This document discusses various skin conditions that can occur during pregnancy. It begins by outlining physiological skin changes caused by hormonal factors, such as increased pigmentation, vascular changes, and pruritis. It then describes several important pathological skin diseases of pregnancy, including intrahepatic cholestasis of pregnancy, atopic eruption of pregnancy, polymorphic eruption of pregnancy, and pemphigoid gestationis. These conditions can cause pruritis, rashes and in severe cases threaten the health of the mother and fetus. The document provides details on presentation, diagnosis, and management of these key pregnancy-related skin diseases.

1. Skin diseases in pregnancy
By
Ahmed Elbohoty MD, MRCOG
Assistant professor of obstetrics and gynecology
Ain Shams University

2. ILOs
—To understand the physiological skin changes in
pregnancy.
— To be able to identify the pregnancy related
skin diseases with their management.
—To identify the skin conditions that affect the
fetus.
3/25/20ELBOHOTY2

3. —Pregnancy results in a variety of
physiological and pathological changes
to the skin.
—Pathological changes to the skin can be
—those that can occur outside
pregnancy
—those that are unique to pregnancy.
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4. Physiological skin changes in pregnancy
—Most changes are recognised to be due to
—hormonal (increased estrogen,
progesterone and ACTH which has
Melanocyte stimulating hormone
activity)
—physical factors.
—The exact aetiology is uncertain.
3/25/20ELBOHOTY4

5. 1. Pigmentation
2.Connective tissue
3.Vasculature
4.Glands
5.Hair and nail
6.Mucous membranes
7.Pruritis
Physiological skin changes in pregnancy
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6. Pigmentation
— Almost all women notice an increase in skin pigmentation
during pregnancy, which is more noticeable in dark-
skinned individuals.
— This usually fades post-delivery, but often does not
disappear completely.
— Forms:
1. Linea nigra (abdomen), Nipples, Axillae, Genitalia,
Perineum
2. Secondary areola (pigmented area appears around the
primary areola commonly during the fifth month)
3.Melasma (chloasma gravidarum or pregnancy mask)3/25/20ELBOHOTY6

7. Melasma
• Sites: Forehead, Malar distribution & Mandibular area
— Incidence: 75%, predominantly in the second or third
trimester.
— The condition may be distressing and often persists for
months and years postpartum.
— Treatment:
— Prophlactic:Avoidance of excessive sunlight exposure and the use of
broad-spectrum sunscreens.
— Therapeutic: (not during the pregnancy): limited response to
topical bleaching creams, hydroquinones , retinoids, steroids and
laser treatments. 3/25/20ELBOHOTY7

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12. Connective tissue
1.Striae gravidarum
2. Skin tags (epithelial polyps)
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13. Stretch marks (striae gravidarum)
— These develop as linear red–purplish areas resulting from the
stretching of skin in the second trimester.
— Sites:abdomen, breasts, thighs, lower back, buttocks and upper
arms.
— Mechanism: rupture of dermal elastic fibres, which explains their
irreversible nature. However, they often fade in the postnatal period
to thin, atrophic, hypopigmented scars.
— Risk factors: personal or family history, dark-skinned women and
excessive abdominal distension in pregnancy.
— Treatment: Use of emollients.
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16. Vascular changes
1.Spider naevi
2.Telangiectasia
3. Palmar erythema
4.Varicosities: Saphenous,Vulval/vestibular/vagina
Haemorrhoidal
5.Vasomotor instability, such as, flushing
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17. Vascular changes
— They are partly due to the increase in estrogen, causing dilatation,
instability, congestion and proliferation of blood vessels that can be
seen on or through the skin.
— Sites: Fair-skinned individuals 66%, and Caucasians compared with
11% in black people
— Areas around the eyes, neck, face, upper chest, hands and arms.
They appear in the second trimester and the majority will disappear
by the third postnatal month.
— If treatment is required for those on the lower extremities,
sclerotherapy or laser treatment can be used.
3/25/20ELBOHOTY17

