skin in preggnancy

8/17/2019 skin in preggnancy

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Skin diseases in

pregnancy


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The dermatoses of pregnancy

can be classifed into the ollowing 3groups:

physiologic skin changes in pregnancy,

dermatoses and cutaneous tumors

aected by pregnancy,

and specifc dermatoses o pregnancy


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Pemphigoid Gestationis


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Pemphigoid Gestationis

&erpes gestationis

•

' pregnancy(associateda)toimm)ne disease.

• )t is not related to or associated withany acti*e or prior herpes *irusinection.

• named herpes gestationis on thebasis o the morphological

herpetiorm eature o the blisters.


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PE3P4IG#I! GESTATI#IS

+eers to a ,istering disease that is clearlyassociated with pregnancy and increased +eta,risk .

)t only occurs during pregnancy or withtrophoblastic tumors%such as hydatiorm mole orchoriocarcinoma.

)ncidence ,-////

&0'(1+3 and &0'(1+2 are more common amongwomen with this disorder.


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linical 4aniestations

• Pr)rit)s may precede onset o *isible skinlesions% which er)pt during the second orthird trimester or postpart)m.

• 5he rash typically begins on the tr)nk asurticarial pla6ues or papules surrounding the)mi,ic)s 7 *esicles may also be present .

• 0esions may be seen on the palms and soles%but rarely on the ace or mucous membranes.

• 4ucosal lesions are present in less than 8/percent o cases.

• 5he eruption spreads rapidly and orms ),,ae .


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"eriumbilical erythematous papules%

*esicles% erosions% and crusts arepresent in this patient withpemphigold gestations.


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4ultiple tense bullae on skin.


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ourse

Co)rse "emphigoid gestationis may remit priorto deli*ery.

&owe*er% 9 percent o patients are postpartumand at least 8 percent subse6uently are with useo oral contracepti*e pills or during menses.

4ost cases spontaneously resol*e in the weeks tomonths ollowing deli*ery.

5he disease usually recurs with subse6uentpregnancies and is oten worse % but may also skippregnancies


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5ense bullae are present on the armso this otherwise healthy 38(year(oldprimigra*ida woman.


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' close(up *iew o a blister re*eals the tense

primary lesion flled with clear uid.


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;tiology

Etio,ogy 5he pathologic )g< antibody in patients with pemphigoidgestationis binds to antigen in the =4> o skin% which is known as bullouspemphigoid antigen 8 !="('


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5he initial clinical maniestations are erythematous urticarial patchesand pla6ues% which are typically periumbilical. 5hese lesions progress

to tense *esicles and blisters. Some patients may present withurticarial pla6ues and may ne*er de*elop blisters !see the images

below$. 5hese hi*elike pla6ues dier rom true urticaria because otheir relati*ely f?ed nature. 5he rash spreads peripherally% oten

sparing the ace% palms% and soles. 4ucosal lesions occur in less than8/A o cases. "atients may ha*e secondary inections at blister sites.


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1iagnosis

• 5wo skin biopsies should be obtainedto make the diagnosis o pemphigoidgestationis. Ro)tine histo,ogy is

perormed on one specimen anddirect imm)no5)orescence isperormed on the other


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1irect immunouorescence microscopyshows linear deposition o 3 along the

dermal(epidermal Bunction.


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• Laoratory tests not necessaryor diagnosis.

• 'ntithyroid antibodies are otenpresent .

• The degree o+ periphera,eosinophi,ia may corre,ate 7ith

disease se8erity


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11?

• "ruritic #rticarial "apules and "la6ues o"regnancy

• 'cute #rticaria

• 'llergic ontact 1ermatitis• icatricial "emphigoid

• 1ermatitis &erpetiormis

•1rug()nduced =ullous 1isorders

• ;rythema 4ultiorme

• 0inear )g' 1ermatosis


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5reatment

• mid to high potency topica, corticosteroidsor initial therapy o locali@ed disease.

• #intments tend to cause less stinging and

may be more eecti*e than other topicalpreparations% but are more cumbersome.

• Nonsedating oral antihistamines are an

acceptable alternati*e. 5opical antihistamines

are not recommended because they are noteecti*e and may induce an allergicresponse.


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• ) these drugs do not controlsymptoms% which is common% then

systemic corticosteroids !eg%prednisone /. mg-kg per day$ areusually eecti*e. 5he dose may betapered% and e*en discontinued% in

some pregnancies. &owe*er%reinstatement o treatmentpostpartum will likely be needed .

http://www.uptodate.com/contents/prednisone-drug-information?source=see_linkhttp://www.uptodate.com/contents/prednisone-drug-information?source=see_link


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"rognosis

• 4ild placental insuCciency

• Detuses are at risk or growth restriction andprematurity.

• Neonatal pemphigoid gestationis 7ha*e a mildcourse that resol*es within weeks

• 5here is minimal risk o adrenal etal suppression

• 5he mother is at high risk o recurrent

pemphigoid gestationis with subse6uentpregnancies .

