Skin & pregnancy


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

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Skin & pregnancy

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