Pregnancy induced or associated some dermatological disorder.eczema of pregnancy.skin disease in pregnancy

1. DERMATOSES ASSOCIATED WITH PREGNANCY
PREPARED BY :
DR. MD. ASHIQUR RAHMAN
EMO BAMCH
GUIDED BY:
ASST. PROF. DR. ATIQUR RAHMAN
HOD OF SKIN & VD BAMCH
DEPARTMENT OF SKIN AND VENERAL DISEASE
BASHUNDHARA AD-DIN MEDICAL COLLEGE HOSPITAL

2. Common Term of Dermatology:
 Dermatosis: Disease of dermatology.
 Dermatitis: Inflammation of Skin.
 Leukoderma – white skin. Also known as achromia.
 Erythema – red skin due to increased blood supply and blanch with pressure
 Erythroderma – the skin condition affects the whole body or nearly the whole body, which is
red all over.
 Macule – an area of colour change less than 1.5 cm diameter. The surface is smooth.
 Patch – a large area of colour change, with smooth surface.
 Papule – a small palpable lesion. The usual definition is that they are less than 0.5 cm
 Plaque- A plaque is a circumscribed, palpable lesion > 1 cm in diameter;
 Nodule – an enlargement of a papule in three dimensions (height, width, length). It is a
solid lesion.
 Vesicle – small fluid-filled blister less than 0.5cm diameter. They may be single or multiple.
 Pustule – a purulent vesicle. It is filled with neutrophils, and may be white, or yellow. Not
all pustules are infected.
 Bulla – a large fluid-filled blister.size>0.5cm . It may be a single compartment or
multiloculated.
 Wheal- A localized swelling of the upper portion of skin. This is usually pink and itchy.
 Centrifugal- from center to periphery
 Centripetal- Periphery to center.

3. DERMATOSES ASSOCIATED WITH PREGNANCY:
● MAINLY 2 TYPES
1.DERMATOSES ASSOCIATED WITH FETAL RISK IN PREGNANCY
 PEMPHIGOID GESTATIONIS
 INTRAHEPATIC CHOLESTASIS OF PREGNANCY
 PUSTULAR PSORIASIS OF PREGNANCY
(IMPETIGO HERPETIFORMIS)
2.DERMATOSES NOT ASSOCIATED WITH FETAL RISK IN PREGNANCY
 PRURITIC URTICARIAL PAPULE & PLAQUE OF PREGNANCY
 ATOPIC ERUPTION OF PREGNANCY

4.  PEMPHIGOID GESTATIONIS:
 It is an immunogically mediated intensely pruritic, vesiculobullous eruption of
mid to late pregnancy that is associated with foetal risk.
 PRESENTATION:
 Diagnosis of PG becomes clear when skin lesions progress to tense blisters
during the second or third trimester. The face and mucous membranes are
usually spared. PG typically starts as a blistering rash in the navel area and
then spreads over the entire body. It is sometimes accompanied by raised, hot,
painful welts called plaques. After one to two weeks, large, tense blisters
typically develop on the red plaques, containing clear or blood-stained fluid.
[4] PG creates a histamine response that causes extreme relentless itching
(pruritus). PG is characterized by flaring and remission during the gestational
and sometimes post partum period. Usually after delivery, lesions will heal
within months, but may reoccur during menstruation.
 Fetal risk:
 low or decreasing volume of amniotic fluid, preterm labor, and intrauterine
growth retardation. Onset of PG in the first or second trimester and presence
of blisters may lead to adverse pregnancy outcomes including decreased
gestational age at delivery, preterm birth, and low birth weight children.

5. PEMPHIGOID GESTATIONIS

6.  INTRAHEPATIC CHOLESTASIS OF PREGNANCY:
 It represent as a reversible form of cholestasis in late pregnancy associated
with biochemical abnormalities and a risk of fetal complications, but
invariably lacking primary cutaneous lesions. Symptom remits within 2-4
weeks of delivery, but recurrence in subsequence pregnancies are common.
 PRESENTATION:
 this condition present in third trimester with itching without a rash.
● Itching, in particular but not limited to that of the palms of the hands and
soles of the feet, without presence of a rash
● Itching that increases in the evening
● Itching that does not respond favorably to anti-histamines or other anti-itch
remedies
● Often, elevated LFT results as well as serum bile acid counts.
 Fetal consequences include:
• Fetal distress
• Meconium ingestion
• Meconium aspiration syndrome
• Stillbirth

