Expert Commentary

6 skin disorders of pregnancy: A management guide

OBG Manag. 2010 June;22(6):24-33

Matthew Bremmer, MD

Marcia S. Driscoll, MD, PharmD

Richard Colgan, MD

You can handle most of these dermatoses, but some require referral

PDF Download

IN THIS ARTICLE

A pocket guide to what you’ll see and how to treat it
Fetal risks with intrahepatic cholestasis of pregnancy
Key practice recommendations

References

1. Sitaru C, Powell J, Messer G, Bröcker EB, Wojnarowska F, Zillikens D. Immunoblotting and enzyme linked immunosorbent assay for the diagnosis of pemphigoid gestationis. Obstet Gynecol. 2004;103(4):757-763.

2. Engineer L, Bohl K, Ahmed AR. Pemphigoid gestationis: a review. Am J Obstet Gynecol. 2000;183(2):483-491.

3. Kroumpouzos G, Cohen LM. Specific dermatoses of pregnancy: an evidence-based systematic review. Am J Obstet Gynecol. 2003;188(4):1083-1092.

4. Shornick JK. Dermatoses of pregnancy. Semin Cutan Med Surg. 1998;17(3):172-181.

5. Shornick JK, Bangert JL, Freeman RG, Gilliam JN. Herpes gestationis: clinical and histological features in 28 cases. J Am Acad Dermatol. 1983;8(2):214-224.

6. Leachman SA, Reed BR. The use of dermatologic drugs in pregnancy and lactation. Dermatol Clin. 2006;24(2):167-197, vi.

7. Hern S, Harman K, Bhogal BS, Black MM. A severe persistent case of pemphigoid gestationis treated with intravenous immunoglobulins and cyclosporine. Clin Exp Dermatol. 1998;23(4):185-188.

8. Fitzpatrick TP. Diseases in pregnancy. Color Atlas and Synopsis of Clinical Dermatology. New York, NY: McGraw Hill; 1997:414–419.

9. Aractingi D, Berkane N, Bertheau P, et al. Fetal DNA in skin of polymorphic eruptions of pregnancy. Lancet. 1998;352(9144):1898-1901.

10. Rudolph CM, Al-Fares S, Vaughan-Jones SA, et al. Polymorphic eruption of pregnancy: clinicopathology and potential trigger factors in 181 patients. Br J Dermatol. 2006;154(1):54-60.

11. Roger D, Vaillant L, Fignon A, et al. Specific pruritic diseases of pregnancy. A prospective study of 3192 pregnant women. Arch Dermatol. 1994;130(6):734-739.

12. McDonald JA. Cholestasis of pregnancy. J Gastroenterol Hepatol. 1999;14(6):515-518.

13. Ohel I, Levy A, Silberstein T, Holcberg G, Sheiner E. Pregnancy outcome of patients with pruritic urticarial papules and plaques of pregnancy. J Maternal Fetal Neonat Med. 2006;19(5):305-308.

14. Geenes V, Williamson C. Intrahepatic cholestasis of pregnancy. World J Gastroenterol. 2009;15(17):2049-2066.

15. Shaw D, Frohlich J, Wittmann BA, Willms M. A prospective study of 18 patients with cholestasis of pregnancy. Am J Obstet Gynecol. 1982;142(6 Pt 1):621-625.

16. Reyes H. The spectrum of liver and gastrointestinal disease seen in cholestasis of pregnancy. Gastroenterol Clin North Am. 1992;21(4):905-921.

17. Lammert F, Marschall H, Glantz A, Matern S. Intrahepatic cholestasis of pregnancy; molecular pathogenesis, diagnosis and management. J Hepatol. 2000;33(6):1012-1021.

18. Huang WM, Seubert DE, Donnelly JG, Liu M, Javitt NB. Intrahepatic cholestasis of pregnancy: detection with urinary bile acid assays. J Perinat Med. 2007;35(6):486-491.