• )ncreased lietime risk o


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PRURITIC URTICARIALPAPULES A! PLA"UES

#$ PREGAC% !"#"""$


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• )s also called polymorphic eruption opregnancy !";"$%

• 5o?ic erythema o pregnancy

• linear )g4 dermatosis o pregnancy


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Incidence

• "#""" is the most common specifcdermatosis o pregnancy.

• 5he incidence is ,-,F/ .

• 5hree(6uarters o patients with the classictype o "#""" are nulliparous .

• "#""" is G( to ,8(old more common inwomen with multiple gestations

• Possi2,y d)e to increased a2domina,distension or higher hormone ,e8e,s


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1iagnosis

• 5he diagnosis o "#""" is clinical%based on characteristic fndings onhistory and physical e?amination.


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linical 4aniestations

• "#""" typically presents as erythematous papules

within striae .• 'bdominal striae are the most common initial site !with

periumbilical sparing$ and may be the only initial site .

• 5he lesions then spread to the e?tremities and coalesce

to orm urticarial pla6ues.• 5he ace% palms% and soles are usually spared.

• Hhite halos oten surround the erythematous papules inpatients with air skin.

• 0esions may also be target(like.

• 'll patients ha*e e?treme pruritus .

• "#""" usually begins late in the third trimester !meanonset 3 weeks$% but may de*elop postpartum.


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;rythematous pla6ues in the distribution o striae are present.


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;rythematous pla6ues are present in areas o striae in thiswoman with "#""".


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)n air(skinned patients with "#"""% a white halo may bepresent around the erythematous papules and pla6ues.


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;tiology

• 5he etiology o "#""" is unknown and may beheterogeneous .The degree o+ stretching o+the adomina, skin may p,ay a ro,e9 PUPPP ismore common 7ith e:cessi8e stretching .)t

has been hypothesi@ed that stretching may causedamage to connecti*e tissue% which results ine:pos)re o+ antigens that trigger aninammatory response.

•

'nother possibility is that it represents animmunologic response to circulating etal antigens.'s an e?ample% one study demonstrated etal 1N'in maternal skin lesions .


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• Co)rse "ruritus may worsenimmediately ater deli*ery% butgenerally resol*es by , days

postpartum.• Laoratory 5here are no

laboratory abnormalities related to

"#"""


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11?

• 'cute #rticaria

• 'llergic ontact 1ermatitis

• hronic #rticaria

• 1rug ;ruptions

• Erythema 3),ti+orme9target,esion

• Pemphigoid gestationis

http://emedicine.medscape.com/article/137362-overviewhttp://emedicine.medscape.com/article/137362-overviewhttp://emedicine.medscape.com/article/1049216-overviewhttp://emedicine.medscape.com/article/1050052-overviewhttp://emedicine.medscape.com/article/1049474-overviewhttp://emedicine.medscape.com/article/1122915-overviewhttp://emedicine.medscape.com/article/1122915-overviewhttp://emedicine.medscape.com/article/1122915-overviewhttp://emedicine.medscape.com/article/1122915-overviewhttp://emedicine.medscape.com/article/1122915-overviewhttp://emedicine.medscape.com/article/1049474-overviewhttp://emedicine.medscape.com/article/1050052-overviewhttp://emedicine.medscape.com/article/1050052-overviewhttp://emedicine.medscape.com/article/1049216-overviewhttp://emedicine.medscape.com/article/137362-overviewhttp://emedicine.medscape.com/article/137362-overview


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"rognosis

• "#""" poses no increased risk o etal ormaternal morbidity !other than maternalpruritus.

•

5he rate o recurrence has not been defned.

• +ecurrence is also uncommon with mensesor oral contracepti*es.

• Se*eral studies ha*e reported apreponderance o male etuses in womenwith "#""".

AT#PIC ERUPTI# #$


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AT#PIC ERUPTI# #$PREGAC%

• Ec(ema in pregnancy% Pr)rigo o pregnancy% andPr)ritic +o,,ic),itis o pregnancy ha*e beengrouped under the uniying term atopic eruption opregnancy .

• 5his classifcation scheme is based upon thepresence o shared clinical eatures% including a

possible association with atopy.

• 'll three disorders may present with inammatory

papules as a primary eature.• one o+ the disorders c,assi6ed 7ithin this

gro)p are associated 7ith ad8erse eects onthe +et)s.


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;c@ema in pregnancy is strongly associatedwith a personal history o atopy !seasonal

rhinitis% asthma% and-or atopic dermatitis$ . Only8/ percent o aected women ha*e a precedinghistory o atopic dermatitis.


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•

Ec(ema Ec(ema is the mostcommon pr)ritic skin disorderocc)rring in pregnancy.

