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Skin & pregnancy

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The effect of pregnancy on skin physiology and reference to specific dermatoses with pregnancy

The effect of pregnancy on skin physiology and reference to specific dermatoses with pregnancy

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  • 1. SKIN and PREGNANCY By Dr M. Y.Abd El-Mawla,MD Zagazig Faculty of Medicine,Zagazig ,EGYPT
  • 2. Introduction
    • Changes in the Skin Due to Pregnancy
    • Skin Conditions Influenced by Pregnancy
    • Pregnancy and Immune-Mediated Disorders
    • Skin Conditions Specific to Pregnancy
    • The Use of Drugs for Dermatologic
  • 3. Changes in the Skin Due to Pregnancy
    • Hyperpigmentation
    • Generalized or increase in pigment at specific areas such as the areolae, genitals, inner thighs, or axillae
    • Melasma : In most cases, the hyperpigmentation : epidermal melanin deposition due to a combination of light exposure and elevated hormones (estrogen, progesterone, and melanocyte-stimulating hormone .
  • 4. Melasma
  • 5. Changes in the Skin Due to Pregnancy
    • Hair& Nail Changes
    • Hirsutism & frontoparietal thinning of male-pattern alopecia : increase in androgens
    • Postpartum: hirsutism resolves and hair may enter the telogen phase, resulting in the diffuse shedding of telogen effluvium
    • Nail changes : transverse grooving, brittleness, distal onycholysis, and subungual hyperkeratosis
  • 6. Telogen effluvium
  • 7. Androgenic aalopecia
  • 8. Vascular Changes in Pregnancy
    • Erythema (most women)
    • Spider telangiectases (66%)
    • Vagina (Jacquemier-Chadwick sign) Cervix (Goodell's sign -- bluish) Palms Gingiva
    • Chest
    • Legs
    • Face
  • 9. Vascular Changes in Pregnancy
    • Varicosities (40% of women)
    • Purpura
    • Vasomotor instability
    • Non pitting edema (50% of women
    • Pyogenic granuloma
    • Legs &Hemorrhoids
    • Lower extremities
    • Facial flushing ,Pallor Cutis marmorata ,Raynaud'sphenomena
    • Face,lids &extremities
    • Gingiva and other sites
  • 10. Pyogenic granuloma
  • 11. Glandular Changes
    • Increased Eccrine glands function:
    • Miliaria ,Hyperhidrosis &Dyshidrotic eczema
    • Decreased Apocrine function:
    • Increased Sebaceous function in third trimester:
    • Acne (variant-pruritic folliculitis of pregnancy) &Sebaceous glands on the areolae (Montgomery's glands)
  • 12. Connective Tissue Changes in Pregnancy
    • Striae distensae (90%) on the abdomen, on the breasts, thighs, and inguinal areas.
    • Mechanical stretch & increased hormones (adrenocortical, estrogen, and relaxin) are the most significant factors in the development of striae,
  • 13. Striae distensae
  • 14. Skin Conditions Influenced by Pregnancy
    • Melanomas : no increased risk of melanoma in pregnancy .When diagnosed during pregnancy may be thicker and therefore have a worse prognosis
    • Nevi: may develop, enlarge, or darken.& show mild cytologic atypia .
    • Dermatofibromas Leiomyomas Keloids Dermatofibrosarcoma: may develop or grow rapidly in pregnancy
  • 15. Other Skin Conditions Influenced by Pregnancy
    • Atopic dermatitis
    • More likely to worsen than improve
    • May present for the first time during pregnancy with keratosis pilaris
    • Irritant hand dermatitis due to washing postpartum &nipple dermatitis due to nursing
  • 16. Other Skin Conditions Influenced by Pregnancy
    • Psoriasis : More likely to improve than worsen
    • Psoriatic arthritis may worsen
    • Impetigo herpetiformis (generalized pustular psoriasis) : during last trimester, but may present earlier &persists until delivery or long after
    • Associated with decreased calcium and/or vitamin D
    • Severe malaise, fever, nausea , vomiting, tetany, seizures
    • Grouped pustules at the margins of symmetric erythematous patches
  • 17. Impetigo herpetiformis
  • 18. Impetigo herpetiformis 2
  • 19. Pregnancy &Autoimmune Disorders
    • Changes in hormones including the increase in estrogen affect the course of autoimmune diseases.
