Skin Eruptions in Pregnancy - TOG article

Question 1

What proportion of pregnant mothers report melasma (chloasma gravidarum)?

Answer 1

75%

Question 2

What treatments for melasma have been tried?

Answer 2

Avoid sunlight exposure - most important

Topical bleaching
Hydroquinones (not licenced in UK)
Retinoids\Steroids
Chemical peel
Laser treatment
Dermabrasion

Not in preg/breastfeeding, limited response

Question 3

What causes striae?

Answer 3

Rupture of dermal elastic fibres

Question 4

What are the risk factors for developing striae?

Answer 4

Personal/family history
Dark skinned women
Excessive abdominal distension
No evidence for Vitamin E, tea tree oil

Question 5

What happens to hidradenitis suppurativa in pregnancy

Answer 5

Tends to improve - decreased apocrine activity

Question 6

What happens to sebaceous glands in pregnancy?

Answer 6

Increased activity in third trimester (acne effect variable)

May develop Montgomery tubercles (follicles) - hypertrophic glands, non pigmented elevations in primary areola

Question 7

What is the prevalence of spider naevi, when do they appear and what is the treatment in pregnancy?

Answer 7

66% in Caucasians, 11% in black
Appear T2, disappear 3/12 postnatal
Sclerotherapy/laser to lower extremities if required

Question 8

What happens to eccrine glands in pregnancy?

Answer 8

Increased secretion towards T3

Causes prickly heat (miliaria) and hyperhidrosis what can cause pruritis

Question 9

What causes increased hair growth antenatally?

Answer 9

Prolongation of anagen phase

Question 10

What is acute telogen effluvium and when does it occur?

Answer 10

Generalised hair shedding with diffuse non-scarring alopecia

Occurs 3-6/12 PN, spontaneous recovery 9-12/12, most recover completely

Question 11

What happens to nails in pregnancy?

Answer 11

Grow faster

May become dystrophic, brittle

Question 12

What happens to mucosa in pregnancy?

Answer 12

Pigmentation, hyperaemia, hypertrophy - may bleed

Question 13

How many pregnancies are affected by pruritis with no underlying haematological/biochemical disorder?

Which sites most affected and when?

What is recurrence rate

Answer 13

18%
Scalp and abdomen, T3 and peaks 1/12 pre delivery

Recurrence rate up to 80%

Question 14

When do dermographism and urticaria commonly occur?

Answer 14

Last half of pregnancy

Question 15

Which pregnancy dermatoses can cause IUGR, prematurity and stillbirth?

Answer 15

Intrahepatic cholestasis of pregnancy and pemphigoid gestationis

Question 16

What is the prevalence of OC?

Answer 16

0. 7% in multiethnic populations

1. 2-1.5% of women with Indian/Pakistani origin

Question 17

What other investigations should be performed when considering OC as a diagnosis?

Answer 17

Viral screen
Liver autoimmune
Pre eclampsia screen
Liver USS

If liver fx improves/worsens rapidly - unlikely OC

Question 18

What is the recurrence rate of OC?

Answer 18

60-70%

Question 19

What is the dose of ursodeoxycholic acid?

Answer 19

15mg/kg OD or in divided doses

Minimal evidence for emollients, antihistamines, vitamin K

Question 20

What is atopic eruption of pregnancy also known as?

Answer 20

Prurigo gestationis (Besnier)
Nurse’s early-onset prurigo of pregnancy
Pruritic folliculitis of pregnancy
Eczema in pregnancy

Question 21

What is the incidence of atopic eruption of pregnancy?

Answer 21

1 in 300

Question 22

What is a risk factor for atopic eruption of pregnancy?

Answer 22

FHx of atopy

Question 23

What are the immunological changes in atopic eruption of pregnancy?

Answer 23

Reduced cellular immunity and decreased Th1 cytokines

Dominant humoral immunity and increased Th2 cytokines

Question 24

In what % of patients does atopic eruption of pregnancy occur as the primary condition?

When does it occur?

Answer 24

80%
Rest exacerbation of pre-existing

Anytime but most T2 and T3. Improves following delivery

Question 25

What presents as erythematous, excoriated nodules or papules on the face, neck, chest, extensor surfaces of limbs, trunk?

