Skin disease in pregnancy

Question 1

What are some common physiological skin changes in pregnancy?

Answer 1

Increased pigementation of

• Face
• Areolae
• Axillae
• Abdominal midline (linea nigra)

Spider naevi of face, arms, upper torso

Striae gravidarum (broad pink linear striae) on lower abdomen and thighs

Pruritus

Question 2

What is shown?

Answer 2

Linea nigra

Question 3

What is shown?

Answer 3

Striae gravidarum

Question 4

How common is pruritus during pregnancy? What investigation should be done?

Answer 4

20% of normal pregnancies affected

But must exclude obstetric cholestasis so check LFTs

Question 5

What happens to pre-existing skin diseases in pregnancy?

Answer 5

Eczema - may worsen, especially hand and nipple eczema postpartum; atopic eczema is the most common rash in pregnancy

Acne - may improve initially then worsen in the third trimester

Acne rosacea - worsens often

Psoriasis - remains unchanged in 40%, improves in 40% and worsens in 20%

Question 6

What is the commonest pregnancy rash?

Answer 6

Atopic eczema

It is a common pruritic skin condition affecting 1–5% of the general population and causes the commonest pregnancy rash

Question 7

How can atopic eczema be treated?

Answer 7

• Emollients
• Bath additives

Question 8

How can pre-existing psoriasis be treated in pregnancy? What is contraindicated?

Answer 8

Topical steroids

Methotrexate is contraindicated

Question 9

How can acne be treated during pregnancy? What is contraindicated?

Answer 9

Oral or topical erythromycin

Retinoids are contraindicated

Question 10

Name 4 dermatoses specific to pregnancy.

Answer 10

• Pemphigoid gestationis (PG) - autoimmune bullous
• Polymorphic eruption of pregnancy (PEP) - pruiritic, inflammatory
• Prurigo of pregnancy - pruritic, excoriated papules
• Pruritic follicilitis of pregnancy (PF) - pruritic folicular papules and pustules

Question 11

What condition is shown?

Clue: usually begins on abdomen in late 2nd/3rd trimester and progresses to widespread clustered blisters sparing the face.

Answer 11

Pemphigus gestationis

Question 12

What condition is shown?

Clue: Presents in 3rd trimester +/- immediately postpartum. Begins on lower abdomen, involving striae, extends to buttocks, thighs, legs and arms, sparing the umbilicus and rarely involving the face, hands and feet.

Answer 12

Polymorphic eruption of pregnancy (PEP)

Question 13

What condition is shown?

Clue: Starts ~25-30 weeks and resolves after delivery. Affects extensor surfaces of limbs, abdomen and shoulders. Common in atopy hx.

Answer 13

Prurigo of pregnancy

Question 14

What condition is shown?

Clue: Starts in 2nd/3rd trimester and resolves with delivery. Follicular eruptions, with papules, pustules that mainly affect the trunk but can involve limbs. Similar to acne.

Answer 14

Pruritic folliculitis of pregnancy

Question 15

What is pemphigoid gestationis and how common is it? When is the onset?

Answer 15

Rare pruritic autoimmune bullous disorder,
affecting 1 in 60,000 pregnancies.

Presents in the late second or third trimester

Question 16

Describe the clinical features of PG, including diagnosis.

Answer 16

Appearance: Lesions begin on the abdomen in 50% and –> widespread clustered blisters sparing the face.

Diagnosis: clinical appearance and by direct immunofluorescence.

Question 17

What is the prognosis of PG?

Answer 17

Common exacerbations and remissions, and flares postpartum in 75% of cases.

PG recurs in most subsequent pregnancies

Question 18

What is the management of PG?

Answer 18

Aim to relieve pruritus and prevent new blister formation:

1. Potent topical steroids
2. +/- oral prednisolone.

Question 19

What is polymorphic eruption of pregnancy? How common is it and when is the onset?

Answer 19

• PEP is a pruritic inflammatory disorder
• Affects 1 in 160 pregnancies - 75% of affected pregnancies are primagravida
• Usually presents in the 3rd trimester +/- postpartum

Question 20

What are the clinical features of PEP?

Answer 20

Begins on the lower abdomen involving pregnancy striae, and extends to thighs, buttocks, legs and arms,

Spares the umbilicus and rarely involves face, hands and feet.

In 70% of patients the lesions become confluent and widespread, resembling a toxic erythema.

Question 21

What is the management of PEP? What is the prognosis?

Answer 21

Symptomatic treatment is sufficient

No tendency to recur

Question 22

What is prurigo of pregnancy and how common is it? When is the onset?

Answer 22

Common pruritic disorder, more common in women with a history of atopy.

Affects 1 in 300 pregnancies

Onset is at 25-30 weeks

Question 23

What are the clinical features of prurigo of pregnancy?

Answer 23

Excoriated papules on extensor limbs, abdomen and shoulders

Question 24

What is the management of prurigo? What is the prognosis?

Answer 24

Treatment is symptomatic with topical steroids and emollients.

Resolves after delivery, with no effect on the mother or baby.

Question 25

What are the clinical features of pruritic folliculitis of pregnancy?

Answer 25

• Pruritic folliculat eruption
• Papules and pustules
• Mainly affect the trunk but can affect the limbs
• Look like acne lesions and sometimes are considered a type of hormonally-induced acne

Question 26

When is the onset of pruritic folliculitis of pregnancy? What is the management?

Answer 26

Onset usually in 2nd/3rd trimester and resolves after delivery

Topical steroids are effective