SKIN CHANGES AND SKIN CHANGES AND DERMATOSES OF DERMATOSES OF

PREGNANCYPREGNANCY

Dr. HUSSEIN ABOUL FOTOUHDr. HUSSEIN ABOUL FOTOUH

DermatologistDermatologist

Al Meeqat General HospitalAl Meeqat General Hospital

Almadina AlmunawaraAlmadina Almunawara

During pregnancy immunologic endocrine During pregnancy immunologic endocrine metabolic and vascular changes occur that metabolic and vascular changes occur that make the pregnant woman susceptible to skin make the pregnant woman susceptible to skin changes both physiologic and pathologic.changes both physiologic and pathologic.

They areThey are A-Physiologic skin changesA-Physiologic skin changes B-Dermatoses aggravated by pregnancyB-Dermatoses aggravated by pregnancy C-Dermatoses of pregnancyC-Dermatoses of pregnancy

Physiologic skin changesPhysiologic skin changes Caused by the hormonal changes of Caused by the hormonal changes of

pregnancypregnancy 11-Pigmentary changes -Pigmentary changes (usually regress postpartum)(usually regress postpartum) -Diffuse hyperpigmentation(90% with -Diffuse hyperpigmentation(90% with

accentuation of normally hyperpigmented accentuation of normally hyperpigmented areas e.g. areolae axillae linea albaareas e.g. areolae axillae linea alba

-Melasma(70% of pregnant)-Melasma(70% of pregnant) -Darkening of nevi-Darkening of nevi -Pigmentation of axillae and inner thighs-Pigmentation of axillae and inner thighs

22-Hair changes (hirsutism postpartum -Hair changes (hirsutism postpartum telogen effluvium postpartum male pattern telogen effluvium postpartum male pattern alopecia)alopecia)

33-Nail changes (subungual hyperkeratosis -Nail changes (subungual hyperkeratosis distal onycholysis transverse grooving and distal onycholysis transverse grooving and brittleness)brittleness)

44-Glandular -Glandular -Increased eccrine activity (hyperhidrosis -Increased eccrine activity (hyperhidrosis

miliaria and dyshidrotic eczema)miliaria and dyshidrotic eczema) -Decreased apocrine activity )(hidradenitis -Decreased apocrine activity )(hidradenitis

suppurativa)suppurativa) -Increased sebaceous activity (exacerbation -Increased sebaceous activity (exacerbation

of AV enlarged Montgomery follicles of of AV enlarged Montgomery follicles of areolae)areolae)

55-Striae distensae or atrophicae-Striae distensae or atrophicae

66--VascularVascular(spider nevi palmar erythema (spider nevi palmar erythema nonpitting facial edema varicosities nonpitting facial edema varicosities dermographism and haemorrhoides)dermographism and haemorrhoides)

77--Gingival hyperemia and gingivitisGingival hyperemia and gingivitis

88--Prurigo gravidarum due to functional Prurigo gravidarum due to functional hepatic disturbance induced by estrogenshepatic disturbance induced by estrogens

Dermatoses aggravated by pregnancyDermatoses aggravated by pregnancy

11-Infections-Infections ( severe seborrhoeic dermatitis or orovulval ( severe seborrhoeic dermatitis or orovulval candidiasis should raise suspicion of HIV during pregnancy)candidiasis should raise suspicion of HIV during pregnancy)

-Viral (H. simplex- condyloma accuminata-Viral (H. simplex- condyloma accuminata ( ( cs is cs is indicated for both)-indicated for both)- varicella zoster) varicella zoster)

-Bacterial (leprosy)- protozoan (trichomoniasis) -Bacterial (leprosy)- protozoan (trichomoniasis) -Fungal (Candida -pityrosporum folliculitis)-Fungal (Candida -pityrosporum folliculitis) .AIDS pregnancy accelerates the development of .AIDS pregnancy accelerates the development of

AIDS in an asymptomatic HIV +ve patient.AIDS in an asymptomatic HIV +ve patient. 22-Inflammatory disorders-Inflammatory disorders -Atopic dermatitis-Atopic dermatitis––acne vulgaris acne vulgaris ––Hidradenitis Hidradenitis

suppurativa suppurativa ––Chronic plaque psoriasis Chronic plaque psoriasis ––Fox Fox fordyce disease (all may improve) -urticariafordyce disease (all may improve) -urticaria

33-Autoimmune diseases -SLE -Autoimmune diseases -SLE –– Dermatomyositis Dermatomyositis