Answer 25

Atopic eruption of pregnancy

Question 26

What is the risk of recurrence of atopic eruption of pregnancy and what effect on mum/fetus?

Answer 26

Limited data. No adverse effects.

Question 27

What is the treatment of atopic eruption of pregnancy?

Answer 27

Symptom relief - oat bath, emollient, topical antipruritics, topical stroids, UV light Topical benzoyl peroxide, erythromycin with zinc acetate lotion

Question 28

What is polymorphic eruption of pregnancy also known as?

Answer 28

``` Pruritic urticarial papules and plaques of pregnancy Toxic erythema of pregnancy Bourne's toxaemic rash of pregnancy Linear IgM dermatosis of pregnancy Nurse's late-onset prurigo ```

Question 29

What is the incidence of polymorphic eruption of pregnancy? When does it present?

Answer 29

1 in 160-300 T3 or immediately postpartum. Resolves 4-6/52 from onset

Question 30

What are the risk factors for polymorphic eruption of pregnancy?

Answer 30

Nulliparity Multiple pregnancy Overdistension of abdominal skin

Question 31

What presents as erythematous papules in striae with periumbilcal sparing, to the trunk and extremities (not palm/soles/face)?

Answer 31

Polymorphic eruption of pregnancy

Question 32

Which condition shows histologically non-specific, negative immunofluoresence

Answer 32

Atopic eruption of pregnancy

Question 33

Which condition histologically shows lymphocytic vasculitis with eosinophils and oedema of the papillary dermis? Later biopsies show spongiosis, hyper- and parakeratosis? Negative immunfluoresence.

Answer 33

Polymorphic eruption of pregnancy

Question 34

What is the treatment for polymorphic eruption of pregnancy

Answer 34

Symptomatic - topical steroids, antihistamines, emollients

Question 35

What is the recurrence and impact on mum/fetus in PEP?

Answer 35

Rare recurrence | No adverse impact

Question 36

What is pemphigoid gestationis also known as?

Answer 36

Pregnancy-related bullous pemphigoid | Herpes gestationis

Question 37

What is the incidence of pemphigoid gestationis and when does it occur?

Answer 37

1 in 1700-50,000 Any time after T2, rarely immediately after childbirth

Question 38

What presents with a rash around the umbilicus, urticarial papules and papules which join to form bullae to trunk, extremities, palms, soles (mucosal sparing)? Blisters after a few weeks around the edge of the rash?

Answer 38

Pemphigoid gestationis

Question 39

What is the mechanism of pemphigoid gestationis and how is diagnosis made?

Answer 39

Autoimmune antibodies against placental proteins and skin Biopsy necessary

Question 40

Which haplotypes are associated with pemphigoid gestationis?

Answer 40

HLA DR3 and 4

Question 41

Which condition histologically shows degenerative changes in basal cells with blister in epidermis and then subsequently between Malphigian layer and subepidermal basement membrane? Direct and indirect (blood/blister fluid) immunofluorescence positive.

Answer 41

Pemphigoid gestationis

Question 42

What is the treatment of pemphigoid gestationis?

Answer 42

Symptom control - topical/PO steroids and antihistamines Caution with ccs - osteoporosis risk Cyclosporin - appears safe but avoid in breastfeeding

Question 43

How many patients experience a flare of pemphigoid gestationis at the time of delivery? When does postnatal flare resolve?

Answer 43

75% - common postnatally Resolve 2-6/52

Question 44

What is the recurrence of pemphigoid gestationis?

Answer 44

May occur - earlier onset and more severe | Also with COCP/menstration

Question 45

What is the impact of pemphigoid gestationis on the fetus?

Answer 45

IUGR - scans monthly Conflicting evidence re:PTL 1 in 10 newborns mild self limiting skin lesions

Question 46

What other conditions are associated with pemphigoid gestationis?

Answer 46

Autoimmune - Graves' - consider TFTs

Question 47

Which patients should be referred to a dermatologist?

Answer 47

Pemphigoid gestationis PEP or atopic eruption where initial management fails Skin eruptions with systemic symptoms