SKINSKINand PREGNANCYand PREGNANCY

ByBy

Dr M. Y.Abd El-Mawla,MDDr M. Y.Abd El-Mawla,MD

Zagazig Faculty of Zagazig Faculty of Medicine,Zagazig ,EGYPTMedicine,Zagazig ,EGYPT

IntroductionIntroduction Changes in the Skin Due to Changes in the Skin Due to

PregnancyPregnancy Skin Conditions Influenced by Skin Conditions Influenced by

PregnancyPregnancy Pregnancy and Immune-Mediated Pregnancy and Immune-Mediated

DisordersDisorders Skin Conditions Specific to Skin Conditions Specific to

PregnancyPregnancy The Use of Drugs for Dermatologic The Use of Drugs for Dermatologic

Changes in the Skin Due to Changes in the Skin Due to PregnancyPregnancy

HyperpigmentationHyperpigmentation

1.1. Generalized or increase in pigment Generalized or increase in pigment at specific areas such as the areolae, at specific areas such as the areolae, genitals, inner thighs, or axillaegenitals, inner thighs, or axillae

2.2. Melasma : In most cases, the Melasma : In most cases, the hyperpigmentation : epidermal hyperpigmentation : epidermal melanin deposition due to a melanin deposition due to a combination of light exposure and combination of light exposure and elevated hormones (estrogen, elevated hormones (estrogen, progesterone, and melanocyte-progesterone, and melanocyte-stimulating hormonestimulating hormone. .

MelasmaMelasma

Changes in the Skin Due to Changes in the Skin Due to PregnancyPregnancy

Hair& Nail ChangesHair& Nail Changes1.1. Hirsutism & frontoparietal Hirsutism & frontoparietal

thinning of male-pattern thinning of male-pattern alopecia : increase in androgens alopecia : increase in androgens

2.2. Postpartum: hirsutism resolves Postpartum: hirsutism resolves and hair may enter the telogen and hair may enter the telogen phase, resulting in the diffuse phase, resulting in the diffuse shedding of telogen effluvium shedding of telogen effluvium

3.3. Nail changes : transverse Nail changes : transverse grooving, brittleness, distal grooving, brittleness, distal onycholysis, and subungual onycholysis, and subungual hyperkeratosishyperkeratosis

Telogen effluviumTelogen effluvium

Androgenic aalopeciaAndrogenic aalopecia

Vascular ChangesVascular Changesin Pregnancyin Pregnancy

Erythema (most Erythema (most women)women)

Spider Spider telangiectasestelangiectases (66%) (66%)

Vagina Vagina (Jacquemier-(Jacquemier-Chadwick sign)Chadwick sign)Cervix (Goodell's Cervix (Goodell's sign -- bluish)sign -- bluish)PalmsPalmsGingiva Gingiva

Chest Chest Legs Legs Face Face

Vascular ChangesVascular Changesin Pregnancyin Pregnancy

Varicosities (40% of Varicosities (40% of women) women)

Purpura Purpura Vasomotor Vasomotor

instability instability

Non pitting edema Non pitting edema (50% of women (50% of women

Pyogenic granuloma Pyogenic granuloma

Legs &HemorrhoidsLegs &Hemorrhoids

Lower extremities Lower extremities Facial flushing ,Pallor Facial flushing ,Pallor

Cutis Cutis marmorata ,Raynaud'marmorata ,Raynaud'sphenomenasphenomena

Face,lids Face,lids &extremities&extremities

Gingiva and otherGingiva and other sitessites

Pyogenic granulomaPyogenic granuloma

Glandular ChangesGlandular Changes

Increased Increased EccrineEccrine glands glands function: function:

Miliaria ,Hyperhidrosis Miliaria ,Hyperhidrosis &Dyshidrotic eczema&Dyshidrotic eczema

Decreased Decreased ApocrineApocrine function: function: Increased Sebaceous function in Increased Sebaceous function in

third trimester:third trimester:

Acne (variant-pruritic folliculitis Acne (variant-pruritic folliculitis of pregnancy) &Sebaceous glands of pregnancy) &Sebaceous glands on the areolae (Montgomery's on the areolae (Montgomery's glands)glands)

Connective TissueConnective Tissue Changes in Pregnancy Changes in Pregnancy

Striae distensaeStriae distensae (90%) on the (90%) on the abdomen, on the breasts, thighs, abdomen, on the breasts, thighs, and inguinal areas. and inguinal areas.