• ;c@ema in pregnancy is stronglyassociated with a personal history oatopy !seasonal rhinitis%

asthma% and-or atopic dermatitis$


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• C,inica, mani+estations anddiagnosis 5his disorder o+ten eginsd)ring the 6rst or second trimester. Symptoms re6uently present in a e?ural

distribution% similar to classic atopic dermatitis.

• 'ny area o the skin may be aected. 0esionsmay be ec@ematous patches or intact ore?coriated papules.

• 5he diagnosis is based upon the recognition oclinical eatures.


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' slightly lichenifed% erythematous patch and e?coriations arepresent in the antecubital old.


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Numerous erythematous papules are present on the hands othis patient with atopic dermatitis.


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• Patho,ogy Skin biopsy is not necessaryin most cases% and fndings are non(specifc.

• Laoratory tests 'lthough laboratory

testing is not indicated% up to 9/ percent opatients may ha*e ele*ated serum )g;le*els .

• Etio,ogy )t is postulated that the

enhancement o 5h8 cytokine productionknown to occur during pregnancy maycontribute to the de*elopment o ec@ema .


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• !ierentia, diagnosis 5he earlier onset%predilection or in*ol*ement o skin e?ures% and theabsence o urticarial pla6ues in abdominal striaehelp to disting)ish this disorder rom "#""".

•Treatment Similar to non(pregnant patients withec@ema% these patients should be encouraged to

maintain ade6uate skin hydration through the use otopical emollients. 0ow( to mid(potency topicalcorticosteroids are useul or controlling symptoms.

• Prognosis ;c@ema in pregnancy has not beenassociated with ad*erse eects on the etus.


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• Pr)rigo o+ pregnancy :

• Other terms that ha*e been used todescribe prurigo o pregnancyinclude prurigo gestationis o

=esnier

• Incidence , in 3// to , in 2/pregnancies


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• C,inica, mani+estations and diagnosis 5he diagnosiso prurigo o pregnancy is c,inica, % based on characteristicfndings on history and physical e?amination.

• "rurigo o pregnancy usually begins in the second or third

trimester %but has been reported in all trimesters.• C,inica, diagnostic criteria consist o erythematous%

e?coriated nodules% or papules on the e?tensor suraces othe limbs and trunk.

• 0esions are grouped and may be crusted or appear

ec@ematous.• Co)rse 5he eruption usually resol*es in the immediate

postpartum period %although it can persist or up to threemonths .


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• Laoratory 0aboratory e*aluation is unnecessary. 5wo studies noted an ele*ated )g;concentration in some patients.

• Patho,ogy =iopsy is not necessary or diagnosis

• Skin biopsies o lesions are nonspecifc. 5here is adermal peri*ascular mononuclear cell infltratewithout eosinophils. 5he epidermis may showacanthosis% hyperkeratosis% and parakeratosis.

•Etio,ogy 5he etiology is unknown. 'relationship with a history o atopy has beenproposed% but remains contro*ersial .


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• !ierentia, diagnosis

• "#"""

• pruritic olliculitis o pregnancy

• holestasis

• scabies% drug reactions

intrahepatic cholestasis o pregnancy should be e?cluded by history and

laboratory testing !eg% bile acids$


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• Treatment He suggest low to mid potencytopical corticosteroids as initial therapy orrelie o symptoms. 5opical corticosteroids areusually eecti*e so systemic glucocorticoid

therapy is unnecessary.• Nonsedating oral antihistamines are an

acceptable alternati*e.

• Prognosis 5here are no etal eects% nor is

there long(term maternal risk ."rurigo opregnancy may recur with subse6uentpregnancies .


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• Pr)ritic +o,,ic),itis o+pregnancy "ruritic olliculitis reers

to steri,e eruption o pruritic%ollicular lesions .

• Incidence 5he incidence is

unknown. )n one prospecti*e series%one case was identifed among 3,J8pregnant women.


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• C,inica, mani+estations and diagnosis 5hediagnosis o pruritic olliculitis is clinical. A p)st),esho),d 2e c),t)red to r),e o)t 2acteria, or candida,+o,,ic),itis .

• "ruritic olliculitis o pregnancy usually presents in thesecond or third trimester.

• 5he eruption consists o ollicularly(based papules and

pustules% primarily on the trunk% but sometimesspreading to the e?tremities.

•

5he appearance is similar to that o steroid induced acne.• Co)rse 5he eruption typically clears within two weeks

o deli*ery


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Steroid ind)ced acne


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• Laoratory 0aboratory tests are unnecessary otherthan to e?clude inection. 0aboratory *alues are normal .

• Patho,ogy =iopsy is not necessary or confrmation othe clinical diagnosis. &istopathology shows aperi*ascular or interstitial lymphohistiocytic infltrate ande?coriation o the epidermis% similar to polymorphic

eruption o pregnancy. 'n acute suppurati*e sterileolliculitis is diagnostic.

• Etio,ogy 5he pathogenesis is unknown.