18. Hair
—Increased hair growth, antenatally, is thought to be
due to prolongation of the anagen phase.
—Acute telogen effluvium, a generalised hair shedding
with diffuse non-scarring alopecia, characteristically
occurs 3–6 months postpartum.
—Generally, recovery is spontaneous and occurs
within 9–12 months, and rarely does hair density fail
to recover completely
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20. Nails
—Nails tend to grow faster during pregnancy and
can become dystrophic, brittle, soft and/or
pigmented.
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21. Mucosal changes
—They include pigmentation, hyperaemia
and hypertrophy, which can lead to
bleeding.
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22. Pruritus
—In the absence of an underlying haematological or
biochemical disorder is a common complaint,
affecting up to 20 % of pregnancies.
—Common sites affected include the scalp and
abdominal skin.
—It can start as early as the third month and peaks
among the before delivery.
—The recurrence rate in subsequent pregnancies is
thought to be up to 80%.
3/25/20ELBOHOTY22

23. —It is important to exclude other possible
cases of pruritus, such as
—Scabies
—contact dermatitis
—drug-induced pruritus
—atopic dermatitis.
—Cholestasis of pregnancy
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24. Dermographism 3/25/20ELBOHOTY24

25. Glands
1. Eccrine glands (present in all skin): Increased function.
Miliaria ,Hyperhidrosis &Dyshidrotic eczema
1. Apocrine (present in axilla and groin) Decreased activity
(improves conditions such as hidradenitis suppurativa)
2. Sebaceous
1.-Activity increased in third trimester but effects on acne
variable
2.- Montgomery tubercles (follicles) may develop (hypertrophic
sebaceous glands, non-pigmented elevations in the primary
areola)
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27. Dermatoses of
Pregnancy
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28. —Diagnosis and management are dependent
upon a structured history and examination, and
understanding of serious and/or common
dermatoses that may require referral to a
dermatologist.
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29. Dermatoses of pregnancy
—The ability to distinguish between dermatoses
of pregnancy is of utmost importance
—Some (intrahepatic cholestasis of pregnancy
and pemphigoid gestationis) can cause
morbidity and mortality of mother and fetus,
such as intrauterine growth restriction,
preterm delivery and stillbirth.
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30. 1. Intrahepatic cholestasis of
pregnancy.
2. Atopic eruption of pregnancy
3. Pemphigoid gestationis
4. Polymorphic eruption of pregnancy
3/25/20ELBOHOTY30

31. Intrahepatic cholestasis of pregnancy
— It presents initially with itching and results in secondary
skin changes as a result of pruritus.
— Incidence: 0.7% in multi-ethnic populations and in 1.2–
1.5% of women of Indian–Asian or Pakistani–Asian origin.
— In Chile, 2.4% of all pregnancies are affected, with a 5%
prevalence in women of Araucanian–Indian origin.
— Its prevalence is known to be determined by genetic,
hormonal and environmental factors, and varies between
populations worldwide.
— Sites & time: pruritis is most severe at night and mainly
affects the hands, feet and pressure sites. 3/25/20ELBOHOTY31

32. Aetiology
— the exact cause of the disease is unknown
— it is likely to result from the cholestatic effects of reproductive hormones in
genetically susceptible women.
— It is estimated that 10–15% of cases of ICP can be explained by known genetic
variation.
— hepatic bile acid receptor is farnesoid X receptor (FXR).
— In response to elevated levels of intrahepatic bile acids, this receptor is
responsible for the coordinated downregulation of synthesis and uptake of bile
acids, and the upregulation of export.
— sulfated progesterone metabolites are partial agonists for FXR and impair bile
acid homeostasis
— estrogen contributed to the development of cholestasis by reducing the
expression and function of several bile acid transport proteins in the liver,
including the main efflux protein, the bile salt export pump (BSEP). 3/25/20ELBOHOTY32