19. Palma J, Reyes H, Ribalta J, et al. Ursodeoxycholic acid in the treatment of intrahepatic cholestasis of pregnancy: a randomized, double-blind study controlled with placebo. J Hepatol. 1997;27(6):1022-1028.

20. Diaferia A, Nicastri PL, Tartagni M, et al. Ursodeoxycholic acid therapy in pregnant women with cholestasis. Int J Gynaecol Obstet. 1996;52:133-140.

21. Nicastri PL, Diaferia A, Tartagni M, Loizzi P, Fanelli M. A randomised placebo-controlled trial of ursodeoxycholic acid and S-adenosylmethionine in the treatment of intrahepatic cholestasis of pregnancy. Br J Obstet Gynaecol. 1998;105(11):1205-1207.

22. Glantz A, Marschall HU, Lammert F, Mattsson LA. Intrahepatic cholestasis in pregnancy: a randomized controlled trial comparing dexamethasone and ursodeoxycholic acid. Hepatology. 2005;42(6):1399-1405.

23. Ambros-Rudolph C, Müllegger M, Vaughan-Jones S, et al. The specific dermatoses of pregnancy revisited and reclassified: results of a retrospective two-center study on 505 pregnant patients. J Am Acad Dermatol. 2006;54(3):395-404.

24. Vaughan Jones SA, Hern S, Nelson-Piercy C, Seed PT, Black MM. A prospective study of 200 women with dermatoses of pregnancy correlating clinical findings with hormonal and immunopathological profiles. Br J Dermatol. 1999;141(1):71-81.

25. Holmes RC, Black MM. The specific dermatoses of pregnancy. J Am Acad Dermatol. 1983;8(3):405-412.

26. Bukhari IA. Impetigo herpetiformis in a primagravida: successful treatment with etretinate. J Drugs Dermatol. 2004;3(4):449-451.

27. Oumeish OY, Parish JL. Impetigo herpetiformis. Clin Dermatol. 2006;24(2):101-104.

28. Kroumpouzos G, Cohen LM. Pruritic folliculitis of pregnancy. J Am Acad Dermatol. 2000;43(1 Pt 1):132-134.

29. Sahin HG, Sahin HA, Metin A, Zeteroglu S, Ugras S. Recurrent impetigo herpetiformis in a pregnant adolescent: case report. Eur J Obstet Gynecol Reprod Biol. 2002;101:201-203.

30. Aka N, Kuscu NK, Yazicioglu E. Impetigo herpetiformis at the 36th week of gestation. Int J Gynecol Obstet. 2000;69(2):153-154.

31. Wade T, Wade S, Jones H. Skin changes and diseases associated with pregnancy. Obstet Gynecol. 1978;52(2):233-242.

Fast Track

Oral corticosteroids are the first line treament for pemphigoid gestationis

Pruritic urticarial papules and plaques of pregnancy primarily strikes women in their first pregnancy

There is evidence that acute pustular psoriasis of pregnancy is not unique to pregnancy but simply a manifestation of ordinary psoriasis

In pruritic folliculitis of pregnancy, lesions often begin on the abdomen and spread to the extremities

The dermatoses of pregnancy are a poorly understood group of conditions. Their only common feature is a tendency to appear during pregnancy.

Only three of these conditions are considered unique to pregnancy, however; the others are probably exacerbations of preexisting conditions triggered by pregnancy. There isn’t even complete agreement on what to call them. To make management even more complex, two patients—mother and fetus—need to be considered in decisions about care.

Who manages these patients is another matter. These conditions fall into overlapping areas of health care, where family physicians, obstetricians, and dermatologists all might have some share in responsibility for diagnosis and treatment. You need to be sufficiently familiar with these conditions so that you can differentiate those that can be treated symptomatically and those that require referral to a specialist. This review and the handy TABLE, will help you toward that end.