7.  PUSTULAR PSORIASIS OF PREGNANCY/IMPETIGO HERPETIFORMIS:
 It is a rare acute pustular eruption often accompanied by fever, leukocytosis, and
an elevated ESR. It is a variant psoriasis.The onset is during the 3rd triamstar of
pregnancy.
 PRESENTATION:
 The condition manifest as erythematous patches.The margins are studded with
subcorneal pustules. Mainly occur in flexor area. And spread in centrifugal
pattern and sometime generalized.the face, palms and soles are spared, the rash
may be pruritic or painful. Associated feature fever, chills ,malaise, diarrhoea,
nausea and arthralgia. Rarely tetany delirium & convulsion occur if hypocalcemia
is severe.Abrupt resolution of symptoms after delivery.but a tendency to recur
during subsequent pregnancies.. And distinguish it to generalized pustular
psoriasis.
 CAUSE/ETIOLOGY:
 Most cases of generalized pustular psoriasis present in patients with existing or
prior psoriasis conditions.[21][22] However, there are many cases of GPP that
arise without a history of psoriasis.[23]

8. TYPICAL PSORIASIS(SILVERY CENTER WITH REDDEN BOARDER)

9. Pustular psoriasis of pregnency

10. FETAL COMPLICATION:
Placental insufficiency, consequent still birth, neonatal death
LAB. DIAGNOSIS:
 Histopathological exam: Classical feature of pustular psoriasis
 Leucocytosis, neutrophilia, high ESR, anemia, hypoalbumonia
 Less common: calcium po4 level, vit D level, s.prothrombin level are
decreased.
 Culture of pustular content: negative unless secondary infection
Provocative Factors Influencing Pustular Psoriasis of Pregnency
Drugs: lithium, aspirin, salicylates, methotrexate, corticosteroids,
progesterone, phenylbutazone, trazodone, penicillin, hydrochloroquine
Irritation from topical therapy: coal tar, anthralin
Infections: dental, upper respiratory
Pregnancy
Solar irradiation

11. DEFERENTIAL DIAGNOSIS OF PSP:
 Most likely-
1)Pustular drug eruption(acute generalized exanthematous pustulosis)
2)Pemphigoid gestationis.
 Consider-
1)Pemphigoid vulgaris
2)Dermatitis herpetiformis
3)Subcorneal pustular psoriasis
4)Pustular eruption in IBD
 Always Rule Out
1) Infectious cause of pustular psoriasis.

12. TREATMENT OF PSP:
 Topical treatments include wet dressing & topical corticosteroids which are
rarely effective
 Systemic corticosteroids are the mainstay of treatment during pregnancy.
 Cyclosporine at the dose between 5 to 10 mg/kg daily.
 Narrowband UVB combined with topical steroids, TNF-α blocker, Infliximab.
 But in all cases fluid status and electrolytes should be monitored with rapid
correction of imbalance. fetal monitoring is essential.as decrease heart rate
will indicate fetal hypoxaemia.Maternal cvs and renal fuction will be
compromised with progression of disease so it should be monitored as
well.Induction of labour is an option if symptom donot subside.After delivery
non nursing mother can be treated with PUVA, oral retinoids
clofazimine,MTX,sulfapyridine and sulfones.

13.  PRURITIC URTICARIAL PAPULES AND PLAQUES
OF PREGNANCY(PUPPP):
 It is a common and self limiting intensely pruritic dermatosis. It occurs almost exclusively in
primigravidas during late pregnancy. Pruritic urticarial papules and plaques of pregnancy (PUPPP),
known in United Kingdom as polymorphic eruption of pregnancy (PEP),[1] is a chronic hives-like rash
that strikes some women during pregnancy. Although extremely annoying for its sufferers (because
of the itch), it presents no long-term risk for either the mother or unborn child. PUPPP frequently
begins on the abdomen and spreads to the legs, feet, arms, chest, and neck.[2]
 CAUSE:
 The cause of the condition is generally unknown,.[1] There is a correlation between the PUPPP rash
and dairy. When some women stop drinking dairy the rash has been known to go away. This skin
condition occurs mostly in first pregnancies (primigravida), in the third trimester and is more likely
with multiple pregnancies (more so with triplets than twins or singletons).[3][4]
 Other than additional associations with hypertension and induction of labour, there are no observed
difference in the outcome of the pregnancy for mothers or babies