•

!ierentia, diagnosis )t may be diCcult todistinguish pruritic olliculitis o pregnancy rom prurigoo pregnancy or "#""". )nectious olliculitis must also be

considered.


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• Treatment He suggest low to midpotency topical corticosteroids as initialtherapy or relie o symptoms .

• Oral corticosteroids are rarely needed.

• Nonsedating oral antihistamines are anacceptable alternati*e.

• Prognosis 4aternal and etal outcome

appear to be normal .• 5here are no data on recurrence with

subse6uent pregnancies.


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PUSTULAR PS#RIASIS #$ PREGAC%

• )s a newer name or impetigo herpetiormis. 5he ormer is more descripti*e and a*oidsthe implication o bacterial or *iral inection%neither o which plays a role in this disease.

•

)t is debated whether pustular psoriasis opregnancy is truly specifc to pregnancy .Hea*or a true association as these womenrarely ha*e a history o psoriasis and the

eruption resol*es postpartum.• Incidence "ustular psoriasis o pregnancy

is e?ceedingly rare.


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• C,inica, mani+estations and diagnosis clinically7 howe*er%we suggest confrmation by histologic e*aluation o a biopsy

specimen% gi*en the potential conse6uences o the disease.• 5he disease can occur anytime during pregnancy. 0esions begin

as erythematous pla6ues with rings o pustules. 5he pla6uesthen enlarge rom the periphery as the center becomes erodedand crusted. 5here may be concentric rings o pustules.

•

5he nails may become onycholytic.• 5he trunk and e?tremities are aected% while the hands% eet%

and ace are usually spared.

• #sually not pruritic. &owe*er% the patient eels ill withsymptoms such as malaise% anore?ia% nausea% *omiting%

diarrhea% e*er% and chills .• "ost(inammatory pigmentation occurs when pla6ues and

pustules resol*e7 howe*er% scarring does not result.


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• Co)rse "ustular psoriasis o pregnancyusually remits 6uickly postpartum% butmay also are ater deli*ery.

•

)t recurs with subse6uent pregnanciesand may also recur with menses or use ooral contracepti*e pills.

• 5he disease tends to be more se*ere and

ha*e an earlier onset with subse6uentpregnancies


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• Laoratory He suggest a complete blood count%calcium le*el% electrolytes% and urinalysis. 0eukocytosisand an ele*ated erythrocyte sedimentation rate arecommon. &ypocalcemia may be present% possiblyrelated to hypoparathyroidism and can lead to tetany%

delirium% and sei@ures. 'lbuminuria% pyuria% andhematuria occasionally occur. "ustules are sterile.

• Patho,ogy He suggest biopsy or confrmation o thediagnosis. 5he pathology is the same as in pustular

psoriasis in the nonpregnant patient. Spongiormpustules with neutrophils are obser*ed in the epidermis."soriasiorm hyperplasia and% possibly% parakeratosisalso occur .


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• Etio,ogy 5he etiology is poorlyunderstood. )t may relate tohormona, changes o pregnancy%

particularly progesterone.4ypoca,cemia andhypoparathyroidism may also be

inciting actors


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• !ierentia, diagnosis • )nectious etiologies o pustules% such as

candidiasis and impetigo% should bee?cluded by appropriate cultures.

• dermatitis herpetiormis%

• pustular drug eruptions

• "ruritic olliculitis o pregnancy is pruritic and

e?clusi*ely periollicular% neither o which istrue o pustular psoriasis o pregnancy.

• "emphigoid gestationis


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• Treatment :systemic corticosteroids as initial therapy. &igh dosesystemic corticosteroids% such as prednisolone up to F/ to G/ mg perday% are gi*en or a ew days and then slowly tapered as symptomsimpro*e% with monitoring in case a are occurs.

• 0ow(dose cyclosporine !8 to 3 mg-kg per day$ may be a treatmentoption or patients who ail to respond to systemic corticosteroids

.'lthough cyclosporine is a category drug% data rom studies inpregnant patients with organ transplantation indicate that the risk oteratogenicity is low% but premature labor and inants who are smallor gestational age ha*e been reported.

• Dor persistent cases% post(deli*ery in non(breasteeding mothers%

other therapies include systemic retinoids and methotre?ate .

• &ypocalcemia must be corrected% when present% and uid andelectrolyte balance should be maintained. 5hese patients sometimesre6uire early deli*ery or relie o symptoms and or etal saety

http://www.uptodate.com/contents/prednisolone-drug-information?source=see_linkhttp://www.uptodate.com/contents/cyclosporine-drug-information?source=see_linkhttp://www.uptodate.com/contents/methotrexate-drug-information?source=see_linkhttp://www.uptodate.com/contents/methotrexate-drug-information?source=see_linkhttp://www.uptodate.com/contents/cyclosporine-drug-information?source=see_linkhttp://www.uptodate.com/contents/prednisolone-drug-information?source=see_link


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• Prognosis

• "lacental insuCciency

• 4iscarriage

• Detal growth restriction

• Stillbirth

• 'ntepartum etal monitoring withnonstress tests or biophysical proflesand ultrasound assessment o etalgrowth are indicated.


