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Dermatologic changes in pregnancy.

Introduction

During pregnancy, the body undergoes a significant number of physiologic and hormonal changes. The effect of these changes on the body's collagen formation, pigment-producing cells, vasculature, immune system, bile acid excretion, and other normal processes of the body, leading to dermatologic manifestations. These skin changes can be stressful for some women, but fortunately many of them resolve spontaneously after giving birth. However, two of the conditions discussed--pemphigoid gestationis and intrahepatic cholestasis of pregnancy--can cause negative effects on the fetus. This article seeks to explore some of the dermatologic changes associated with pregnancy, as well as provide an overview of some of the current treatment options.

pemphigoid gestationis and intrahepatic cholestasis of pregnancy--can cause negative effects on the fetus

Striae gravidarum

More commonly known as "stretch marks," these discolored striations of the skin affect up to 90% of pregnant women by the 3rd trimester (Kroumpouzos 2001). They most commonly occur on the abdomen, buttocks, breasts, thighs and arms. The cause of these stretch marks is multifactorial, but both physical stretching and hormonal changes play a part. Hormones such as relaxin, adrenocortical steroids, and estrogen are increased during pregnancy and can contribute to the formation of stretch marks by affecting collagen formation. (Thomas 2004). Although many women will use Vitamin E cream, cocoa butter, aloe vera lotion, or olive oil, these remedies have not been proven to prevent stretch marks. However, there are some post-partum treatment options available, including topical tretinoin and oral tretinoin (Kang 1998). In severe cases, laser treatment may also be used (McDaniel 2002).

Hyperpigmentation

Darkening of the skin as well as existing moles and scars commonly occurs in pregnancy. The areolae, axillae, and genitals are most commonly affected, but linea nigra and melasma are well-known variations of hyperpigmentation as well. Linea nigra is the darkened vertical line that runs down the abdomen in the midline. Typically it will fade in the post-partum period. Melasma (also known as cholasma or the mask of pregnancy) is noted by darkened gray-brown patches on the face, most commonly on the cheeks, bridge of the nose, forehead, chin, and above the upper lip. It is worsened by sunlight and UV radiation, and so the best way to treat and prevent worsening of melasma is by using broad spectrum UVA and UVB sunscreen as well as by avoiding excess sun exposure (Kroumpouzos 2001). Most cases resolve after birth, but the condition may recur with future pregnancies or with oral contraceptive use (Kroumpouzos 2001). For cases of melasma that are severe or fail to resolve, a combination of topical tretinoin, hydroquinone, and corticosteroids may be used (Torok et al 2005).

Spider angiomas

Spider angiomas are vascular dermatologic conditions that appear as a superficial cluster of web-like vessels with a central spot. They may also be referred to as spider nevi or spider telangiectasias. Increased estrogen levels in pregnancy affect the vasculature, causing dilation, instability, proliferation, and increased permeability of vessels (Kroumpouzos 2001). They most commonly occur in the face, neck, and arms, and typically appear in the first and second trimesters (Kroumpouzos 2001). Treatment is often unnecessary as these lesions often resolve spontaneously after the birth of a child. However, it may take anywhere from 6 weeks to 9 months for resolution (Henry et al. 2006). Spider telangiectasias that fail to resolve may be treated with fine-needle electrocautery, pulsed dye laser or intense pulse light system.

Dermatoses of Pregnancy

The most recent classification of these dermatoses of pregnancy proposed by Ambros-Rudolph, Mullegger, Vaughan-Jones, Kerl, and Black (2006) includes the following diseases:

