Pregnancy Dermatoses

Nathan W Rojek, MD

Assistant Professor of Dermatology

UC Irvine School of Medicine

Objectives

• List the dermatoses of pregnancy

• Compare and contrast the clinical presentations of the different pregnancy dermatoses

• Identify the treatment options for each specific condition

• Recognize which pregnancy dermatoses confer a risk to the fetus

Pemphigoid Gestationis (PG) is a rare, pruritic, autoimmune bullous disease that typically develops during late pregnancy or immediately post-partum

PG is caused by IgG1 autoantibodies targeting a transmembrane hemidesmosomal protein

Performing a biopsy for direct immunofluorescence is essential to confirm the diagnosis of PG

The primary goals of treatment are to relieve pruritus and suppress blister formation

Mild Cases

• Potent topical steroids plus: – Emollients (petrolatum)

– Systemic antihistamines

Moderate-to-Severe Cases

• Systemic steroids – 0.5mg/kg prednisone daily

Most disease activity spontaneously remits during the weeks to months following delivery

• OCPs induce flares and/or recurrences in 25-50% of patients

• Likely to recur in future pregnancies → earlier onset & more severe course

• ↑ risk of developing Graves disease in future

PG increases the risk of prematurity and small-for-gestational age neonates

Polymorphic eruption of pregnancy (PEP) is a common, pruritic, condition of unknown etiology that typically develops during

late pregnancy or immediately post-partum

PEP has nonspecific skin biopsy findings, negative immunofluorescence, and normal labs

PEP is self-limited and without serious sequelae, so the majority of patients require only topical steroids and oral antihistamines

PEP usually does not recur and has no maternal or fetal risks

Intrahepatic cholestasis of pregnancy (ICP) is rare and presents as pruritus without primary skin lesions with onset during 3rd trimester

ICP is a result of genetically-linked, hormone-dependent, reversible cholestasis

Elevated total serum bile acid levels are diagnostic for ICP

Ursodeoxycholic acid (UDCA) is the treatment for ICP

• Safe for mother & fetus

• 15mg/kg po daily started ASAP and continued until delivery

• Goal is normalization of serum bile acid levels

Pruritus typically persists until delivery and then resolves spontaneously within days

• 45-70% of patients get recurrence with another pregnancy

• OCPs routinely induce recurrence

ICP is associated with multiple maternal and fetal risks

Maternal Risks

• Steatorrhea

• Vitamin K deficiency

• Intra- and postpartum hemorrhage

Fetal Risks

• Prematurity (20-60%)

• Intrapartum fetal distress (20-30%)

• Fetal loss (1-2%)

Atopic eruption of pregnancy (AEP) is the most common pruritic disorder during pregnancy and 75% of cases begin before 3rd trimester

AEP occurs due to the normal pregnancy-induced immune shift towards a dominant Th2 response

AEP has histologic changes typical of eczematous conditions, negative immunofluorescence, and ↑ serum IgE in up to 70% of patients

AEP has no serious sequelae, so the majority of patients require only topical steroids and emollients

Mild Cases

• Topical steroids plus: – Emollients (petrolatum)

– Systemic antihistamines

Moderate-to-Severe Cases

• Narrow-band UVB

Maternal and fetal prognoses are excellent, though recurrences in subsequent pregnancies are common

Objectives

• List the dermatoses of pregnancy

• Compare and contrast the clinical presentations of the different pregnancy dermatoses

• Identify the treatment options for each specific condition

• Recognize which pregnancy dermatoses confer a risk to the fetus

Thanks for listening! Any questions?