33. presentation
— ICP typically presents with pruritus in the third trimester, and in
approximately 80% of women, it presents after 30 weeks of gestation.
— pruritus is on the palmar aspect of the hands and plantar aspect of the
feet; however, it may be generalised, the symptoms may be worse at
night, leading to disturbed sleep.
— The pruritus often deteriorates as the pregnancy advances, alongside
worsening liver function.
— there is no specific rash associated with ICP
— Constitutional symptoms of cholestasis, including dark urine and pale
stools, and right upper quadrant pain may occur.
— jaundice is rare, affecting less than 10% of women with ICP.
— A family history of cholestasis in pregnancy supports the diagnosis, and is
present in up to 14% of affected women, but is not essential 3/25/20ELBOHOTY33

34. —Pruritus disturbs the sleeping pattern, thus
severely affecting the quality of life and general
health of a pregnant woman.
—Obstetric complication: stillbirth, premature
birth, meconium passage, fetal distress,
delivery by caesarean section and postpartum
haemorrhage, but some of this evidence is of
poor quality.
3/25/20ELBOHOTY34

35. Assessment
— History:
— Unexplained itching
— Evidence of cholestasis : pale stool, dark urine and jaundice
— Risk factors: personal or family history of obstetric cholestasis,
multiple pregnancy, carriage of hepatitis C and presence of gallstones.
— Exam:
— No rash
— Blood pressure measurement to exclude preeclampsia
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36. Investigations:
— Exclusion of other conditions : a viral screen, liver autoimmune and liver
ultrasound.
— Monitoring of liver function and bile acids.
— For transaminases,gamma-glutamyl transferase and bilirubin, the upper
limit of normal throughout pregnancy is 20% lower than the non
pregnant range.
— Women with persistent pruritus and normal biochemistry
should have LFTs repeated every 1–2 weeks. and if becomes
high should be measered10 days after delivery
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38. Prognosis
—Recurrence in subsequent pregnancies:
à60% to 70% or Use of CHC
—Resolves within the first month after delivery
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41. Treatment
— Ursodeoxycholic acid
— Naturally occuring hydrophilic bile acid that enhances excretion of hydrophobic
bile acids, other hepatotoxic compounds, and sulfated progesterone metabolites.
— It reduces maternal pruritus and liver function,
— 15 mg/kg a day as a single dose or in two divided doses
— Topical emollients
— Sedating antihistamines
— Water-soluble vitamin K if Prolonged PT
— Cholestyramine may be effective however it exagerates nuterional
deficiencies
3/25/20ELBOHOTY41

42. Atopic eruption of pregnancy
— Atopic eruption of pregnancy is known to be a benign
condition with an incidence of 1 in 300.
— There is a higher incidence in women with a family history
of atopy.
— The pathogenesis of this condition is thought to be linked
to pregnancy-specific immunological changes.
— Reduced cellular immunity and reduced production ofTh1
cytokines (interleukin[IL]-2, IL-12, interferon gamma) and
increased secretion ofTh2 cytokines (IL-4, IL-10).
3/25/20ELBOHOTY42

43. —In 80% of cases atopic eruption of pregnancy
occurs as the primary condition and in the rest
of patients as an exacerbation of a pre-existing
complaint.
—It presents as erythematous, excoriated
nodules or papules on the face, neck, chest and
extensor surfaces of the limbs and trunk.
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45. Treatment
— Topical emollients
— Topical anti-pruritics
— Topical steroids
— Antihistamines
— Ultraviolet light
— Topical benzoyl peroxide preparations and erythromycin with zinc
acetate lotion
3/25/20ELBOHOTY45