-Pemphigus vulgaris -Pemphigus vulgaris –– Systemic sclerosis Systemic sclerosis -Rheumatoid arthritis (improve)-Rheumatoid arthritis (improve) 44-Metabolic diseases -Metabolic diseases -Porphyria cutanea tarda -Porphyria cutanea tarda –– Acrodermatitis Acrodermatitis

enteropathicaenteropathica 55- Connective tissue disorders- Connective tissue disorders -Ehler Danlos syndrome -Ehler Danlos syndrome –– Pseudoxanthoma Pseudoxanthoma

elasticumelasticum 66- Tumors- Tumors -Pyogenic granuloma -Pyogenic granuloma ––Glomus tumor Glomus tumor ––

Hemangioma Hemangioma ––Hemangioendothelioma Hemangioendothelioma ––dermatofibroma dermatofibroma ––neurofibroma -melanomaneurofibroma -melanoma

77-Miscellaneus -Miscellaneus ––SarcoidosisSarcoidosis (may improve (may improve

during pregnancy)during pregnancy) ––Mycosis fungoides -Mycosis fungoides -Neurofibromatosis Erythrokeratoderma Neurofibromatosis Erythrokeratoderma variabilisvariabilis

DERMATOSES OF PREGNANCY(6DERMATOSES OF PREGNANCY(6))

11-Intrahepatic cholestasis of pregnancy (ICP)-Intrahepatic cholestasis of pregnancy (ICP) 22-Impetigo herpetiformis (IH)-Impetigo herpetiformis (IH) 33-Herpes gestationis (HG)-Herpes gestationis (HG) 44-Pruritic urticarial papules and plaques of -Pruritic urticarial papules and plaques of

pregnancy (PUPPP)pregnancy (PUPPP) 55-Prurigo of pregnancy (PP)-Prurigo of pregnancy (PP) 66-Pruritic folliculitis of pregnancy (PFP)-Pruritic folliculitis of pregnancy (PFP)

Intrahepatic cholestasis of pregnancyIntrahepatic cholestasis of pregnancy

It is seen in the third trimester ( unlike physiologic It is seen in the third trimester ( unlike physiologic prurigo gravidarum which occurs in the first prurigo gravidarum which occurs in the first trimester) . It is characterized by trimester) . It is characterized by

-Elevated liver function tests and serum bile acids-Elevated liver function tests and serum bile acids -Generalized pruritus ( high bile salts) and -Generalized pruritus ( high bile salts) and

excoriations (excoriations (without primary skin lesions)without primary skin lesions) with jaundice in with jaundice in 50% of cases that resolves after delivery50% of cases that resolves after delivery

-Malabsorption of fat with weight loss vitamin k -Malabsorption of fat with weight loss vitamin k deficiency------- IU Hgedeficiency------- IU Hge

-Increased fetal distress and stillbirths-Increased fetal distress and stillbirths -50% recurrence with subsequent pregnancies-50% recurrence with subsequent pregnancies TTT emollients cholestyramin UVB evening primrose TTT emollients cholestyramin UVB evening primrose

oil.oil.

IMPETIGO HERPETIFORMIS(IH)IMPETIGO HERPETIFORMIS(IH) A variant of pustular psoriasis( histopathologically) A variant of pustular psoriasis( histopathologically)

characterized by characterized by widespread sheets of widespread sheets of erythema with pustular margin starting erythema with pustular margin starting in flexuresin flexures sparing face hands and feet there is sparing face hands and feet there is fever diarrhea and vomiting.fever diarrhea and vomiting.

-It starts usually in the third trimester and resolves -It starts usually in the third trimester and resolves postpartum but may recur with subsequent postpartum but may recur with subsequent pregnancies pregnancies

-associated with hypocalcaemia high ESR and -associated with hypocalcaemia high ESR and leukocytosis.leukocytosis.

TTT prednisolone 40 mg daily calcium and TTT prednisolone 40 mg daily calcium and termanination is indicated (termanination is indicated (stillbirth and placental stillbirth and placental insufficiency).insufficiency).

Herpes gestationis (HG)Herpes gestationis (HG) an autoimmune bullous an autoimmune bullous disorder closely related to Bullous pemphigoiddisorder closely related to Bullous pemphigoid . .OnsetOnset::

-second or third trimester .Recurrence is common -second or third trimester .Recurrence is common with subsequent pregnancies and oral contraceptives with subsequent pregnancies and oral contraceptives

-Intensely pruritic erythematous plaques on the -Intensely pruritic erythematous plaques on the abdomen periumblical----------generalized bullous abdomen periumblical----------generalized bullous eruption sparing face mucous membranes palms and eruption sparing face mucous membranes palms and soles soles

-Histopathology subepidermal separation basal cell -Histopathology subepidermal separation basal cell necrosis eosinophilic spongiosis.necrosis eosinophilic spongiosis.