Mechanical stretch & increased Mechanical stretch & increased hormones (adrenocortical, hormones (adrenocortical, estrogen, and relaxin) are the estrogen, and relaxin) are the most significant factors in the most significant factors in the development of striae, development of striae,

Striae distensaeStriae distensae

Skin Conditions Influenced Skin Conditions Influenced by Pregnancyby Pregnancy

Melanomas :Melanomas :no increased risk of no increased risk of melanoma in pregnancy .When melanoma in pregnancy .When diagnosed during pregnancy may be diagnosed during pregnancy may be thicker and therefore have a worse thicker and therefore have a worse prognosisprognosis

Nevi: Nevi: may develop, enlarge, or may develop, enlarge, or darken.& show mild cytologic atypiadarken.& show mild cytologic atypia..

Dermatofibromas Leiomyomas Dermatofibromas Leiomyomas Keloids Dermatofibrosarcoma: Keloids Dermatofibrosarcoma: may may develop or grow rapidly in pregnancy develop or grow rapidly in pregnancy

Other Skin Conditions Other Skin Conditions Influenced by PregnancyInfluenced by Pregnancy

Atopic dermatitisAtopic dermatitis1.1. More likely to worsen More likely to worsen

than improve than improve

2.2. May present for the first May present for the first time during pregnancy with time during pregnancy with keratosis pilaris keratosis pilaris

3.3. Irritant hand dermatitis Irritant hand dermatitis due to washing postpartum due to washing postpartum &nipple dermatitis due to nursing&nipple dermatitis due to nursing

Other Skin Conditions Other Skin Conditions Influenced by PregnancyInfluenced by Pregnancy

PsoriasisPsoriasis: : More likely to improve than More likely to improve than worsen worsen

Psoriatic arthritis may worsen Psoriatic arthritis may worsen Impetigo herpetiformisImpetigo herpetiformis (generalized (generalized

pustular psoriasis) : pustular psoriasis) : during last during last trimester, but may present earlier trimester, but may present earlier &persists until delivery or long after &persists until delivery or long after

1.1. Associated with decreased calcium Associated with decreased calcium and/or vitamin D and/or vitamin D

2.2. Severe malaise, fever, nausea , vomiting, Severe malaise, fever, nausea , vomiting, tetany, seizures tetany, seizures

3.3. Grouped Grouped pustulespustules at the margins of at the margins of symmetric erythematous patches symmetric erythematous patches

Impetigo herpetiformisImpetigo herpetiformis

Impetigo Impetigo herpetiformis 2herpetiformis 2

Pregnancy &Autoimmune Pregnancy &Autoimmune DisordersDisorders

Changes in hormones including the Changes in hormones including the increase in estrogen affect the course increase in estrogen affect the course of autoimmune diseases. of autoimmune diseases.

The fetoplacental unit directs maternal The fetoplacental unit directs maternal immunity toward immunity toward humoralhumoral responses responses by favoring certain cytokines and other by favoring certain cytokines and other inflammatory mediatorsinflammatory mediators

EnhancedEnhanced humoral immunity & humoral immunity & weakened weakened cellular immunity lead to cellular immunity lead to variable effects that are dependent on variable effects that are dependent on the specific disease process .the specific disease process .

Systemic lupus Systemic lupus erythematosuserythematosus

SLE may worsen and may flare postpartum. SLE may worsen and may flare postpartum. Lupus patients are advised to avoid trying Lupus patients are advised to avoid trying

to conceive when their disease is activeto conceive when their disease is active Underlying lupus renal disease may Underlying lupus renal disease may

worsen during pregnancy. worsen during pregnancy. There is a significant risk of eclampsia;There is a significant risk of eclampsia; Active disease in the mother, maternal use Active disease in the mother, maternal use

of potentially teratogenic medications, and of potentially teratogenic medications, and pathogenic antibodies (pathogenic antibodies (anti-Roanti-Ro---- ) ) transmitted from the mother may present transmitted from the mother may present risks to the fetus. risks to the fetus.

