Skin Eruptions in Pregnancy - TOG article Flashcards
What proportion of pregnant mothers report melasma (chloasma gravidarum)?
75%
What treatments for melasma have been tried?
Avoid sunlight exposure - most important
Topical bleaching Hydroquinones (not licenced in UK) Retinoids\Steroids Chemical peel Laser treatment Dermabrasion
Not in preg/breastfeeding, limited response
What causes striae?
Rupture of dermal elastic fibres
What are the risk factors for developing striae?
Personal/family history
Dark skinned women
Excessive abdominal distension
No evidence for Vitamin E, tea tree oil
What happens to hidradenitis suppurativa in pregnancy
Tends to improve - decreased apocrine activity
What happens to sebaceous glands in pregnancy?
Increased activity in third trimester (acne effect variable)
May develop Montgomery tubercles (follicles) - hypertrophic glands, non pigmented elevations in primary areola
What is the prevalence of spider naevi, when do they appear and what is the treatment in pregnancy?
66% in Caucasians, 11% in black
Appear T2, disappear 3/12 postnatal
Sclerotherapy/laser to lower extremities if required
What happens to eccrine glands in pregnancy?
Increased secretion towards T3
Causes prickly heat (miliaria) and hyperhidrosis what can cause pruritis
What causes increased hair growth antenatally?
Prolongation of anagen phase
What is acute telogen effluvium and when does it occur?
Generalised hair shedding with diffuse non-scarring alopecia
Occurs 3-6/12 PN, spontaneous recovery 9-12/12, most recover completely
What happens to nails in pregnancy?
Grow faster
May become dystrophic, brittle
What happens to mucosa in pregnancy?
Pigmentation, hyperaemia, hypertrophy - may bleed
How many pregnancies are affected by pruritis with no underlying haematological/biochemical disorder?
Which sites most affected and when?
What is recurrence rate
18%
Scalp and abdomen, T3 and peaks 1/12 pre delivery
Recurrence rate up to 80%
When do dermographism and urticaria commonly occur?
Last half of pregnancy
Which pregnancy dermatoses can cause IUGR, prematurity and stillbirth?
Intrahepatic cholestasis of pregnancy and pemphigoid gestationis
What is the prevalence of OC?
- 7% in multiethnic populations
1. 2-1.5% of women with Indian/Pakistani origin
What other investigations should be performed when considering OC as a diagnosis?
Viral screen
Liver autoimmune
Pre eclampsia screen
Liver USS
If liver fx improves/worsens rapidly - unlikely OC
What is the recurrence rate of OC?
60-70%
What is the dose of ursodeoxycholic acid?
15mg/kg OD or in divided doses
Minimal evidence for emollients, antihistamines, vitamin K
What is atopic eruption of pregnancy also known as?
Prurigo gestationis (Besnier)
Nurse’s early-onset prurigo of pregnancy
Pruritic folliculitis of pregnancy
Eczema in pregnancy
What is the incidence of atopic eruption of pregnancy?
1 in 300
What is a risk factor for atopic eruption of pregnancy?
FHx of atopy
What are the immunological changes in atopic eruption of pregnancy?
Reduced cellular immunity and decreased Th1 cytokines
Dominant humoral immunity and increased Th2 cytokines
In what % of patients does atopic eruption of pregnancy occur as the primary condition?
When does it occur?
80%
Rest exacerbation of pre-existing
Anytime but most T2 and T3. Improves following delivery
What presents as erythematous, excoriated nodules or papules on the face, neck, chest, extensor surfaces of limbs, trunk?
Atopic eruption of pregnancy
What is the risk of recurrence of atopic eruption of pregnancy and what effect on mum/fetus?
Limited data. No adverse effects.
What is the treatment of atopic eruption of pregnancy?
Symptom relief - oat bath, emollient, topical antipruritics, topical stroids, UV light
Topical benzoyl peroxide, erythromycin with zinc acetate lotion
What is polymorphic eruption of pregnancy also known as?
Pruritic urticarial papules and plaques of pregnancy Toxic erythema of pregnancy Bourne's toxaemic rash of pregnancy Linear IgM dermatosis of pregnancy Nurse's late-onset prurigo
What is the incidence of polymorphic eruption of pregnancy?
When does it present?
1 in 160-300
T3 or immediately postpartum. Resolves 4-6/52 from onset
What are the risk factors for polymorphic eruption of pregnancy?
Nulliparity
Multiple pregnancy
Overdistension of abdominal skin
What presents as erythematous papules in striae with periumbilcal sparing, to the trunk and extremities (not palm/soles/face)?
Polymorphic eruption of pregnancy
Which condition shows histologically non-specific, negative immunofluoresence
Atopic eruption of pregnancy
Which condition histologically shows lymphocytic vasculitis with eosinophils and oedema of the papillary dermis? Later biopsies show spongiosis, hyper- and parakeratosis? Negative immunfluoresence.
Polymorphic eruption of pregnancy
What is the treatment for polymorphic eruption of pregnancy
Symptomatic - topical steroids, antihistamines, emollients
What is the recurrence and impact on mum/fetus in PEP?
Rare recurrence
No adverse impact
What is pemphigoid gestationis also known as?
Pregnancy-related bullous pemphigoid
Herpes gestationis
What is the incidence of pemphigoid gestationis and when does it occur?
1 in 1700-50,000
Any time after T2, rarely immediately after childbirth
What presents with a rash around the umbilicus, urticarial papules and papules which join to form bullae to trunk, extremities, palms, soles (mucosal sparing)? Blisters after a few weeks around the edge of the rash?
Pemphigoid gestationis
What is the mechanism of pemphigoid gestationis and how is diagnosis made?
Autoimmune antibodies against placental proteins and skin
Biopsy necessary
Which haplotypes are associated with pemphigoid gestationis?
HLA DR3 and 4
Which condition histologically shows degenerative changes in basal cells with blister in epidermis and then subsequently between Malphigian layer and subepidermal basement membrane?
Direct and indirect (blood/blister fluid) immunofluorescence positive.
Pemphigoid gestationis
What is the treatment of pemphigoid gestationis?
Symptom control - topical/PO steroids and antihistamines
Caution with ccs - osteoporosis risk
Cyclosporin - appears safe but avoid in breastfeeding
How many patients experience a flare of pemphigoid gestationis at the time of delivery?
When does postnatal flare resolve?
75% - common postnatally
Resolve 2-6/52
What is the recurrence of pemphigoid gestationis?
May occur - earlier onset and more severe
Also with COCP/menstration
What is the impact of pemphigoid gestationis on the fetus?
IUGR - scans monthly
Conflicting evidence re:PTL
1 in 10 newborns mild self limiting skin lesions
What other conditions are associated with pemphigoid gestationis?
Autoimmune - Graves’ - consider TFTs
Which patients should be referred to a dermatologist?
Pemphigoid gestationis
PEP or atopic eruption where initial management fails
Skin eruptions with systemic symptoms