    • The fetoplacental unit directs maternal immunity toward humoral responses by favoring certain cytokines and other inflammatory mediators
    • Enhanced humoral immunity & weakened cellular immunity lead to variable effects that are dependent on the specific disease process .
  • 20. Systemic lupus erythematosus
    • SLE may worsen and may flare postpartum.
    • Lupus patients are advised to avoid trying to conceive when their disease is active
    • Underlying lupus renal disease may worsen during pregnancy.
    • There is a significant risk of eclampsia;
    • Active disease in the mother, maternal use of potentially teratogenic medications, and pathogenic antibodies ( anti-Ro -- ) transmitted from the mother may present risks to the fetus.
  • 21.  
  • 22. Ro(SS-A) &Foetal risk
    • Neonatal lupus in mothers with circulating anti-Ro(SS-A) antibodies
    • Increased risk of prematurity and spontaneous abortion
    • Congenital heart block
  • 23. Nonatal lupus
  • 24. Antiphospholipid syndrome( aPLs)in pregnant with SLE
    • Approximately one third of patients who have SLE also have aPLs..
    • aPLs : heterogeneous group of autoantibodies that bind phospholipids, proteins, or a phospholipid–protein complex on platelets and or vascular endothelium.
    • Two best characterized : the lupus anticoagulant (LA) and anticardiolipin antibodies (aCL)
    • .
  • 25. Suggested clinical and laboratory criteria for the diagnosis of APS
    • Pregnancy Loss
    • Recurrent spontaneous abortion & Unexplained fetal death
    • Thrombosis: Venous thrombosis & Arterial thrombosis, stroke
    • Autoimmune thrombocytopenia& hemolytic anemia
    • Transient ischemic attacks
    • Chorea gravidarum &Livedo reticularis
    • Laboratory criteria
    • Lupus anticoagulant, Anticardiolipin antibodies , >15–20 IgG binding units& activated partial thromboplastin time .
  • 26. Conditions Specific to Pregnancy
    • Herpes gestationis (HG) (also known as "pemphigoid gestationis") .
    • Pruritic and urticarial papules and plaques of pregnancy (PUPPP).
    • Intrahepatic cholestasis of pregnancy (ICP) may present with intense pruritus.
    • Prurigo of pregnancy
    • Pruritic folliculitis of pregnancy
  • 27. Herpes Gestationis H G (pemphigoid gestationis )
    • The incidence 1 in 50,000 pregnancies
    • Developing during the second or third trimester (mean onset, 21 weeks) & reported in the first trimester.
    • Intensely pruritic, urticarial lesions on the abdomen in half of the cases especially periumbilically , with a rapid progression to multiple, generalized bullae. Face, mucous membranes, palms, and soles : spared .
  • 28.
    • Improving during the later part of pregnancy, only to flare at delivery or postpartum in about 75% of patients
    • Histopathology : a subepidermal vesicle with perivascular infiltration (lymphocytes & eosinophils).
    • Direct immunofluorescence :C3 with or without IgG in a linear band along the basement membrane zone (BMZ). The antibody localizes to the roof of the blister.
    • A mismatch of HLA antigens between the mother and father, manifested by an immunologic response against the paternal class II antigens at the placental BMZ with cross-reaction at the skin BMZ.
  • 29. Foetal Risk in in HG
    • The newborn shows signs of HG in less than 10% of cases.
    • The foetal risk : prematurity and low birthweight ,
  • 30. Urticarial plaques & vesiculations
  • 31.  
