Normal physiological changes of pregnancy include alterations to skin, hair, and nails as discussed in Chapter 4 (Skin). In addition, several dermatoses are seen only in pregnancy. Finally, it is axiomatic that skin diseases that affect childbearing-age women are commonly encountered in pregnancy.
Four dermatoses considered unique to pregnancy include intrahepatic cholestasis of pregnancy, pruritic urticarial papules and plaques of pregnancy (PUPPP), atopic eruption of pregnancy (AEP), and pemphigoid gestationis (Table 62-1). As a group, these are diagnosed in up to 5 percent of pregnancies with the following relative occurrences: intrahepatic cholestasis 1 in 100; PUPPP, 1 in 130 to 350; atopic eruptions, 1 in 300 to 450, and pemphigoid, 1 in 50,000 (Chander, 2011). Their gross appearance may be similar to each other or to other skin disorders, and pruritus is a common feature of all four. Only intrahepatic cholestasis and pemphigoid gestationis have been linked with adverse fetal outcomes.
TABLE 62-1Pregnancy-specific Dermatoses |Favorite Table|Download (.pdf) TABLE 62-1 Pregnancy-specific Dermatoses
|Disorder ||Frequency ||Characteristic Lesion ||Adverse Pregnancy Effects ||Treatment |
|Cholestasis of pregnancy ||Common ||No primary lesions, secondary excoriations from scratching ||Increased perinatal morbidity ||Antipruritics, cholestyramine, ursodeoxycholic acid |
|Pruritic urticarial papules and plaques of pregnancy (PUPPP) ||Common ||Erythematous pruritic papules or plaques; patchy or generalized on abdomen, thighs, buttocks, especially within striae, but with umbilical sparing ||None || |
|Atopic eruptions of pregnancy (AEP) || || ||None || |
| Eczema of pregnancy ||Common ||Dry, red scaly patches on extremity flexures, neck, face || || |
| Prurigo of pregnancy ||Common ||1–5 mm pruritic red papules on extensor surfaces, trunk || ||} Antipruritics, emollients, topical corticosteroids, oral steroids if severe |
|Pruritic folliculitis of pregnancy ||Rare ||Small red papules, sterile pustules on trunk || || |
|Pemphigoid gestationis ||Rare ||Erythematous pruritic papules, plaques, vesicles, and bullae; abdomen often with umbilical involvement, extremities ||Preterm birth, fetal- growth restriction, transient neonatal lesions || |
Intrahepatic Cholestasis of Pregnancy
Previously termed pruritus gravidarum and in contrast to the other pregnancy-specific dermatoses, intrahepatic cholestasis of pregnancy generally has no primary skin lesions. Rarely, a rash preceded pruritus (Chao, 2011). Pruritus is associated with abnormally elevated serum bile acid levels, and hepatic aminotransferase levels may also be mildly increased. Adverse fetal affects have been linked to this condition, and it is discussed in detail in Chapter 55 (Hepatic Disorders).
This rare autoimmune bullous disease is notable for its maternal and fetal effects. Initially, pruritic papules and urticarial plaques form and are then followed in most cases after 1 to 2 weeks by vesicles or bullae. Lesions are frequently distributed periumbilically, and they often develop on other skin surfaces with sparing of mucous membranes, scalp, and face (Fig. 62-1).
Pemphigoid gestationis. A. Bullae commonly develop within erythematous plaques. (Photograph contributed by Dr. Amit Pandya.) ...