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•He report two successi*epregnancies o a patient with twodierent outcomes: stillbirth in the

frst pregnancy7 and a healthynewborn

in the second.

Intrahepatic cho,estasis o+


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ppregnancy

• Incidence :


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• Estrogens and progesterone • ;strogens are known to cause cholestasis

in both e?perimental and clinical

conditions% and a role in )" is likely .)"occurs mainly during the third trimesterwhen serum concentrations o estrogenreach their peak. )" is also more common

in twin pregnancies% which are associatedwith higher le*els o circulating estrogensthan singleton pregnancies


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• )" also may be associated with alterations inprogesterone metabolism% and the administrationo progesterone may be a risk actor or )". 5heormation o large amounts o sulated

progesterone metabolites% may result in saturationo the hepatic transport system!s$ utili@ed orbiliary e?cretion o these compounds in somegenetically predisposed women.

• )t is recommended that progesterone treatment bea*oided in pregnant women with a pre*ious historyo )" and immediately withdrawn whencholestasis occurs during pregnancy.


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• )n patients with a history o cholestasisunder oral contracepti*es or )"%symptoms o cholestasis may be

obser*ed ater o*arian stimulation or)KD7patients with a history o cholestasisrelated to estrogen e?posure should bemonitored careully when undergoing

o*arian stimulation% and i possible%mildly stimulated.

CLIICAL


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3AI$ESTATI#S• 5he onset o )" is typically heralded by the

de*elopment o pruritus% which may be intolerable. )t is

oten generali@ed% but predominates on the palms andthe soles o the eet and is worse at night. "ruritus may

precede laboratory abnormalities .

• 'bdominal pain is uncommon. ;ncephalopathy or otherstigmata o li*er ailure are unusual% and their presenceshould initiate a search or other causes o li*er disease.

• "hysical e?amination is nonspecifc% but may show

e?coriations due to scratching. Iaundice occurs in lessthan ,/ percent% typically ater the onset o itching. 5he

presence o Baundice without pruritus is rare and shouldprompt in*estigation o other causes.

Laoratory 6ndings


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y g

• Ser)m tota, i,e acid concentrations

increase in ICP and may e the 6rst or on,y,aoratory anorma,ity

• !Other laboratory fndings 7ele*ations in theserum concentrations o a,ka,ine phosphatase*

and tota, and direct i,ir)in concentrations.• S)rprising,y* the ser)m concentrations o+

gamma>g,)tamy, transpeptidase /GGT0 arenorma, or modest,y e,e8ated* 7hich is)n)s)a, in most other +orms o+ cho,estatic,i8er disease in 7hich GGT ,e8e,s para,,e,other cho,estatic markers.


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• Serum aminotranserases areele*ated and may reach *aluesgreater than ,/// unit-0.

• 5he prothrombin time is usuallynormal.


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ULTRAS##GRAP4% Onultrasonography% the biliary ducts arenot dilated% and hepatic parenchyma

appears normal

!IAG#SIS


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!IAG#SIS

• 4ost women are diagnosed during the second orthird trimester.

• 5he diagnosis o )" is based upon the presence

o pruritus associated with ele*ated total serumbile acids le*els and-or aminotranserases% andthe absence o diseases that may produce similar

laboratory fndings and symptoms. 5he

cardinal eature o )" !ie% pruritus$helps distinguish it rom other types o li*erdisease that can share similar laboratory eatures.


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• TREAT3ET 5reatment or )"ocuses on reducing symptoms andpre*enting maternal and etal

complications. Se*eral drugs ha*ebeen studied% and most ocus onrelie*ing symptoms. #rsodeo?ycholic

acid!#1'% ursodiol$ has emergedas the most promising treatment.

http://www.uptodate.com/contents/ursodeoxycholic-acid-ursodiol-drug-information?source=see_linkhttp://www.uptodate.com/contents/ursodeoxycholic-acid-ursodiol-drug-information?source=see_linkhttp://www.uptodate.com/contents/ursodeoxycholic-acid-ursodiol-drug-information?source=see_linkhttp://www.uptodate.com/contents/ursodeoxycholic-acid-ursodiol-drug-information?source=see_link


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• Ursodeo:ycho,ic acid #1'increases bile ow and has beenused to relie*e pruritus and impro*e

li*er biochemical tests in cholestaticli*er diseases.

• 3// mg three times a day !or

, mg-kg per day$ until deli*ery.

omplications


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omplications

at(soluble *itamin defciency

3ATERAL $#LL#?>UP A! #UTC#3E • 5he maternal prognosis in )" is good .


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• "ruritus usually disappears in the frst ew days

ollowing deli*ery% accompanied by normali@ation

o serum bile acid concentrations and other li*ertests.