Ro(SS-A) &Foetal riskRo(SS-A) &Foetal risk

Neonatal lupus in mothers Neonatal lupus in mothers with circulating anti-Ro(SS-with circulating anti-Ro(SS-A) antibodies A) antibodies

Increased risk of prematurity Increased risk of prematurity and spontaneous abortion and spontaneous abortion

Congenital heart block Congenital heart block

Nonatal lupusNonatal lupus

Antiphospholipid Antiphospholipid syndrome(syndrome(aPLs)in pregnant aPLs)in pregnant

with SLEwith SLE Approximately one third of patients Approximately one third of patients

who have SLE also have aPLs.. who have SLE also have aPLs.. aPLs : heterogeneous group of aPLs : heterogeneous group of

autoantibodies that bind autoantibodies that bind phospholipids, proteins, or a phospholipids, proteins, or a phospholipid–protein complex on phospholipid–protein complex on platelets and or vascular platelets and or vascular endothelium.endothelium.

Two best characterized : the lupus Two best characterized : the lupus anticoagulant (LA) and anticoagulant (LA) and anticardiolipin antibodies (aCL) anticardiolipin antibodies (aCL)

. .

Suggested clinical and Suggested clinical and laboratory criteria for the laboratory criteria for the

diagnosis of APSdiagnosis of APS Pregnancy Loss Pregnancy Loss Recurrent spontaneous abortion & Recurrent spontaneous abortion &

Unexplained fetal deathUnexplained fetal death Thrombosis: Venous thrombosis & Thrombosis: Venous thrombosis &

Arterial thrombosis, strokeArterial thrombosis, stroke Autoimmune thrombocytopenia& Autoimmune thrombocytopenia&

hemolytic anemia hemolytic anemia Transient ischemic attacks Transient ischemic attacks Chorea gravidarum &Livedo reticularisChorea gravidarum &Livedo reticularis Laboratory criteriaLaboratory criteria Lupus anticoagulant, Anticardiolipin Lupus anticoagulant, Anticardiolipin

antibodies , >15–20 IgG binding units& antibodies , >15–20 IgG binding units& activated partial thromboplastin time .activated partial thromboplastin time .

Conditions Specific to Conditions Specific to PregnancyPregnancy

Herpes gestationis (HG) (also known Herpes gestationis (HG) (also known as "pemphigoid gestationis") .as "pemphigoid gestationis") .

Pruritic and urticarial papules and Pruritic and urticarial papules and plaques of pregnancy (PUPPP). plaques of pregnancy (PUPPP).

Intrahepatic cholestasis of Intrahepatic cholestasis of pregnancy (ICP) may present with pregnancy (ICP) may present with intense pruritus. intense pruritus.

Prurigo of pregnancyPrurigo of pregnancy Pruritic folliculitis of pregnancyPruritic folliculitis of pregnancy

Herpes Gestationis H G Herpes Gestationis H G (pemphigoid gestationis(pemphigoid gestationis))

The incidence 1 in 50,000 pregnancies The incidence 1 in 50,000 pregnancies Developing during the second or third Developing during the second or third

trimester (mean onset, 21 weeks) & trimester (mean onset, 21 weeks) & reported in the first trimester. reported in the first trimester.

Intensely pruritic, urticarial lesions on Intensely pruritic, urticarial lesions on the abdomen in half of the cases the abdomen in half of the cases especially especially periumbilicallyperiumbilically, with a rapid , with a rapid progression to multiple, generalized progression to multiple, generalized bullae. Face, mucous membranes, bullae. Face, mucous membranes, palms, and soles : palms, and soles : sparedspared. .

