis of pregnancy
 Polymorphic eruption of pregnancy
PEP
Definition : is a benign, self-limiting pruritic inflammatory disorder that usually affects
nulliparous women , It is also called PUPPP or Pruritic Urticarial Papules and Plaques
of Pregnancy.
onset : late in the third trimester / immediately postpartum
duration : lasts 4-6 weeks and resolves within 2weeks postpartum

Incidence : PEP is relatively common

Pathophysiology :
It has been hypothesized that stretching may cause damage to connective tissue,
which results in exposure of dermal antigens that trigger an inflammatory response.
PEP is more common with excessive stretching, especially in women with multiple
gestation .
Clinically : PEP typically presents as extremely pruritic, erythematous papules
within striae .

Distribution : Abdominal striae are the most common initial site (with
periumbilical sparing) and may be the only initial site .
The lesions then spread to the extremities, chest, and back and coalesce to
form urticarial plaques .
The face, palms, and soles are usually spared.

Recurrence : Recurrence is rare

Fetal prognosis: PEP poses no increased risk of fetal morbidity
maternal prognosis : no increased risk of morbidity
• Diagnosis — The diagnosis of PEP is usually clinical, based upon
history and physical examination

• treatment : The goal of treatment is relief of symptoms.

topical corticosteroids
Topical antihistamine
 pemphigoid gestations
(herpes gestationis)
• Definition : a rare pregnency-associated autoimmune blistering skin condition.
• Pathophysiology :
• specific immunoglobulin type G (IgG) in the blood, binds to the BP-
180 protein located in the basement membrane of the skin leading to tissue
damage and blistering. The usual function of BP-180 is to help stick
the epidermis and dermis together, so the blister split is in the basement
membrane .
• BP-180 protein is also found in the placenta. It appears it is the placenta, not the
skin, that triggers the autoimmune response in pemphigoid gestations, which
explains why this condition starts in pregnancy
• onset : second and third trimesters of pregnancy or the
immediate postpartum period.
• Duration: spontaneously resolve in the weeks to months following delivery
It may develop during the first pregnancy or appear for the first time in
a multiparous woman.
• Clinically :
Intense pruritus may precede the onset of visible skin lesions.
The rash typically begins as urticarial plaques or papules surrounding the umbilicus ; vesicles may also be
present . Lesions may be seen on the palms and soles but rarely on the face or mucous membranes. The
eruption spreads rapidly and forms tense blisters .
Distribution :
Initially there are periumbilical then it spreads to other parts of the body, including the trunk, buttocks,
and arms. The entire body surface may be involved, but the mucous membranes are usually spared.
Risk of recurrence : high risk of recurrence with subsequent
pregnancies and is often worse, but may also skip pregnancies.

Fetal prognosis : The fetal prognosis is generally good, despite an

increased risk of prematurity and small-for-gestational-age babies due
to mild placental failure. There is no increased risk of miscarriage.
• A few newborns present with blisters (neonatal pemphigoid
gestationis), due to the transplacental passage of maternal IgG
autoantibodies
pemphigoid gestations
• Diagnosis :
• The diagnosis of pemphigoid gestationis is based upon the
combination of clinical findings , examination of a perilesional skin
biopsy for routine histopathology and direct immunofluorescence
(DIF), and measurement of serum levels of anti-BP180 antibodies by
enzyme-linked immunosorbent assay (BP180 NC16A ELISA).
Treatment :
The main goals of treatment of pemphigoid gestationis are to decrease blister
formation, promote the healing of blisters and erosions, and relieve pruritus.
• high-potency topical corticosteroids therapy of localized disease.
• If symptoms are not controlled by topical corticosteroids, then systemic corticosteroids (eg, prednisone
0.5 mg/kg per day) are usually effective

• Severe, persistent postpartum pemphigoid gestationis may require

• higher doses of systemic corticosteroids or alternative
immunosuppressant agents.

• for the symptomatic control of pruritus.