  • 32.  
  • 33.  
  • 34. Pruritic and Urticarial Papules and Plaques of Pregnancy(PUPPP)
    • Occuring in approximately 1 in 240 pregnant women, typically in the third trimester in first pregnancy
    • The urticarial papules begin within striae on the abdomen and thighs and, sparing the periumbilical region, face, palms, and soles.
    • The lesion may be also vesicles or targetoid.
    • Not to recur in subsequent pregnancies
  • 35.
    • Biopsy : a spongiotic epidermis with a perivascular inflammatory infiltrate: increased numbers of eosinophils.
    • Immunofluorescence : negative
    • Poseing no risk to the mother (except pruritus) or fetus, resolveing postpartum .
    • Aetiology :
    • Abdominal distention: eliciting an inflammatory response by damaging the connective tissue &
    • A substance released from placenta into the maternal circulation triggers fibroblast proliferation
  • 36.  
  • 37.  
  • 38. Intrahepatic Cholestasis of Pregnancy (ICP)
    • In the third trimester of pregnancy (mean, 31 weeks) with a mild form of intrahepatic bile secretory dysfunction.
    • Features : 1 -generalized pruritus with or without jaundice 2 -absence of primary skin lesions, (3) biochemical abnormalities consistent with cholestasis,( elevated serum bile acids (mean, 1349 mug/100 mL) and (4) resolution after delivery.
    • Recurrence with subsequent pregnancy
  • 39. Pathophysiology
    • Estrogens interfere with the diffusion of fluid across the canalicular membrane of the hepatocyte and subsequently with hepatic bile acid secretion.
    • Inhibition of hepatic glucuronyl-transferase
    • Altered estrogen metabolism in the liver, resulting in reduced biliary volume and excretion of these compounds
  • 40. Prurigo of pregnancy (PP )
    • The incidence : 1 in 300 pregnancies.
    • In all trimesters of pregnancy
    • Erythematous papules and nodules on the extensor surfaces of the extremities and occasionally on the abdomen
    • Recurrence during subsequent pregnancies is variable
    • Related to an atopic background
  • 41.  
  • 42. Pruritic folliculitis of pregnancy (PFP)
    • Generalized, pruritic erythematous, follicular papules, developing from the fourth to the ninth month of gestation .
    • A form of steroid acne, with no evidence of any immunologic or hormonal abnormalities.
    • Some authors[ have suggested that PFP and PP should be included within the spectrum of " polymorphic eruption of pregnancy.
  • 43.  
  • 44. The Use of Drugs for Dermatologic Conditions in Pregnancy
  • 45. FDA Pregnancy Categories
    • A Controlled studies show no fetal risk
    • B No risk to human fetus despite possible animal risk.
    • C Risk cannot be ruled out; human studies are lacking.
    • D Positive evidence for risk to human fetus, but benefits may outweigh risks of drug
    • X Contraindicated in pregnancy; there is no reason to risk use of drug in pregnancy
    • Undetermined No pregnancy category yet assigned
  • 46.
    • Topical corticosteroids during pregnancy :with a low risk to the fetus( Category C risk) as the risk cannot be ruled out because no human studies have been done.
    • Topical povidone-iodine and podophyllin place a fetus at risk. : not recommended for use during pregnancy
    • Analgesics : associated with minimal risk to the fetus or infant. Indomethacin::associated with problems in infants .
  • 47.
    • Retinoids and antineoplastic : isotretinoin (used to treat acne vulgaris) & antineoplastic eg methotrexate: category X.
    • Antipruritic agents. : doxepin: avoided during pregnancy and lactation. Hydroxyzine : risk in the first trimester of pregnancy and is associated with a risk of congenital abnormality.
    • Antibiotics: including tetracycline & ciprofloxacin--pose potential risks during pregnancy.. Penicillins are considered comparatively safe during pregnancy
  • 48.
    • THANK YOU