• He ollow li*er biochemical tests and bile acidconcentration si? to eight weeks ater deli*ery to

confrm that pre*iously noted abnormalities ha*eresol*ed.

• 5he patient should be reerred to a li*er specialistto assess or underlying hepatobiliary diseases ilaboratory abnormalities do not return to normal.

• Rec)rrence in s)se@)entpregnancies holestasis recurs duringsubse6uent pregnancies in F/ to 9/ percent.


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• Association 7ith otherdisorders "opulation(basedstudies suggest that )" may be

associated with subse6uentde*elopment o hepatobiliary cancer%immune(mediated disease% and

cardio*ascular disease.

4ormona, contraception


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• Estrogen>progestin 5he administration o estrogen(

progestin contracepti*es to women with a history o )" rarely results in recurrent cholestasis

• 5he enters or 1isease ontrol and "re*ention and the Horld&ealth Organi@ation consider estrogen(progestin contraceptionan acceptable choice or women with a past history o )" sincethe benefts generally outweigh the risks. &owe*er% in womenwith cholestasis related to use o estrogen(progestin oralcontracepti*es% non(estrogen methods o contraception arepreerred due to the increased risk or recurrent cholestasis .

• Progestin>on,y ' history o )" or cholestasis related to useo estrogen(progestin oral contracepti*es is not a restriction to

use o progestin(only contracepti*es .5he risk o recurrentcholestasis is low.

• ;reast+eeding )" is not a contraindication to breasteeding.

$ETAL $#LL#?>UP A!


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#UTC#3E• )" carries signifcant risk or the etus .• "rematurity

• 4econium(stained amniotic uid

• )ntrauterine demise• Neonatal respiratory distress syndrome

!which appears to be associated with

bile acids entering the lungs.$• 5he risk o spontaneous etal death is

the most concerning issue.


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• He deli*er women with )" at 3Fweeks !3F/-9ths to 3FF-9ths$ o gestationor upon diagnosis i )" is diagnosed

at L39 weeks o gestation.

ON1)5)ON +'S& "+;S;N5'5)ON "+;


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pla6ues opregnancy17

and *esicles7 rash frst appears on abdomen%oten along striae and occasionally in*ol*ese?tremities7 ace usually is not aected

corticosteroids orpruritus7 systemiccorticosteroids ore?treme symptoms

"rurigo o

pregnancy1

;rythematous papules and nodules on the

e?tensor suraces o the e?tremities

No identifed ad*erse

eects

4idpotency topical

corticosteroids andoral antihistamines

)ntrahepaticcholestasis o

pregnancy1,18,19

;?coriations rom scratching7 distribution isnonspecifc

+isk o prematuredeli*ery% meconium(stained amniotic uid%intrauterine etaldemise

Oral antihistaminesor mild pruritus7ursodeo?ycholic acid!ursodiol 'ctigallP$ ormore se*ere cases

"emphigoidgestationis20,21

"ruritic papules% pla6ues% and *esicles e*ol*inginto generali@ed *esicles or bullae7 initial

periumbilical lesions may generali@e% although theace% scalp% and mucous membranes usually arenot aected

Newborns may ha*eurticarial% *esicular% or

bullous lesions7 risk opremature deli*eriesandnewborns who aresmall or gestationalage

Oral antihistaminesand topical

corticosteroids ormild cases7 systemicoral corticosteroids orse*ere cases

)mpetigoherpetiormis22,23

+ound% arched% or polycyclic patches co*ered withsmall painul pustules in a herpetiorm pattern7most commonly appears on thighs and groin% butrash may coalesce and spread to trunk and

e?tremities7 ace% hands% and eet are notaected7 mucous membranes may be in*ol*ed

+eports o increasedetal morbidity

Systemiccorticosteroids7antibiotics orsecondarily inected

lesions

"ruritic olliculitiso pregnancy1

;rythematous ollicular papules and sterilepustules on the abdomen% arms% chest% and back

No identifed ad*erseeects

5opicalcorticosteroids%topical ben@oylpero?ide !=en@ac$% orultra*iolet = lighttherapy

http://www.aafp.org/afp/2007/0115/p211.htmlhttp://www.aafp.org/afp/2007/0115/p211.htmlhttp://www.aafp.org/afp/2007/0115/p211.htmlhttp://www.aafp.org/afp/2007/0115/p211.htmlhttp://www.aafp.org/afp/2007/0115/p211.htmlhttp://www.aafp.org/afp/2007/0115/p211.htmlhttp://www.aafp.org/afp/2007/0115/p211.htmlhttp://www.aafp.org/afp/2007/0115/p211.htmlhttp://www.aafp.org/afp/2007/0115/p211.htmlhttp://www.aafp.org/afp/2007/0115/p211.htmlhttp://www.aafp.org/afp/2007/0115/p211.htmlhttp://www.aafp.org/afp/2007/0115/p211.htmlhttp://www.aafp.org/afp/2007/0115/p211.htmlhttp://www.aafp.org/afp/2007/0115/p211.htmlhttp://www.aafp.org/afp/2007/0115/p211.htmlhttp://www.aafp.org/afp/2007/0115/p211.htmlhttp://www.aafp.org/afp/2007/0115/p211.htmlhttp://www.aafp.org/afp/2007/0115/p211.htmlhttp://www.aafp.org/afp/2007/0115/p211.htmlhttp://www.aafp.org/afp/2007/0115/p211.htmlhttp://www.aafp.org/afp/2007/0115/p211.html