Improving during the later part of Improving during the later part of pregnancy, only to flare at delivery or pregnancy, only to flare at delivery or postpartum in about 75% of patients postpartum in about 75% of patients

HistopathologyHistopathology : a subepidermal vesicle : a subepidermal vesicle with perivascular infiltration with perivascular infiltration (lymphocytes & eosinophils). (lymphocytes & eosinophils).

Direct immunofluorescenceDirect immunofluorescence :C3 with or :C3 with or without IgG in a linear band along the without IgG in a linear band along the basement membrane zone (BMZ). The basement membrane zone (BMZ). The antibody localizes to the roof of the antibody localizes to the roof of the blister. blister.

A mismatch of HLA antigens between the A mismatch of HLA antigens between the mother and father, manifested by an mother and father, manifested by an immunologic response against the immunologic response against the paternal class II antigens at the placental paternal class II antigens at the placental BMZ with cross-reaction at the skin BMZ. BMZ with cross-reaction at the skin BMZ.

Foetal Risk in in HGFoetal Risk in in HG

The newborn shows The newborn shows signs of HG in less signs of HG in less than 10% of cases. than 10% of cases.

The foetal risk : The foetal risk : prematurity and low prematurity and low birthweightbirthweight, ,

Urticarial plaques & Urticarial plaques & vesiculationsvesiculations

Pruritic and Urticarial Pruritic and Urticarial Papules and Plaques of Papules and Plaques of

Pregnancy(PUPPP)Pregnancy(PUPPP) Occuring in approximately 1 in 240 Occuring in approximately 1 in 240

pregnant women, typically in the pregnant women, typically in the third trimester in first pregnancythird trimester in first pregnancy

The urticarial papules begin The urticarial papules begin within within striaestriae on the abdomen and thighs on the abdomen and thighs and, and, sparing sparing the the periumbilicalperiumbilical region, face, palms, and soles. region, face, palms, and soles.

The lesion may be also vesicles or The lesion may be also vesicles or targetoid. targetoid.

Not to recur in subsequent Not to recur in subsequent pregnancies pregnancies

Biopsy Biopsy : : a spongiotic epidermis with a a spongiotic epidermis with a perivascular inflammatory infiltrate: perivascular inflammatory infiltrate: increased numbers of eosinophils. increased numbers of eosinophils.

ImmunofluorescenceImmunofluorescence : negative : negative Poseing no risk to the mother Poseing no risk to the mother

(except pruritus) or fetus, (except pruritus) or fetus, resolveing postpartumresolveing postpartum. .

Aetiology :Aetiology :1.1. Abdominal distention: eliciting an Abdominal distention: eliciting an

inflammatory response by inflammatory response by damaging the connective tissue & damaging the connective tissue &

2.2. A substance released from A substance released from placenta into the maternal placenta into the maternal circulation triggers fibroblast circulation triggers fibroblast proliferationproliferation

Intrahepatic Cholestasis of Intrahepatic Cholestasis of Pregnancy (ICP)Pregnancy (ICP)

In the third trimester of pregnancy In the third trimester of pregnancy (mean, 31 weeks) with a mild form of (mean, 31 weeks) with a mild form of intrahepatic bile secretory dysfunction.intrahepatic bile secretory dysfunction.

Features :Features :11-generalized pruritus with or -generalized pruritus with or without jaundice without jaundice 22-absence of primary -absence of primary skin lesions, skin lesions, (3)(3) biochemical biochemical abnormalities consistent with abnormalities consistent with cholestasis,(cholestasis,(elevated serum bile acids elevated serum bile acids (mean, 1349 mug/100 mL)(mean, 1349 mug/100 mL) and (4) and (4) resolution after delivery. resolution after delivery.

Recurrence with subsequentRecurrence with subsequent pregnancypregnancy

PathophysiologyPathophysiology

Estrogens interfere with the diffusion of Estrogens interfere with the diffusion of fluid across the canalicular membrane fluid across the canalicular membrane of the hepatocyte and subsequently of the hepatocyte and subsequently with hepatic bile acid secretion. with hepatic bile acid secretion.