TABLE

Skin disorders of pregnancy: What you’ll see, how to treat

Disorder	Lesions	Diagnosis and sequelae	Treatment	Recurrence
Pemphigoid gestationis^3,5	Erythematous papules that progress to vesicles and bullae, in a periumbilical distribution that spares the face, palms, and soles	Mean onset at 21 weeks; postpartum in 20% of cases Direct immunofluorescence microscopy shows linear C3 deposition Newborn may be small for gestational age, but no associated morbidity or mortality	Oral corticosteroids, 20–60 mg/d OR Intravenous immunoglobulin OR Cyclosporine in refractory cases	Frequent; skips a pregnancy 8% of the time
Pruritic urticarial papules and plaques of pregnancy^8-10	Urticarial papules and plaques on the abdomen, legs, arms, buttocks, chest, and back	Usually presents after 34th week but can present at any stage Diagnosis is clinical No increase in fetal morbidity or mortality	Topical corticosteroids and antihistamines	Uncommon
Intrahepatic cholestasis of pregnancy^14,17,19-22	No primary lesions; secondary excoriations in any area that the patient can reach	Onset after 30th week in 80% of patients Strongly indicated by serum bile acid level >11 µmol/L Increased fetal mortality	Ursodeoxycholic acid, 450-1,200 mg/d	Frequent
Eczema of pregnancy/pruritus of pregnancy^4,10,24	Grouped, crusted erythematous papules, patches, and plaques, most often on extensor surfaces of the arms and legs or on the abdomen	Onset at any point in pregnancy Clinical diagnosis No increase in fetal morbidity or mortality	Symptomatic treatment with topical corticosteroids or antihistamines	Frequent
Acute pustular psoriasis of pregnancy^26-28	Erythematous plaques and pustules that start on the inner thighs and groin and spread to the trunk and extremities	Onset at any point in pregnancy Clinical diagnosis by appearance of lesions and association with systemic illness Increased incidence of miscarriage, stillbirth, and maternal mortality	Prednisone, 15–60 mg/d OR Cyclosporine, 100 mg twice daily, in refractory cases Management of associated hypocalcemia	Unknown
Pruritic folliculitis of pregnancy^24,28	Papules and pustules concentrated around hair follicles, often beginning on the abdomen and spreading to the extremities	Onset most often in third trimester Clinical diagnosis No associated fetal morbidity or mortality	Topical corticosteroids	Unknown

DERMATOSES UNIQUE TO PREGNANCY

1. Pemphigoid gestationis

Years ago, this disorder was referred to as herpes gestationis, because the lesions are herpetiform. Pemphigoid gestationis (PG) has an incidence of approximately 1 in 10,000 pregnancies.^1,2 Time of onset is usually about the 21st week of gestation, although, in about 20% of cases, the eruption appears immediately postpartum.³

Presentation. The disease usually begins with urticarial papules and plaques around the umbilicus and extremities. Bullous lesions tend to develop as the disease progresses, and are often not present on first presentation (FIGURE 1). Lesions of PG tend to spare the face, palms, and soles. Mucosal surfaces are involved in fewer than 20% of cases. In about 75% of cases, PG flares around the time of delivery, regressing spontaneously after the baby is born.⁴

FIGURE 1 Pemphigoid gestationis

As the disease progresses, bullous lesions tend to develop.

Pathophysiology. The pathophysiology of PG is nearly identical to that of bullous pemphigoid, a blistering skin disorder seen more often in elderly patients.⁵ Pemphigoid disorders are immune processes, involving an immunoglobulin G (IgG) immune response directed at a 180-kDa hemidesmosome transmembrane glycoprotein. This protein is the common target in several subepidermal blistering diseases.

Differential diagnosis. Disorders that may have some of the same features as PG include pruritic urticarial papules and plaques of pregnancy (PUPPP), erythema multiforme, intrahepatic cholestasis of pregnancy (ICP), contact dermatitis, and drug reactions.

Diagnosis. A biopsy is necessary for definitive diagnosis. Direct immunofluorescence (DIF) microscopy of a sample of perilesional skin can show tissue-bound immunoreactants. Linear deposition of the complement component protein C3 along the basement membrane zone is diagnostic for PG. IgG is also deposited about 40% of the time.³