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"soriasis during pregnancy

●" i i i d i i 2/ t F/ t


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●"soriasis impro*es during pregnancy in 2/ to F/ percent o women% worsensin ,/ to 8/ percent% and remains stable in the remainder. )n women whoimpro*e% the degree o impro*ement can be dramatic. )n the postpartum

period% psoriasis se*erity remains the same or worsens in most women

●)deally% women should plan pregnancy when they are in remission and omedication or taking the minimum eecti*e dose o medications that ha*ethe best etal saety profles. &owe*er% postponing pregnancy until a periodo remission oten is unrealistic. 5he selection o treatments with good etal

saety profles is particularly important or these patients..

●Dor women with limited psoriasis !ie% non(debilitating psoriasis that in*ol*esless than to ,/ percent o the body surace area$% we suggest topical ratherthan systemic therapy . ;mollients and moisturi@ers are useul or reducingbothersome scale. Our frst(line medical treatment is a low( to medium(potency topical corticosteroid

●Dor women with psoriasis that cannot be managed ade6uately with topicaltherapy !ie% resistant or e?tensi*e disease$% we suggest narrowbandultra*iolet = !#K=$ phototherapy rather than systemic therapies because othe saety and eCcacy o phototherapy in pregnancy . =ecause psoriasisoten im ro*es durin re nanc women who re uired s stemic treatment


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Dungal inections


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Dungal inections

•+e6uire longer duration o ttt

4oles Q melanoma


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4oles Q melanoma

•?hat is the appearance o+ mo,es in pregnancy?hat to ,ook +or1uring pregnancy% moles can get darker and larger%particularly on the belly and breasts. 5hese benignchanges are usually symmetric. 5hereore% any

asymmetric change in si@e% shape or colour should bee?amined by your dermatologist.' dermatoscopic e*aluation !e?amination moles witha hand(held microscope$ o the mole during

pregnancy may re*eal some modifcations in thestructure which will oten completely resol*e aterdeli*ery


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•?hat is the appearance o+ me,anomain pregnancy?hat to ,ook +or

5he appearance o melanoma in pregnancy

is identical to that in non(pregnant women.'ny spot that changes in colour% si@e% orshape or bleeds% becomes an open wound!ulceration$% painul% or itchy must bee?amined by a dermatologist.


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•4o7 is me,anoma treated in pregnant patientsAre these in8estigations sa+e +or the ay Hhen the doctor suspects a melanoma% a dermatosopic e?amination ollowed by an e?cision o the spotwill be perormed and the tissue e?amined under a microscope !histopatho,ogic e:amination09 thiswill take , to 8 weeks. 5his e?amination will establish whether it is a melanoma and% i so% the thicknesso the melanoma. 5he condition is staged in the same way in pregnant as in non(pregnant women.In order to esta,ish the stage o+ the me,anoma* 8ario)s +eat)res m)st e consideredinc,)ding'

( the thickness !how deep the melanoma has grown into the skinthin melanoma !R,mm deep$ usually has a *ery good outlook$

( the type o the melanoma( in*ol*ement o lymph nodes( the spread o the melanoma into other organs !metastases$

#sually no urther tests are done or thin melanoma.

Some other medica, tests may e )sed +or staging the me,anoma' sentine, ,ymph nodeiopsy* ),traso)nds* or 3RI /magnetic resonance imaging0. A,, these proced)res are sa+e inpregnancy. Sentinel node biopsy is used in some cases to know i the melanoma has spread beyond theskin% and is done by biopsy o the frst lymph node into which the melanoma drains. Sometimes it maybe worth waiting until ater deli*ery% but i essential there is no e*idence that the blue dye used harmsthe baby% but occasionally the mother can ha*e a serious allergic reaction to it% which could harm thebaby. 3ethods )sing B>rays or radioacti8e isotopes m)st e a8oided.


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•

4o7 is me,anoma treated in pregnancy Hhat are the implications o the treatment or the baby 5he treatment depends on the stage o the melanoma. 5he frst treatment o allmelanoma is surgical !remo*al o the melanoma under local anaesthesia$7 no urthertreatment is needed or thin melanoma. 5his procedure is sae or the unborn baby.