Inhibition of hepatic glucuronyl-Inhibition of hepatic glucuronyl-transferasetransferase

Altered estrogen metabolism in the Altered estrogen metabolism in the liver, resulting in reduced biliary liver, resulting in reduced biliary volume and excretion of these volume and excretion of these compounds compounds

Prurigo of pregnancy Prurigo of pregnancy (PP(PP ))

The incidence : 1 in 300 The incidence : 1 in 300 pregnancies. pregnancies.

In all trimesters of pregnancy In all trimesters of pregnancy Erythematous papules and nodules Erythematous papules and nodules

on the extensor surfaces of the on the extensor surfaces of the extremities and occasionally on extremities and occasionally on the abdomenthe abdomen

Recurrence during subsequent Recurrence during subsequent pregnancies is variablepregnancies is variable

Related to an atopic backgroundRelated to an atopic background

Pruritic folliculitis of Pruritic folliculitis of pregnancypregnancy (PFP)(PFP)

Generalized, pruritic erythematous, Generalized, pruritic erythematous, follicular papules, developing from follicular papules, developing from the fourth to the ninth month of the fourth to the ninth month of gestation .gestation .

A form of steroid acne, with no A form of steroid acne, with no evidence of any immunologic or evidence of any immunologic or hormonal abnormalities.hormonal abnormalities.

Some authors[ have suggested that Some authors[ have suggested that PFP and PP should be included PFP and PP should be included within the spectrum ofwithin the spectrum of " "polymorphic polymorphic eruption of pregnancy.eruption of pregnancy.

The Use of Drugs for The Use of Drugs for Dermatologic Conditions Dermatologic Conditions

in Pregnancyin Pregnancy

FDA Pregnancy CategoriesFDA Pregnancy Categories AA Controlled studies show no fetal riskControlled studies show no fetal risk

BB No risk to human fetus despite No risk to human fetus despite possible animalpossible animal risk. risk.

CC Risk cannot be ruled out; human Risk cannot be ruled out; human studies are lacking.studies are lacking.

DD Positive evidence for risk to human Positive evidence for risk to human fetus, but benefits may outweigh risks of fetus, but benefits may outweigh risks of drugdrug

XX Contraindicated in pregnancy; there Contraindicated in pregnancy; there is no reason to risk use of drug in is no reason to risk use of drug in pregnancypregnancy

UndeterminedUndetermined No pregnancy No pregnancy category yet assignedcategory yet assigned

Topical corticosteroidsTopical corticosteroids during during pregnancy :with a low risk to the pregnancy :with a low risk to the fetus( fetus( Category CCategory C risk) as the risk risk) as the risk cannot be ruled out because no cannot be ruled out because no human studies have been done. human studies have been done.

Topical Topical povidone-iodinepovidone-iodine and and podophyllinpodophyllin place a fetus at risk. : place a fetus at risk. : not recommended for use during not recommended for use during pregnancypregnancy

AnalgesicsAnalgesics: associated with minimal : associated with minimal risk to the fetus or infant. risk to the fetus or infant. Indomethacin::associated with Indomethacin::associated with problems in infants .problems in infants .

Retinoids Retinoids and and antineoplasticantineoplastic: : isotretinoin (used to treat acne isotretinoin (used to treat acne vulgaris) & antineoplastic eg vulgaris) & antineoplastic eg methotrexate: category X. methotrexate: category X.

AntipruriticAntipruritic agents. : doxepin: agents. : doxepin: avoided during pregnancy and avoided during pregnancy and lactation. Hydroxyzine : risk in the lactation. Hydroxyzine : risk in the first trimester of pregnancy and is first trimester of pregnancy and is associated with a risk of congenital associated with a risk of congenital abnormality. abnormality.

Antibiotics:Antibiotics:including tetracycline & including tetracycline & ciprofloxacin--pose potential risks ciprofloxacin--pose potential risks during pregnancy.. Penicillins are during pregnancy.. Penicillins are considered comparatively safe during considered comparatively safe during pregnancypregnancy

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