Direct Immuno Fluorescence shows linear c3 and IgG Direct Immuno Fluorescence shows linear c3 and IgG at BMZat BMZ

HG factor is a circulating IgG Ab. that binds toAg2 in HG factor is a circulating IgG Ab. that binds toAg2 in BMZ the same antigen is found in the placenta.It BMZ the same antigen is found in the placenta.It stimulates complement pathway----c3 deposition at stimulates complement pathway----c3 deposition at BMZ---chemotaxis of eosinophils----proteolytic BMZ---chemotaxis of eosinophils----proteolytic enzymes-----dermoepidermal separation enzymes-----dermoepidermal separation

TTT mild cases potent topical steroids TTT mild cases potent topical steroids and systemic antihistaminesand systemic antihistamines

-prednisone 20-prednisone 20——40mg daily40mg daily

-Plasmapheresis-Plasmapheresis

NB Avoid dapsone-----neonatal NB Avoid dapsone-----neonatal hemolysis and avoid oral hemolysis and avoid oral contraception-------HG recurrencescontraception-------HG recurrences

PRURITIC URTICARIAL PAPULES AND PLAQUES OF PRURITIC URTICARIAL PAPULES AND PLAQUES OF PREGNANCY (PUPPP) SYN. POLYMORPHIC ERUPTION PREGNANCY (PUPPP) SYN. POLYMORPHIC ERUPTION OF PREGNANCYOF PREGNANCY

The most common 1to 300 preg.The most common 1to 300 preg. -occurs in primigravidas in the third trimester -occurs in primigravidas in the third trimester

and does not usually recur in subsequent and does not usually recur in subsequent pregnancies.pregnancies.

-severely pruritic polymorphous eruptions -severely pruritic polymorphous eruptions (urticarial-papules-plaques-and erythema (urticarial-papules-plaques-and erythema multiforme like lesions) usually begin in the multiforme like lesions) usually begin in the striae on the abdomen and spreading striae on the abdomen and spreading peripherally .The face palms and soles are peripherally .The face palms and soles are commonly spared.It resolves after delivery.commonly spared.It resolves after delivery.

--HISTOPATHOLOGY mild spongiosis and superficial HISTOPATHOLOGY mild spongiosis and superficial perivascular inflammatory cell infiltrate with many perivascular inflammatory cell infiltrate with many eosinophilseosinophils

PathogenesisPathogenesis

Rapid abdominal distention in primigravidas in Rapid abdominal distention in primigravidas in third trimester may cause damage to third trimester may cause damage to connective tissue in the striae and trigger the connective tissue in the striae and trigger the inflammatory response to PUPPPinflammatory response to PUPPP..

--It is harmless to the fetus and motherIt is harmless to the fetus and mother. .

TTT Antihistamines TTT Antihistamines –– short course of oral short course of oral prednisone prednisone ––topical steroids and antipruritics-topical steroids and antipruritics-UVB therapyUVB therapy

PRURIGO OF PREGNANCY (PP)PRURIGO OF PREGNANCY (PP)

-Onset 2-Onset 2ndnd or 3 or 3rdrd trimester with no recurrence with trimester with no recurrence with

subsequent pregnancy.subsequent pregnancy.

-Clinically pruritic papules or nodules on extensors of -Clinically pruritic papules or nodules on extensors of limbs or abdomen (similar to nodular prurigo) as limbs or abdomen (similar to nodular prurigo) as there may be an atopic background. No there may be an atopic background. No complications.complications.

-TTT topical steroids -TTT topical steroids –– antihistamines antihistamines –– resolution ----- resolution -----weeks after pregnancyweeks after pregnancy

PRURITIC FOLLICULITIS OF PREGNANCY(PFP)PRURITIC FOLLICULITIS OF PREGNANCY(PFP)

-Onset 2-Onset 2ndnd or 3 or 3rdrd trimester with no recurrence with trimester with no recurrence with subsequent pregnancy.subsequent pregnancy.

-Clinically similar to steroid acne (pruritic -Clinically similar to steroid acne (pruritic erythematous follicular papules on limbs and erythematous follicular papules on limbs and abdomen).abdomen).

-No complications-No complications

-TTT Topical steroids -TTT Topical steroids –– Resolution is postpartum Resolution is postpartum

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