The document discusses several changes that can occur to a woman's skin and underlying tissues during pregnancy. These include hyperpigmentation, melasma, hair and nail changes, vascular changes like spider telangiectases, glandular changes influencing sweating and acne, and connective tissue changes resulting in striae distensae. Several skin conditions like psoriasis and autoimmune disorders may also be influenced by pregnancy. Specific conditions that can occur include herpes gestationis, PUPPP, intrahepatic cholestasis of pregnancy, and pruritic folliculitis. The use of various drugs during pregnancy is also addressed, with categories assigned based on potential fetal risk.

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.

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

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

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

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.

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

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