Dermatological conditions in pregnancy

Question 1

Polymorphic Eruption of Pregnancy also known as:

Answer 1

pruritic and urticarial papules and plaques of pregnancy (PUPPP)

Question 2

what is PUPPP characterised by?

Answer 2

1. Urticarial papules (raised itchy lumps)
2. Wheals (raised itchy areas of skin)
3. Plaques (larger inflamed areas of skin)

(PUPPP) – (U for Umbilical sparing rash)

Question 3

How are PUPPP symptoms managed?

Answer 3

The condition will get better towards the end of pregnancy and after delivery. Management is to control the symptoms, with:

1. Topical emollients
2. Topical steroids
3. Oral antihistamines
4. Oral steroids may be used in severe cases

Question 4

what is atopic eruption of pregnancy/when does it present?

Answer 4

Atopic eruption of pregnancy essentially refers to eczema that flares up during pregnancy. This includes both women that have never suffered with eczema and those with pre-existing eczema.

Atopic eruption of pregnancy presents in the first and second trimester of pregnancy.

Question 5

what are the 2 types of atopic eruption of pregnancy?

Answer 5

1. E-type, or eczema-type: with eczematous, inflamed, red and itchy skin, typically affecting the insides of the elbows, back of knees, neck, face and chest.
2. P-type, or prurigo-type: with intensely itchy papules (spots) typically affecting the abdomen, back and limbs.

Question 6

how is atopic eruption of pregnancy managed?

Answer 6

The condition will usually get better after delivery. Management is with:

1. Topical emollients
2. Topical steroids
3. Phototherapy with ultraviolet light (UVB) may be used in severe cases
4. Oral steroids may be used in severe cases

Question 7

what is melasma?

Answer 7

also known as mask of pregnancy.
- It is characterised by increased pigmentation to patches of the skin on the face. This is usually symmetrical and flat, affecting sun-exposed areas.

Question 8

what is melasma associated with?

Answer 8

Melasma is thought to be partly related to the increased female sex hormones associated with pregnancy.

It can also occur with the combined contraceptive pill and hormone replacement therapy. It is also associated with sun exposure, thyroid disease and family history.

Question 9

how is melasma managed?

Answer 9

1. Avoiding sun exposure and using suncream
2. Makeup (camouflage)
3. Skin lightening cream (e.g. hydroquinone or retinoid creams), although not in pregnancy and only under specialist care
4. Procedures such as chemical peels or laser treatment (not usually on the NHS)

Question 10

what is pyogenic granuloma?

Answer 10

Pyogenic granuloma is also known as lobular capillary haemangioma. This is a benign, rapidly growing tumour of capillaries. It present as a discrete lump with a red or dark appearance.

They occur more often in pregnancy, and can also be associated with hormonal contraceptives.

They can also be triggered by minor trauma or infection.

Question 11

how does pyogenic granuloma usually present?

Answer 11

Pyogenic granuloma present with a rapidly growing lump that develops over days up to 1-2 cm in size, (but can be larger). They often occur on fingers, or on the upper chest, back, neck or head.

They may cause profuse bleeding and ulceration if injured.

Question 12

differentials/treatment for pyogenic granuloma:

Answer 12

Other differentials, such as malignancy, need to be excluded (particularly nodular melanoma). When they occur in pregnancy, they usually resolve without treatment after delivery.

Treatment is with surgical removal with histology to confirm the diagnosis.

Question 13

what is pemphigoid gestationis:

Answer 13

Pemphigoid gestationis is a rare autoimmune skin condition that occurs in pregnancy.

Autoantibodies are created that damage the connection between the epidermis and the dermis. The pregnant woman’s immune system may produce these antibodies in response to placental tissue.

This causes the epidermis and dermis to separate, creating a space that can fill with fluid, resulting in large fluid-filled blisters (bullae).

Question 14

presentation of pemphigoid gestationis:

Answer 14

Pemphigoid gestationis usually occurs in the second or third trimester. The typical presentation is initially with an itchy red papular or blistering rash around the umbilicus, that then spreads to other parts of the body. Over several weeks, large fluid-filled blisters form.

The rash usually resolves without treatment after delivery. It may go through stages of improvement and worsening during pregnancy and after birth. The blisters heal without scarring.

Question 15

treatment of pemphigoid gestationis:

Answer 15

1. Topical emollients
2. Topical steroids
3. Oral steroids may be required in severe cases
4. Immunosuppressants may be required where steroids are inadequate
5. Antibiotics may be necessary if infection occurs

Question 16

risks of pemphigoid gestationis to the baby:

Answer 16

1. Fetal growth restriction
2. Preterm delivery
3. Blistering rash after delivery (as the maternal antibodies pass to the baby)

Question 17

what is prurigo gestationis?

Answer 17

Prurigo of pregnancy is a benign non-specific pruritic (itchy) papular rash that arises during pregnancy

(usually trunks & upper limbs with abdominal sparing).

Question 18

what causes the commonest pregnancy rash:

Answer 18

Atopic eruption of pregnancy: common pruritic condition affecting up to 5% of population

-causes commonest pregnancy rash

Question 19

spot diagnosis

Answer 19

PG: Pemphigoid Gestationis

Question 20

spot diagnosis

Answer 20

PEP (polymorphic eruption of pregnancy or PUPPP)

Question 21

spot diagnosis

Answer 21

prurigo of pregnancy

Question 22

what is the commonest pruritis of pregnancy?

Answer 22

o Prurigo of pregnancy (prurigo gestationis)
- Affects 20% of normal pregnancies, do LFTs to exclude obstetric cholestasis
o Starts 3rd trimester (25-30 weeks) of pregnancy, resolve after delivery, no effect on mother or baby
o SS: present as excoriated papules on extensor limbs, abdo, shoulder
o M: symptomatic treatment + topical steroids and emollients