1. Pemphigoid gestationis (PG) (herpes gestationis).

Also known as herpes gestationis, this is the rarest of the dermatoses of pregnancy, affecting only one out of every 2,000-60,000 women (Ambros 2011). It most commonly presents in the third trimester as pruritic red papules and plaques that progress to form bullae. It typically affects the umbilicus and may spread to the chest, back, and extremities (Warshauer et al. 2013). Pemphigoid gestationis is one of the two dermatoses of pregnancy that can have adverse effects on the fetus. The other (intrahepatic cholestasis of pregnancy) is discussed later in this article. PG is associated with an increased risk of prematurity and low birth weight, and the incidence increases with increased severity of maternal disease, marked by onset of PG before the third trimester (Warshauer et al 2013 and Ambros 2011). Antibodies formed by the mother's immune system may cross the placenta and cause up to 10% of infants to develop transient bullae (Warshauer et al 2013 and Ambros 2011). In mild cases, oral antihistamines or topical corticosteroids may be used to treat PG. More severe cases may require oral corticosteroids (Warshauer et al. 2013). Women who develop PG are at increased risk of developing other autoimmune diseases later in life, such as Graves disease, and are at risk of developing flare-ups of PG with future pregnancies or use of oral contraceptive pills (Kroumpouzos 2001).

2. Polymorphic eruption of pregnancy (PEP)

Formerly known as pruritic urticarial papules and plaques of pregnancy (PUPP), polymorphic eruption of pregnancy describes a benign pruritic inflammatory disorder that first appears along the stretch marks of the abdomen and may spread to the buttocks and thighs (Ambros 2011). Unlike pemphigoid gestationis, the umbilicus is typically not affected. Approximately 1 in 160 pregnant women are affected (Ambros 2011), most commonly late in the third trimester or in the immediate post- partum period. PEP is typically self-limited, resolving spontaneously in 4-6 weeks from its initial appearance (Ambros 2011). The etiology is unclear, but the pruritus may be alleviated with oral antihistamines or topical corticosteroids. If the rash becomes more widespread or severe, a brief trial of corticosteroids may be used (Ambros-Rudolph 2011; Warshauer, et al. 2013).

3. Intrahepatic cholestasis of pregnancy (ICP)

Intrahepatic cholestasis of pregnancy (ICP), formerly known as pruritus gravidarum, is due to a defect in the excretion of bile salts, causing the excess to deposit on the skin. Patients may present with severe pruritus with or without jaundice, absence of rash, and with laboratory markers of cholestasis, the most specific of which is total serum bile acid (Palma et al. 1997). The pruritus typically starts in the soles of the feet and the palms of the hands and may progress to include the abdomen, back, and face. ICP is the second dermatosis of pregnancy associated with potentially harmful effects on the fetus. As a result, it is important to recognize and correctly diagnose ICP. The potential risks to the fetus include prematurity, intrauterine fetal distress, and intrauterine fetal demise (Ambros 2011). The pruritus can be treated with oral antihistamines; however severe cases may require Ursodeoxycholic acid to not only alleviate symptoms but also to reduce the harmful effects on the fetus.

4. Atopic eruption of pregnancy (AEP)

Atopic eruption of pregnancy encompasses eczema, prurigo, and pruritic folliculitis. The clinical overlap of these conditions has caused them to be classified into a larger spectrum known as atopic eruption of pregnancy. This group of dermatologic disorders is the most common of the dermatoses of pregnancy, accounting for almost 50% of cases (Ambros 2011). Unlike the above dermatoses of pregnancy, these conditions typically manifest before the third trimester. Women may present with pruritic eczematous eruptions (commonly on neck and flexural surfaces) or with pruritic popular eruptions (typically on abdomen and extremities). While they do not affect the fetus, the child may have an increased risk for atopic dermatitis as an infant (Ambros 2011). While the cause of these lesions is not known, topical steroids and oral antihistamines may be used on a short-term basis to provide symptomatic relief. As with many of the other dermatologic changes in pregnancy, AEP may recur in future pregnancies (Ambros 2011).

Tips for Parents

* Review pictures of dermatologic changes that occur in pregnancy early on

* Make note of pruritis (itchiness), examine the body for a rash

* Keep a journal of how far along in pregnancy a rash developed

* Make note of where a rash starts, if it is on the abdomen, trunk, limbs, and if the periumbilical region is involved

* Timing of onset is key in diagnosis and treatment

In pregnancy, the mother's body undergoes many changes; some are temporary while others are permanent.