First-generation oral antihistamine chlorpheniramine or second-generation
loratadine and cetirizine
 Atopic eruption of pregnancy
• Definition : is a pruritic disorder of pregnancy that presents as an
eczematous or papular eruption in patients with an atopic background.
• Incidence : AEP is the most common of the pregnancy dermatoses,
accounting for over 50 percent of all cases.
• Onset: It starts during early pregnancy, with 75 percent of cases occurring
before the third trimester,
• Recurrence : recur in subsequent pregnancies.
• Fetal prognosis: not associated with adverse effects on the fetus , but
there's higher risk of developing atopic skin changes later on
• Maternal prognosis: Prognosis is good even in severe cases.
• Diagnosis: The diagnosis is usually clinical, based upon the recognition of
clinical features in a patient with a personal or family history of atopy.
3 types :
1. Eczema
• The vast majority of patients with AEP present with a widespread
eczematous eruption (the E-type AEP) involving the face, neck, and
flexural areas, similar to classic atopic dermatitis .
• However, any area of the skin may be affected.
• Lesions may be eczematous patches or intact or excoriated papules.
Papules can be follicle based, grouped, or scattered . Skin dryness,
which may be severe, is invariably present.
 2. Prurigo of pregnancy

• A less common presentation of AEP is prurigo of

pregnancy, also called P-type AEP, which presents with
erythematous, excoriated nodules or papules on the
extensor surfaces of the limbs and trunk.
• Lesions are grouped and may be crusted or appear
eczematous. The eruption usually resolves in the
immediate postpartum period , although it can persist
for up to three months .
 3. Pruritic folliculitis of pregnancy
• In rare cases, AEP presents as a follicular
papulopustular eruption (formerly known as
pruritic folliculitis of pregnancy). Scattered
follicle-based papules and pustules appear
initially on the abdomen but may spread to
the trunk and extremities and become
generalized.
• The appearance is similar to that of steroid-
induced acne and is only mildly pruritic.
• The eruption typically clears within two
weeks of delivery .
 pustular psoriasis of pregnancy
( impetigo herpetiformis)
• is a rare variant of generalized pustular psoriasis that occurs in pregnency.

• onset : presents during the third trimester but may occur earlier or in the
immediate postpartum period
remits quickly postpartum but may flare after delivery
• Fetal prognosis : Placental insufficiency with severe sequelae such as miscarriage,
fetal growth restriction, or stillbirth may occur
Clinically :
Pruritus is usually absent.
• Pustular psoriasis of pregnancy presents as symmetric, erythematous plaques studded at the
periphery with sterile pustules in a circinate pattern . The plaques then enlarge from the periphery as
the center becomes eroded and crusted . There may be concentric rings of pustules. The pustules are
typically sterile.
• Distribution : The eruption begins in the flexural areas and spreads centrifugally. The trunk and
extremities are usually involved, while the hands, feet, and face are usually spared. Oral and
esophageal erosions may occur.
• onycholysis and pitting

accompanied by constitutional symptoms which may include fever, malaise, nausea and
diarrhea, arthralgias, tachycardia, delirium, and seizures.
• Diagnosis:
• The diagnosis can be made clinically, based upon history and physical
examination
• confirmation by histologic evaluation of a biopsy specimen
• Laboratory findings : Leukocytosis and elevated erythrocyte
sedimentation rate are common. Hypocalcemia may be present,
possibly related to hypoparathyroidism, Albuminuria,
hypoalbuminemia, pyuria, and hematuria occasionally occur.
treatment :
Because of the associated risk for the fetus, prompt institution of treatment is
required for women with PPP. Fetal monitoring with nonstress tests or
biophysical profiles and ultrasound assessment of fetal growth are indicated.
Hypocalcemia must be corrected, when present, and fluid and electrolyte
balance should be maintained. These patients sometimes require early
delivery for relief of symptoms and for fetal safety .
• initial therapy. High-dose systemic corticosteroids, such as prednisolone
 INTRAHEPATIC CHOLESTASIS OF
PREGNANCY
• Intrahepatic cholestasis of pregnancy (ICP, obstetric cholestasis) is the only
pregnancy dermatosis without primary skin changes.
• Patients experience severe, generalized pruritus, predominantly on the palms and
soles, and may present with excoriations secondary to scratching.
• Onset : Late pregnancy after 31 wk .
• Recurrence : 45 – 70% of subsequent pregnancies
• Diagnosis : elevated liver transaminase ,total bile acid > 10 mmol/L , total and
direct bilirubin
• Fetal prognosis : 60% prematurity , intrapartum fetal distress, still birth and
increased risk for neonatal respiratory distress syndrome.
• maternal prognosis is generally favorable, although one study suggests that
affected women have an increased risk of later hepatobiliary disease and
Intra/postpartum h’age .