SKIN DISEASES IN PREGNANCY

During pregnancy, the female body undergoes many metabolic, endocrine, and physiological changes. These changes can bring about skin problems in pregnant women. It is important to determine these skin disorders, as some of them may cause harm to the mother and fetus.

Common Skin Changes During Pregnancy

Many of the changes experienced by pregnant women are natural or normal changes that are expected to occur. These include:

• Hyperpigmentation – varying degrees of increased pigmentation in the skin are usually seen, most commonly affecting the areolae, nipples, armpits, inner thighs, and genital skin. Moles and scars can also darken. A dark brown vertical line that appears on the abdomen is called linea nigra. There is no cure for this, but it fades away over time after birth.
• Melasma (chloasma) – also called the “mask of pregnancy.” It usually appears as dark brown patches of skin on the face. Exacerbating factors include sun exposure and intake of oral contraceptive pills in non-pregnant women. It is important to use a broad-spectrum sunscreen with an SPF of 30 or higher. Improvement may be seen after giving birth, but it may not fully resolve. Topical hydroquinone, retinoids like tretinoin, and topical corticosteroids may be given as treatment after birth.
• Striae distensae/ striae gravidarum (stretch marks) – one of the most common changes seen in almost 90% of pregnant women. These appear as pink-purple, atrophic (thinned out) lines or bands, commonly seen on areas of the body that are prone to stretch, such as the abdomen, breasts, arms, thighs, or buttocks. After giving birth, these stretch marks may fade over time, but they do not completely vanish. Some treatment options that can be done postpartum include topical retinoids (tretinoin) and laser treatment.
• Hair changes – seen as a development of excessive hair (hirsutism), usually on the face, arms, legs, and back of pregnant women. There can also be mild thickening of scalp hair, however, after giving birth, increased shedding of hair may be experienced. Hirsutism normally resolves after giving birth, but if it persists, cosmetic removal of hair can be an option.
• Nail changes – in pregnant patients, nails may become more brittle and can develop grooves. There can also be thickening of the nail bed and separation of the nail from the nail bed. These most likely will resolve after giving birth.
• Vascular changes – hormonal changes in pregnancy can cause alterations in the caliber of blood vessels. It can cause blood vessels to dilate or congest and can become unstable. These usually disappear or resolve postpartum. Some vascular changes include palmar erythema, spider telangiectasias or angiomas (small visible blood vessels on the face, neck, arms), and edema or swelling commonly found on the face, eyelids, or extremities.

Skin Diseases in Pregnancy

There are skin disorders that can only develop during pregnancy. Some of them carry maternal and fetal risks, while some are benign.