It is important to understand some of the dermatologic changes that occur as these are visible and the patient may be more aware. This topic is important for childbirth educators because understanding some of the physiologic changes in pregnancy can help make parents more aware and know when medical intervention may be necessary. A good idea of reviewing photos of some of the normal physiologic changes in pregnancy is a good start. One may try to treat rashes or lesions on their own without proper education on the effects of the medication used on the mother and child. Some dermatologic disorders put the child at risk for future atopic diseases where important education can help alleviate future visits to the provider. Women who develop some disorders such as PG are at a higher risk later in life of developing autoimmune disorders. Properly educating patients on some of the dermatologic changes occurring in pregnancy will alleviate some concerns when these changes are benign and common.

References

Ambros-Rudolph, C. M. (2011). Dermatoses of pregnancy--clues to diagnosis, fetal risk and therapy. Annals of Dermatology, 23(3), 265-75.

Ambros-Rudolph, C. M., Mullegger, R. R., Vaughan-Jones, S. A., Keri, H., & Black, M. M. (2006). The specific dermatoses of pregnancy revisited and reclassified: Results of a retrospective two-center study on 505 pregnant patients. Journal of the American Academy of Dermatology, 54(3), 395-404.

Henry, F., Quatresooz, R, Valverde-Lopez, J. C., & Pierard, G. E. (2006). Blood vessel changes during pregnancy: a review. American Journal of Clinical Dermatology, 7(1), 65-69.

Kang, S. (1998). Topical tretinoin therapy for management of early striae. Journal of the American Academy of Dermatology, 39(2 pt 3)S90-S92.

Kroumpouzos, G., & Cohen, L. M. (2001). Dermatoses of pregnancy. Journal of the American Academy of Dermatology, 45, 1-19.

McDaniel, D. H. Laser therapy of stretch marks. Dermatological Clinics, 20, 67-76.

Palma, J., Reyes, H., Ribalta, J., Hernandez, I., Sandoval, L., Almuna, R., Liepins, J., Lira, F., Sedano, M., Silva, O., Toha, D. & Silva, J. J. (1997). Ursodeoxycholic acid in the treatment of cholestasis of pregnancy: A randomized, double-blind study controlled with placebo. Journal of Hepatology, 27(6), 1022-1028.

Thomas, R. G., & Liston, W. A. (2004). Clinical associations of striae gravidarum. J Obstetrics and Gynaecology, 24, 270-271.

Torok, H. M., Jones, T., Rich, R, Smith, S., & Tschen, E. (2005). Hydroquinone 4%, tretinoin 0.05%, fluocinolone acetonide 0.01%: a safe and efficacious 12-month treatment for melasma. Cutis, 75, 57-62.

Tunzi, M & Gray, GR. Common skin conditions in pregnancy. Am Fam Physician, 2007Jan 15, 75(2):211-218

Warshauer E, & Mercurio M. Update on dermatoses of pregnancy. Int J Dermatol, 2013 Jan, 52(1):6-13.

By Samantha J. Bartling, BS, and Patrick M. Zito, DO PharmD RPh FASCP FRSPH

Samantha J. Bartling is a fourth year medical student at Rowan University School of Osteopathic Medicine. She completed her undergraduate education at The College of New Jersey where she earned her Bachelor of Science in Biology. Upon graduation from medical school, Samantha will continue her medical education as an intern in the United States Navy.

Dr. Patrick M. Zito is both a practicing physician and pharmacist serving as contributing faculty member at Walden University School of Nursing as a clinicalpharmacy/pharmacology specialist. He is also an executive advisory board member at the Center for Applied Health Sciences. His research interests are in infectious diseases, applied sports nutrition, hormone modulation to injury repair, and preventative pharmacological and nonpharmacological approaches to tissue damage and aging, reconstructive surgery, dermatology, skin cancer therapeutics.
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Author:Bartling, Samantha J.; Zito, Patrick M.
Publication:International Journal of Childbirth Education
Article Type:Report
Geographic Code:1USA
Date:Apr 1, 2016
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