14. FIGURE: PUPPP

15.  ATOPIC ERUPTION OF PREGNANCY/PRURITIC
FOLLICULITIS/PRURIGO OF PREGNANCY/ECZEMA OF
PREGNANCY:
 Lesions typically appear before the 3rd trimester and may resemble to classical atopic
dermatitis E-type, popular P-type. AEP is the most common of the pregnancy dermatoses
(incidence 1:300-3000). Affected women may experience dry skin, with rough red patches
or itchy bumps affecting any part of the body. They may or may not have experienced
eczema before pregnancy. This condition does not harm the baby and often improves after
the baby is born.
 CAUSE:
 “Atopy” describes a problem with the immune system that causes people to be prone to
eczema, asthma or hay-fever. It often runs in families. “Atopy” is associated with poor skin
barrier function, causing dry and sensitive skin. Women with AEP may have had eczema
(atopic dermatitis) before pregnancy, or they may develop a rash for the first time during
pregnancy.
 PRESENTATION:
 Atopic eruption of pregnancy develops relatively early in pregnancy.
 There are two forms of this condition:
1. Eczematous (E-type AEP) – rough and red patches develop. This typically occurs on the
face, neck, creases of elbows and backs of knees
2. Prurigo (P-type AEP) – bumps develop and can affect widespread areas like the abdomen,
arms and legs

16. ATOPIC ERUPTION OF PREGNANCY

17. SUMMARY OF DERMATOSES OF PREGNANCY:
Disease Morphology Distributi
on
Usual Onset Fetal Risk Synonym(
s)
Pemphigoid
gestationis
Urticarial papules
& plaques
progress to
vesicles & bullae
Begins on
trunk,then
progress to
generalized
eruption
spares face,
mucus
membrane,
palms &
soles
2nd or 3rd
trimester,or
immediately
postpartum
Small for
gestationalage
, preterm
delivery,
neonatal
pemphigoid
gestationis
Herpis
gestationis
Intrahepatic
Cholestasis of
pregnancy
Excoriations
&excoriated
papules
(+/- jaundice)
Localized to
palms, soles
or
generalized
3rd trimester Preterm
delivery, fetal
distress,
fetal death
Cholestasis of
pregnancy,
Obstretics
cholestasis,Pr
urigo
gravidarum,Ic
terus
gravidarum
Pustular
psoriasis of
pregnancy
Erythematous
patches with
subcorneal
pustules at their
margins
Begins in the
flexures
generalize in
centrifugal
pattern
3rd trimester Placental
insufficiency
may lead to
still birth or
neonatal
death
Impetigo
Herpetiformis

18. SUMMARY OF DERMATOSES OF PREGNANCY:
Disease Morphology Distribution Usual Onset Fetal
Risk
Synonym(s)
Pruritic
urticarial
papules &
plaques of
pregnancy
Polymorphous
including
urticarial
papules &
plaques
(+/-vesicles)
Begins within
abdomenial
striae spreads
to trunk &
extremities
spare
umbilicus
3rd trimester
or immediate
postpartum
None Polumorphic
eruption of
pregnancy,
Boumer’s
toxaemic Rash of
pregnancy,Nurses
late onset prurigo
of pregnancy
E-type AEP Eczematous
Patches &
Plaques
Face, neck,
Cheast,
flexural
extremities
2nd or 3rd
trimester
(less
commonly)
None Eczema of
pregnancy
P-type AEP Excoriated or
Crusted Papules
Extremities
occasionally
trunk
2nd or 3rd
trimester
(less
commonly)
None Prurigo of
Pregnancy

19. Frequency of dermatoses in pregnancy:
1)Atopic eruption of pregnancy: 49.7% 2)PUPPP: 21.6% 3)Impetigo Herpetiformis: 4.25%
4)Gestational pemphigoid: 4.2% 5) Intrahepatic cholestasis of pregnancy: 3%
6)Prurigo gestationis: 0.8% 7)Pruritic folliculitis of pregnancy: 0.2%
Dermatoses in pregnancy
AEP PUPPP Impetigo.H G.P I.C.P Prurigo G. P.F.P

20. LAST OF ALL…….