SKIN CHANGES AND DERMATOSES OF PREGNANCYDr. HUSSEIN ABOUL FOTOUH Dermatologist Al Meeqat General Hospital Almadina Almunawara
During pregnancy immunologic endocrine metabolic and vascular changes occur that make the pregnant woman susceptible to skin changes both physiologic and pathologic. They are A-Physiologic skin changes B-Dermatoses aggravated by pregnancy C-Dermatoses of pregnancy
Physiologic skin changes Caused by the hormonal changes of pregnancy 1-Pigmentary changes (usually regress postpartum) -Diffuse hyperpigmentation(90% with accentuation of normally hyperpigmented areas e.g. areolae axillae linea alba -Melasma(70% of pregnant) -Darkening of nevi -Pigmentation of axillae and inner thighs
2-Hair changes (hirsutism postpartum telogen effluvium postpartum male pattern alopecia) 3-Nail changes (subungual hyperkeratosis distal onycholysis transverse grooving and brittleness) 4-Glandular -Increased eccrine activity (hyperhidrosis miliaria and dyshidrotic eczema) -Decreased apocrine activity )(hidradenitis suppurativa) -Increased sebaceous activity (exacerbation of AV enlarged Montgomery follicles of areolae) 5-Striae distensae or atrophicae
Vascular(spider nevi palmar erythema-6nonpitting facial edema varicosities(dermographism and haemorrhoidesGingival hyperemia and gingivitis-7Prurigo gravidarum due to functional-8 hepatic disturbance induced by estrogens
Dermatoses aggravated by pregnancy 1-Infections ( severe seborrhoeic dermatitis or orovulval candidiasis should raise suspicion of HIV during pregnancy) -Viral (H. simplex- condyloma accuminata ( cs is indicated for both)- varicella zoster) -Bacterial (leprosy)- protozoan (trichomoniasis) -Fungal (Candida -pityrosporum folliculitis) .AIDS pregnancy accelerates the development of AIDS in an asymptomatic HIV +ve patient. 2-Inflammatory disorders -Atopic dermatitis–acne vulgaris –Hidradenitis suppurativa –Chronic plaque psoriasis –Fox fordyce disease (all may improve) -urticaria
DERMATOSES OF PREGNANCY(6) 1-Intrahepatic cholestasis of pregnancy (ICP) 2-Impetigo herpetiformis (IH) 3-Herpes gestationis (HG) 4-Pruritic urticarial papules and plaques of pregnancy (PUPPP) 5-Prurigo of pregnancy (PP) 6-Pruritic folliculitis of pregnancy (PFP)
Intrahepatic cholestasis of pregnancy It is seen in the third trimester ( unlike physiologic prurigo gravidarum which occurs in the first trimester) . It is characterized by -Elevated liver function tests and serum bile acids -Generalized pruritus ( high bile salts) and excoriations (without primary skin lesions) with jaundice in 50% of cases that resolves after delivery -Malabsorption of fat with weight loss vitamin k deficiency------- IU Hge -Increased fetal distress and stillbirths -50% recurrence with subsequent pregnancies TTT emollients cholestyramin UVB evening primrose oil.
(IMPETIGO HERPETIFORMIS(IH A variant of pustular psoriasis( histopathologically) characterized by widespread sheets of erythema with pustular margin starting in flexures sparing face hands and feet there is fever diarrhea and vomiting. -It starts usually in the third trimester and resolves postpartum but may recur with subsequent pregnancies -associated with hypocalcaemia high ESR and leukocytosis. TTT prednisolone 40 mg daily calcium and termanination is indicated (stillbirth and placental insufficiency).
Herpes gestationis (HG( an autoimmune bullous :disorder closely related to Bullous pemphigoid .Onset -second or third trimester .Recurrence is common with subsequent pregnancies and oral contraceptives -Intensely pruritic erythematous plaques on the abdomen periumblical----------generalized bullous eruption sparing face mucous membranes palms and soles -Histopathology subepidermal separation basal cell necrosis eosinophilic spongiosis. Direct Immuno Fluorescence shows linear c3 and IgG at BMZ HG factor is a circulating IgG Ab. that binds toAg2 in BMZ the same antigen is found in the placenta.It stimulates complement pathway----c3 deposition at BMZ---chemotaxis of eosinophils----proteolytic enzymes-----dermoepidermal separation
TTT mild cases potent topical steroids and systemic antihistamines -prednisone 20—40mg daily -Plasmapheresis NB Avoid dapsone-----neonatal hemolysis and avoid oral contraception-------HG recurrences
PRURITIC URTICARIAL PAPULES AND PLAQUES OF PREGNANCY (PUPPP( SYN. POLYMORPHIC ERUPTION OF PREGNANCY The most common 1to 300 preg. -occurs in primigravidas in the third trimester and does not usually recur in subsequent pregnancies. -severely pruritic polymorphous eruptions (urticarial-papules-plaques-and erythema multiforme like lesions) usually begin in the striae on the abdomen and spreading peripherally .The face palms and soles are commonly spared.It resolves after delivery. -HISTOPATHOLOGY mild spongiosis and superficial perivascular inflammatory cell infiltrate with many
PathogenesisRapid abdominal distention in primigravidas inthird trimester may cause damage toconnective tissue in the striae and trigger the.inflammatory response to PUPPP.It is harmless to the fetus and mother-TTT Antihistamines – short course of oralprednisone –topical steroids and antipruritics-UVB therapy
PRURIGO OF PREGNANCY (PP) -Onset 2nd or 3rd trimester with no recurrence with subsequent pregnancy. -Clinically pruritic papules or nodules on extensors of limbs or abdomen (similar to nodular prurigo) as there may be an atopic background. No complications. -TTT topical steroids – antihistamines – resolution -----weeks after pregnancy
PRURITIC FOLLICULITIS OF PREGNANCY(PFP) -Onset 2nd or 3rd trimester with no recurrence with subsequent pregnancy. -Clinically similar to steroid acne (pruritic erythematous follicular papules on limbs and abdomen). -No complications -TTT Topical steroids – Resolution is postpartum