Skin Eruptions Specific to Pregnancy

Question 1

What are the 4 dermatosis of pregnancy?

Answer 1

1- atopic eruption of pregnancy
2- pemphigoid gestationis
3- polymorphic eruption of pregnancy
4- Intrahepatic cholestasis

Question 2

Among physiological skin changes in pregnancy, what is the most common change?

Answer 2

Melasma , 75 % of pregnant women
Often in 2nd&3rd trimester.
📌 all treatments of melasma ( hydroquinone, retinol, laser …) are contraindicated in pregnancy.
📌 in pregnancy: just sunblock.

Question 3

What is the main cause of stariae gravidarum? What are the risk factors?

Answer 3

📌 Rupture of dermal elastic fibers
[ changes in the connective tissues ]
📌 Risk factors: family histor, dark skinned women, excessive abdominal distention.

Question 4

What is the treatment of striae gravidarum?

Answer 4

Emollients
No evidence that vit E or tea tree oil have any special value.

Question 5

What is the incidence of spider naevi in pregnancy as a physiological change ? When they appear?

Answer 5

66 % in caucasians
11 % in black
🚩face ,neck , hands, arms
🚩in the 2nd trimester, usually disappear around 3rd month postnatally.
🚩 treatment: sclerotherapy , laser

Question 6

Acute telogen effluvium, when it happens?, when the recovery?

Answer 6

3 - 6 months postpartum
Recovery: within 9- 12 months

Question 7

What is the percentage of pregnant women affected by pruritus in the absence of any biochemical disorder? What is the recurrence rate?

Answer 7

Incidence: 18 %
Recurrence in subsequent pregnancies: 80 %

Question 8

How to take a history from a pregnant woman with pruritus?

Answer 8

1- duration
2- progression of the condition
3- relieving or exacerbating factors
& associated symptoms: pain, redness, burning.
4- family hx
5- job - travel
6- past medical hx: asthma, hay fever
7- drug Hx + allergies
8- past dermatological problems
9- previous treatment tried for this condition
10- impact of this condition on quality of life.

Question 9

What is the most common dermatosis of pregnancy?

Answer 9

Atopic eruption 1 / 300
Other terminology of this :
(Prurigo gestationis - pruritic folliculitis - eczema of pregnancy)

Question 10

What are the risk factors of atopic eruption in pregnancy? What is the parthogenesis?

Answer 10

family history of atopy
80 % 👉 primary condition
20% 👉 exacerbation of preexisting condition
📌 pathogenesis : pregnancy specific immunological changes

Question 11

How atopic eruption of pregnancy presented?

Answer 11

2nd or 3rd trimester ( can occur earlier)
Erythematous, excoriated Nodules or papules on the face, neck, chest, extensor surfaces of the limbs

Question 12

How is atopic eruption of pregnancy diagnosed?

Answer 12

Clinically- no other investigations needed
Histopathology : non specific
Immunofluorescence: negative

Question 13

When does atopic eruption of pregnancy improve?

Answer 13

After delivery
No postpartum exacerbation
No data about recurrence

Question 14

What are the treatment options for atopic eruption of pregnancy?

Answer 14

Symptomatic: oatmeal bath - topical antipruritic: 1% menthol- calamine
Topical steroids- oral antihistamine- ultraviolet light to help alleviate symptoms
📌 cool environment is recommended
📌 topical benzoyl peroxide/ erythromycin with zinc acetate lotion are sometimes effective

Question 15

What is the incidence of polymorphic eruption of pregnancy?

Answer 15

1/ 160 - 1/ 300 of pregnancies

Question 16

How is polymorphic eruption of pregnancy ( PUPPP) presents?

Answer 16

🔴Periumbilical sparing
Pruritic urticaria papules & plaques within the abdominal striae/ progresses to trunk &extremities sparing ( palms -soles - face)
🚩Usually in 3rd trimester or immediately postpartum
🚩 self-limiting : 4-6w from the time of onset

Question 17

What are the risk factors for polymorphic eruption of pregnancy (PUPPP) ?

Answer 17

Nulliparity - multiple pregnancies
Any other cause of over distension of the abdominal skin

Question 18

How is PUPPP diagnosed?

Answer 18

Clinically
🍀Biopsy ONLY: if no response to intial treatment or there is a doubt in the diagnosis
🍀 immunofluorescence: ( direct/indirect) : NEGATIVE [ help in DD with pemphigoid gestationis]

Question 19

What is the first line treatment for polymorphic eruption of pregnancy ( PUPPP)?

Answer 19

1-TOPICAL STEROIDS
Oral steroids are virtually never required
2- antihistamines / emollients

Question 20

What is the recurrence rate of PUPPP?

Answer 20

RARE

Question 21

What is the impact of PUPPP on maternal & fetal outcomes?

Answer 21

NOOO impact

Question 22

When does pemphigoid gestationis ( herpes gestationis) occur?

Answer 22

After 2nd & 3rd trimester,
& rarely after delivery

Question 23

What is the incidence rate of pemphigoid gestationis?

Answer 23

1/1700 - 1/ 50,000

Question 24

How does pemphigoid gestationis appear ?

Answer 24

1-Urticarial papules &plaques: around the umbilicus extending to extremities, palms & soles
With MUCOSAL SPARING
2- Blisters; around the edge of the rash

Question 25

What is the cause behind pemphigoid gestationis?

Answer 25

It's believed that autoimmune condition with antibodies against target antigen ( proteins of placenta & skin) ** corelation with HAlA type DR3-DR4

Question 26

How is pemphigoid gestationis diagnosed?

Answer 26

SKIN BIOPSY is necessary 2 samples : from perilessional skin 1 for histology 1 for immunofluorescence

Question 27

What is the treatment of pemphigoid gestationis?

Answer 27

1- Topical & oral steroids Antihistamines 2- antibiotics: can be helpful 3- CYCLOSPORINE safe in pregnancy 🚩 alendronic acid is contraindicated in pregnancy 4- cases unresponsive to systemic steroids may benefit from immunophoresis

Question 28

Why is CYCLOSPORINE considered safe in pregnancy & contraindicated in breastfeeding?

Answer 28

Owing to the potential for immunosuppression & neutropenia

Question 29

What is the course of pemphigoid gestationis in pregnancy?

Answer 29

Exacerbations & remissions are characteristic 📌 flare up at delivery 75% of patients 📌 flare up postpartum: common

Question 30

When does pemphigoid gestationis resolve?

Answer 30

2-6 weeks postpartum

Question 31

What is the recurrence of pemphigoid gestationis?

Answer 31

There is a recurrence in subsequent pregnancies with earlier onset & increasing severity 🍀 Also with: OC or during MENSTRUATION

Question 32

What are the fetal outcomes in a pregnancy complicated by pemphigoid gestationis?

Answer 32

1- IUGR 👉 monthly scan 2- preterm delivery: conflicting evidence 3- 1/10 babies will devlop SKIN LESIONS due to passive transfer of antibodies

Question 33

What is the autoimmune disease that associated with pemphigoid gestationis?

Answer 33

GRAVES DISEASE 👉👉 consider TFTs

Question 34

When to refer a pregnant with skin eruption to obstetric consultant?

Answer 34

1- pemphigoid gestationis 2- Intrahepatic cholestasis

Question 35

When to refer a pregnant with a skin eruption to a dermatologist?

Answer 35

1-Any skin eruption where initial management fails or associated with systemic symptoms 2- pemphigoid gestationis