Dor thick melanoma or ones that ha*e spread chemotherapy may be considered. 5hisshould only be gi*en ater the frst three months o pregnancy% and careul

consideration gi*en to use later in pregnancy because it can aect the baby. 'notherorm o treatment or melanoma is immunotherapy which is not ad*ised inpregnancy because it increases the risk o spontaneous abortions.

Can me,anoma spread to the ay)n most cases o melanoma the baby will not be aected by the melanoma or by thetreatment !surgical$.

I+ the disease is at a ,ate stage* 7hen ,ymph nodes or interna, organs arein8o,8ed /ad8anced disease0* the disease may spread to the p,acenta andthe ay. )n this situation the placenta should be e?amined and baby watched orany signs o melanoma in the ollowing months7 howe*er% this situation is *ery rare.


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•!oes pregnancy 7orsen the prognosis o+ me,anoma"regnancy itsel does not worsen the prognosis omelanoma.&owe*er% in pregnancy diagnosis and treatment are otendelayed which may lead to a late stage melanoma with a

worse prognosis. )t is thereore important to remo*e a molethat is suspicious or melanoma as early as possible.'lso% the melanoma does not inuence the outcome o thepregnancy or mother and baby

'N;


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'N;

•

acne is common during pregnancy. )n act% more than one out oe*ery two pregnant women can e?pect to de*elop acne. )n somecases% the acne may be se*ere.

• 5he primary cause o acne when youEre pregnant is the increasedhormone le*els in the frst trimester. 5he higher le*el increasesthe skinEs production o natural oils. )tEs hard to predict who will

de*elop pregnancy acne. Mou ha*e a higher risk% though% i youha*e a history o acne or ha*e acne ares at the start o your

menstrual cycle. ) you do not de*elop acne during the frsttrimester% itEs unlikely youEll ha*e breakouts that are out o theordinary during the second or third trimesters.

•

Managing acnewhen youEre pregnant can be tricky. 5hatEs becausemany prescription and o*er(the(counter treatments come with a

high risk o birth deects. )n general% you should a*oid anymedication that has e*en a remote chance o harming your baby.

http://www.webmd.com/baby/default.htmhttp://www.webmd.com/skin-problems-and-treatments/acne/ss/slideshow-acne-dictionaryhttp://www.webmd.com/skin-problems-and-treatments/acne/acne-causeshttp://www.webmd.com/baby/guide/first-trimester-of-pregnancyhttp://www.webmd.com/women/tc/normal-menstrual-cycle-topic-overviewhttp://www.webmd.com/skin-problems-and-treatments/acne/acne-vulgaris-home-treatmenthttp://www.webmd.com/baby/tc/birth-defects-testing-what-are-birth-defects-testshttp://www.webmd.com/drugs/index-drugs.aspxhttp://www.webmd.com/drugs/index-drugs.aspxhttp://www.webmd.com/baby/tc/birth-defects-testing-what-are-birth-defects-testshttp://www.webmd.com/skin-problems-and-treatments/acne/acne-vulgaris-home-treatmenthttp://www.webmd.com/women/tc/normal-menstrual-cycle-topic-overviewhttp://www.webmd.com/baby/guide/first-trimester-of-pregnancyhttp://www.webmd.com/skin-problems-and-treatments/acne/acne-causeshttp://www.webmd.com/skin-problems-and-treatments/acne/ss/slideshow-acne-dictionaryhttp://www.webmd.com/baby/default.htm


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•

)t usually subsides when hormone le*els return to normal. So thesaest thing to do is to a*oid any prescription acne medications oro*er(the(counter chemical spot treatments. )nstead% you can rely ondrug(ree home remedies.

•Isotretinoinis an oral medication that has re*olutioni@ed the way se*ereacne is treated. &owe*er% itEs especially dangerous when you are

pregnant.• 5hatEs because the drug can aect a etus and cause serious birth

deects.

•1rug category ? T..ne*er used in pregnancy

•=ecause the risks are so high% women o childbearing age who takethe drug need to be on two orms o birth control starting at least one

month beore they begin therapy. 5hey also need to stay on twoorms o birth control or at least one month ater therapy ends. 'lso%women must ha*e pregnancy testsbeore% during% and ater treatment

http://www.webmd.com/drugs/2/drug-6662/isotretinoin+oral/detailshttp://www.webmd.com/parenting/baby/default.htmhttp://www.webmd.com/sex/birth-control/default.htmhttp://www.webmd.com/sex/birth-control/ss/slideshow-birth-control-optionshttp://www.webmd.com/baby/home-pregnancy-testshttp://www.webmd.com/baby/home-pregnancy-testshttp://www.webmd.com/baby/home-pregnancy-testshttp://www.webmd.com/baby/home-pregnancy-testshttp://www.webmd.com/sex/birth-control/ss/slideshow-birth-control-optionshttp://www.webmd.com/sex/birth-control/default.htmhttp://www.webmd.com/parenting/baby/default.htmhttp://www.webmd.com/drugs/2/drug-6662/isotretinoin+oral/details


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skin in preggnancy

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