46. Polymorphic eruption of pregnancy
—It is a benign, self-limiting, pruritic inflammatory
disorder of pregnancy with the reported incidence
being 1 in 300 pregnancies, usually presenting in
the third trimester or immediately postpartum.
—Risk factors include nulliparity, multiple pregnancies
and any other cause of overdistension of the
abdominal skin in pregnancy.
3/25/20ELBOHOTY46

47. Sites:
—The condition initially presents with pruritic,
erythematous papules commonly located
within the abdominal striae and with
periumbilical sparing. It progresses to the
trunk and extremities, sparing the palms and
soles in the majority of cases, and does not
affect the face.
—The lesions can coalesce to form plaques or
wheals, often resembling target lesions.
—Most of the time it resolves within 4–6 weeks
from the time of onset. 3/25/20ELBOHOTY47

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50. Treatment
—This dermatosis is usually self-limiting and
treatment is predominantly for symptom
control to relieve pruritus and reduce
inflammation.
—Topical steroids are often used as the first line
of treatment.
—Antihistamines and emollients may also be
beneficial. 3/25/20ELBOHOTY50

51. Pemphigoid gestationis
— (pregnancy-related bullous pemphigoid, gestational
pemphigoid and herpes gestationis).
— The incidence of this dermatosis is very rare, affecting
between 1 in 1700 and 1 in 50 000 pregnancies, and it
occurs any time after the second trimester.
— It is believed to be an autoimmune condition with
antibodies against target antigen (proteins of placenta and
the skin).
— There is a recognised correlation with the HLA-DR3 and
HLA-DR4 of the fetus or the partener
3/25/20ELBOHOTY51

52. —The rash usually appears around the umbilicus
as urticarial papules and plaques, which join to
form bullae, extending to involve the trunk,
extremities, palms and soles with mucosal
sparing.
—Large, tense blisters can form after a few weeks
around the edge of the rash.
—Other autoimmune diseases, including Graves’
disease can be present.
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53. Pemphigoid Gestationis
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56. —A skin biopsy is necessary to make the
diagnosis.
—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).
.
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57. Complications
—IUGR
—? Preterm labour
—Self-limiting skin lesions in neonate 10%
of cases
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58. Mangement
—Increase fetal monitoring
—Topical/oral corticosteroids
—Antihistamines
—Immunosuppressants
—Postnatal survilance:A postnatal flare-up is
also common and usually resolves within 2
to 6 weeks
3/25/20ELBOHOTY58

59. Skin Conditions Influenced by
Pregnancy
3/25/20ELBOHOTY59

60. — Melanomas : no increased risk of
melanoma in pregnancy.
— Nevi: may develop, enlarge, or darken
— Atopic dermatitis : More likely to worsen
than improve
— Psoriasis: More likely to improve than
worsen hover Psoriatic arthritis may worsen
3/25/20ELBOHOTY60

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63. Systemic lupus erythematosus
— SLE may worsen and may flare postpartum.
— 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.
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65. Nonatal lupus
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66. Summary points
3/25/20ELBOHOTY
— Pregnancy causes changes in the immune system
— The two commonest skin conditions in pregnancy are atopic eruption of
pregnancy and polymorphic eruption of pregnancy
— Pemphigoid gestationis is a rare autoimmune bullous disease that can
cause reduced fetal growth and prematurity
— Many common skin diseases may flare in pregnancy and treatment may
need to be modified for the safety and wellbeing of the mother and fetus
— Pemphigoid gestationis, pemphigus vulgaris, and systemic lupus
erythematosus can all lead to neonatal involvement from passive transfer
of maternal antibodies across the placenta
— Emollients are the mainstay of treatment in reducing pruritus and giving
women relief of symptoms
66

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68. 3/25/20ELBOHOTY
— Pregnant patient at 26 weeks ,Came with skin itching and
papules mainly at the flexor surfaces of upper and lower
limbs, skin biopsy showed complement deposition, likely
diagnosis is:
~Obstetric cholestasis
~pimphigoid gestationis
~PEP
68

69. Thank you