Dermatoses in pregnancy

Question 1

List 3 types of rash in pregnancy

Answer 1

Polymorphic eruption of pregnancy (used to be called PUPs)
Pemphigoid gestationis
atopic eruption of pregnancy

Question 2

What is the incidence of PUPPS?

Answer 2

1:200

Question 3

What is the incidence of pemphigoid gestationis?

Answer 3

1:10-50,000

Question 4

What is the incidence of atopic eruption of pregnancy?

Answer 4

1:300

Question 5

What is the pathophysiology of PUPPS?

Answer 5

• not known
• stretching of skin resulting in damage to connective tissue
• associated with obesity, multiple pregnancy, primiparous

Question 6

What is the pathophysiology of pemphigoid gestationis?

Answer 6

• autoimmune condition (pregnancy specific)
• IgG antibodies target basement membrane zone protein BP180
• associated with; T1DM, graves, rheumatoid arthritis (other AI conditions)
• HLA-DR3 and HLA-DR4 association

Question 7

What is the pathophysiology of atopic eruption of pregnancy?

Answer 7

• association with atopy
• TH2 mediated
• associated with multiparity
• 3 types - eczema, prurigo of pregnancy, pruritic folliculitis of pregnancy

Question 8

What is the timing of onset of PUPPs rash?

Answer 8

Third trimester

Question 9

What is the timing of onset of Pemphigoid gestationis?

Answer 9

• anytime but more commonly 3rd trimester

- earlier in each subsequent pregnancy

Question 10

What is the timing of onset of atopic eruption of pregnancy?

Answer 10

earlier onset

75% in 1st and 2nd trimester

Question 11

What is the distribution of the PUPPS rash?

Answer 11

abdominal and proximal limbs

umbilical sparing

Question 12

What is the distribution of pemphigoid gestationis rash?

Answer 12

Peri-umbilical and abdominal
spreads peripherally to limbs, palms and soles
does not affect face or mucous membranes

Question 13

What is the distribution of atopic eruption of pregnancy rash?

Answer 13

typical atopic sites - extensor surfaces/creases

abdo/back/chest

Question 14

How would the rash of PUPPs be described

Answer 14

Urticarial papules and plaques
halo around the papules/plaques
severe pruritis

Question 15

How would the rash of pemphigoid gestationis be described?

Answer 15

pruritic, erythematous plaques
target lesions
after 2/52 vesicles and tense bullae may form

Question 16

How would the rash of atopic eruption of pregnancy be described?

Answer 16

diffuse eczematous changes to face, neck, flexion areas

eczematous brown nodules or papules

Question 16

How would the rash of atopic eruption of pregnancy be described?

Answer 16

diffuse eczematous changes to face, neck, flexion areas

eczematous brown nodules or papules

Question 16

How would the rash of atopic eruption of pregnancy be described?

Answer 16

diffuse eczematous changes to face, neck, flexion areas
eczematous brown nodules or papules
follicular papules or pustule eruptions

Question 17

How long does PUPPs take to resolve?

Answer 17

• self limiting
• 4-6 weeks
• does not usually recur

Question 18

How long does Pemphigoid gestationis take to resolve?

Answer 18

• may improve nearing end of pregnancy
• flares can occur postpartum
• may develop into bullous pemphigoid
• may recur in subsequent pregnancies or with use of OCP

Question 19

How long does atopic eruption of pregnancy take to resolve?

Answer 19

pruritis improves after delivery
papules may persist for several months post partum
may recur in subsequent pregnancies

Question 19

How long does atopic eruption of pregnancy take to resolve?

Answer 19

pruritis improves after delivery
papules may persist for several months post partum
may recur in subsequent pregnancies

Question 20

Are there any fetal effects associated with PUPPs?

Answer 20

No

Question 21

Are there any fetal effects with pemphigoid gestationis?

Answer 21

• low brith weight
• pre term
• stillbirth - 30%
• similar transient bullous eruption in 10% of babies

Question 22

Are there any fetal effects associated with atopic eruption in pregnancy?

Answer 22

no

Question 23

How is diagnosis of PUPPs made?

Answer 23

Clinical diagnosis can biopsy to rule out other conditions negative immunoflourescence distinguishes PUPPs from pemphigoid

Question 24

How is the diagnosis of pemphigoid gestationis made?

Answer 24

skin biopsy/histology direct immunofluorescence - c3 complement deposition at basement membrane indirect immunofluorescence - antibodies in maternal serum

Question 25

How is diagnosis of atopic eruption of pregnancy made?

Answer 25

clinical | if folliculitis obtain culture to rule out bacterial or candida infection

Question 26

How do you manage PUPPs?

Answer 26

``` reassure cool soothing baths emollients 1% menthol in aqueous cream topical steroids sedating anti-histamines consider systemic steroids if severe and intractable ```

Question 27

How do you manage pemphigoid gestationis

Answer 27

Simple measures - cool soothing baths, emollients topical steroids 0.05% clobetasone (lower potency than clobetasol) sedative anti-histamines systemic steroids sometimes azathioprine or cyclosporine is required

Question 28

How do you manage atopic eruption of pregnancy?

Answer 28

Topical steroids 1% hydrocortisone topical benzoyl peroxide to pustular lesions anti-histamines PRN