• Pemphigoid Gestationis – otherwise known as herpes gestationis and appears during the second or third trimester or even after giving birth. Lesions initially appear as red, itchy rashes that develop into small blisters called vesicles or larger blisters called bullae. Lesions can appear on the trunk and abdomen, sparing the face, palms, soles, and mucous membranes. Fetal risks include preterm delivery and small-for-gestational-age births. Newborns can also have the same lesions. Mild cases can be treated with oral antihistamines and topical corticosteroids, while severe cases can be treated with systemic oral contraceptives.
• Intrahepatic Cholestasis of Pregnancy – usually does not present with any primary skin lesions. Instead, patients experience itching during the third trimester, commonly in the palms and soles, and often occurring at night. Excoriations or scratch marks may appear due to persistent scratching. Other symptoms such as nausea, vomiting, or fatigue may be present and can progress to jaundice (yellowing of the skin), dark-colored urine, or lightly colored stool. It is recommended to obtain liver function tests and serum bile acids to check and assess the condition of the liver. Fetal risks to watch out for include preterm delivery, fetal distress, and even fetal death. Oral antihistamines can be given for mild cases, while ursodeoxycholic acid may be given for more severe cases. A multidisciplinary team of doctors may be needed to properly monitor the liver function and serum bile acids, as well as the condition of the fetus and the mother.
• Pustular Psoriasis of Pregnancy – otherwise known as Impetigo Herpetiformis. Lesions usually appear in the third trimester of pregnancy and present as red patches with small painful pustules at the margins. The most commonly affected areas include the flexural areas, thighs, and groin, spreading centrifugally. Other symptoms may be present, such as diarrhea, fever, nausea, vomiting, and lymphadenopathy (enlarging of the lymph nodes). Fetal risks include placental insufficiency that may lead to stillbirth or neonatal death. Symptoms rapidly resolve after delivery, but other treatment options include systemic corticosteroids and antibiotics, if a secondary bacterial infection is present.
• Polymorphic Eruption of Pregnancy (PEP) – otherwise known as Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP) is a benign condition that usually appears during the third trimester or immediately postpartum, although it may also occur as early as the first trimester. Lesions are polymorphous, which means that they can appear in many forms. Most are urticarial (raised lesions, red in color), while some can appear as vesicles or smaller red dots that are intensely itchy. Lesions appear first on the abdominal stretch marks and then spread to the trunk and extremities. The face and the area around the belly button are usually spared. There are no known fetal or maternal risks involved in PEP, and treatment usually consists of oral antihistamines and topical corticosteroids. For severe cases, systemic corticosteroids may be given. Resolution of the rash usually happens one to two weeks after giving birth.
• Atopic Eruption of Pregnancy (AEP) – is the most common skin disorder of pregnancy, present in around 50% of patients. It usually occurs prior to the third trimester and presents as dry skin, red patches, or raised lesions affecting the face, neck, chest, flexural extremities, and trunk. Patients with or without a history of atopic dermatitis can develop this skin disease. Prognosis is good for both mother and fetus, and lesions rapidly respond to treatment. Treatment options include emollients or moisturizers, topical corticosteroids, and antihistamines. For severe, recalcitrant cases, management includes a short course of oral corticosteroids, antibiotics for any secondary bacterial infections, and the use of phototherapy under the supervision of a specialist.

Take-Home Messages

Many skin disorders can appear or flare up during pregnancy because of the many physiological, hormonal, and metabolic changes that occur in a pregnant woman’s body. It is important to visit your dermatologist in order to determine what kind of skin disease you have and if there are any maternal or fetal risks involved. Treatment depends on the type and severity of the disease, but in all cases, treatment should focus on giving women relief from the symptoms. Proper surveillance of any skin diseases in pregnant women should be done in order to ensure the safety and wellbeing of the mother and the fetus.

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References:

• Gray, M. T. R. (n.d.). Common Skin Conditions During Pregnancy - American Family Physician. AAFP Home | American Academy of Family Physicians. Retrieved April 18, 2022, from https://www.aafp.org/afp/2007/0115/p211.html#:~:text=Pregnancy%2Dspecific%20skin%20conditions%20include,and%20pruritic%20folliculitis%20of%20pregnancy.
• Kang, S. (2018). Fitzpatrick’s Dermatology, Ninth Edition, 2-Volume Set (EBOOK). McGraw Hill Professional.
• Kroumpouzos, G., & Cohen, L. M. (2001). Dermatoses of pregnancy. Journal of the American Academy of Dermatology, 1, 1–22. https://doi.org/10.1067/mjd.2001.114595
• Linea Nigra: Pregnancy Line - American Pregnancy Association. (2014, August 21). American Pregnancy Association. https://americanpregnancy.org/healthy-pregnancy/pregnancy-concerns/pregnancy-line-linea-nigra/
• Skin Conditions During Pregnancy | ACOG. (n.d.). Home | ACOG. Retrieved April 18, 2022, from https://www.acog.org/womens-health/faqs/skin-conditions-during-pregnancy
• Skin problems in pregnancy  | DermNet NZ. (n.d.). DermNet NZ – All about the Skin  | DermNet NZ. Retrieved April 18, 2022, from https://dermnetnz.org/topics/skin-changes-in-pregnancy
• Vaughan Jones, S., Ambros-Rudolph, C., & Nelson-Piercy, C. (2014). Skin disease in pregnancy. BMJ, jun03 3, g3489–g3489. https://doi.org/10.1136/bmj.g3489

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