Pregnancy-induced eczema, aggravation of pre-existing skin disorders, and skin problems independent of pregnancy may occur during pregnancy.
In their treatment, it should be noted that some medicines are contraindicated during pregnancy.
If a pregnant woman presents with itching, ALT and bile acid levels should be tested to exclude hepatic cholestasis of pregnancy.
If pregnancy-induced eczema is suspected, a dermatologist normally needs to be consulted.
Diagnosis
Is the problem acute or chronic? Did it exist already before pregnancy? Does the patient have any history of skin disorders, such as atopic eczema?
Does the patient have systemic symptoms in association with the skin problem, such as fever or malaise?
Do the patient's contacts, such as children, have skin problems (scabies, impetigo, ringworm, pox diseases)?
Travel history
Are the lesions itchy (atopic eczema, pregnancy-induced eczema)?
Examine the skin status thoroughly, including other important areas (the scalp, palms, soles of the feet, oral mucosa, nails).
Physiological skin changes during pregnancy
Physiological itching, pruritus gravidarum
Typically during the 1st or 2nd trimester of pregnancy
Often mild, more diffuse and predominantly on the trunk
Possibly associated with dry skin
In most women, the skin becomes less greasy and may be dryer.
Non-medicated ointments and skin oils can be used to alleviate subjective symptoms. There is no evidence of their effectiveness in preventing pregnancy stretch marks (striae gravidarum).
Increased sweating
Streak lines, or striae
Usually in the abdominal, buttock and breast areas
Appearance of skin tags on the neck, in armpits and in the groin
Linea nigra
Linear hyperpigmentation in the midline on the abdomen
A physiological phenomenon
Hyperpigmentation of the nipples and genital area
A physiological phenomenon, particularly in people with dark skin
Vascular skin changes
Telangiectasia
Small haemangiomas
Leg oedema
Varicose veins
Persistent erythema on the palms
In about 3 months after delivery there is often usually transient, significant hair loss (telogen effluvium) Hair Loss and Balding.
May occur for the first time or be aggravated during pregnancy.
In the systemic form of the disease the patient will have general symptoms, in forms restricted to the skin scaly, patchy eczema aggravated by sunlight, usually on the face and upper trunk.
Pregnancy-induced eczemas
The main symptom of pregnancy-induced eczema is an itchy rash with onset during pregnancy. There are usually no general symptoms but itching disturbs sleep and therefore causes fatigue. It is characteristic for such eczemas to heal some time after delivery.
Atopic dermatitis during pregnancy
The most common form of pregnancy-induced eczema
Clinically resembles atopic eczema, with onset during early pregnancy (usually the 1st or 2nd trimester).
Patchy or nodular eczema (with prurigo nodules due to skin picking)
The main problem is itching predominantly at night and the resulting sleep problems.
No effect on fetal development or any particular risk for the course of the pregnancy
Complex pregnancy-induced eczema
Usually occurs in the last trimester of the first pregnancy.
In some cases occurs only after delivery or persists after delivery.
More common in multiple pregnancies
May also occur for a short period of time immediately after delivery.
Itchy plaques and papules predominantly on the abdomen, often starting in the area of abdominal striae gravidarum; proximally on the limbs
Usually calms down in 4-6 weeks.
No tendency to recur in future pregnancies
No effect on fetal development or any particular risk for the course of the pregnancy
Gestational pemphigoid
A rare autoimmune blistering disease usually with onset in the 2nd or 3rd trimester
A rapidly growing, erythematous tumour that bleeds easily
Typically situated on the fingers or toes
May occur after mild injury.
Darkening of pigmented naevi (benign darkening, observation is usually sufficient)
Malignant skin tumours, such as melanoma
Rare but possible during pregnancy
Biopsies should be taken of the lesions if malignancy is suspected.
Condylomas
A latent condyloma/HPV infection may erupt into rapidly growing, visible condylomas that will regress after pregnancy.
Workup
If hepatic cholestasis of pregnancy is suspected, ALT and bile acids
In atopic eczema, the clinical picture is usually sufficient for diagnosis. If there are differential diagnostic problems, a serum IgE test and full blood count can be performed. Elevated IgE levels or eosinophilia suggest atopic eczema but normal levels will not exclude the disease.
If the eczema does not respond to treatment or if it is severe, systemic glucocorticoids and some immunosuppressive medicines (e.g. ciclosporine) can be used under the supervision of a dermatologist.
The first-line treatment of hepatic cholestasis of pregnancy is ursodeoxycholic acid Interventions for Treating Cholestasis in Pregnancy, which usually normalizes the level of bile acids, other laboratory findings and the patient's symptoms. Antihistamines, guar gum and cholestyramine have also been used for symptomatic treatment.
In eczematous diseases, the treatment of first choice is intermittent low or midpotency topical glucocorticoids for 1-2 weeks at a time, for instance. High potency ointments can be used for exacerbations for 1-2 weeks at a time.
For psoriasis, topical mid- to high potency glucocorticoid ointments can be used intermittently, in courses of 2-3 weeks, for example. Keratolytic ointments (containing urea, for example) can be used to soften and remove thick scale. Non-medicated ointments usually reduce the need for glucocorticoid ointments and decrease exacerbations.
The treatment of condylomas is not recommended during pregnancy. Reassessment of the method of delivery in late pregnancy may be necessary if there are numerous condylomas in the birth canal.
In patients with erythema nodosum, rest, a break from standing work, keeping the legs elevated at rest, moist compresses, wearing compression socks and symptomatic analgesic medication, such as paracetamol or NSAIDs (not during the last trimester), are often sufficient.
Specialist consultation
A dermatologist should be consulted if pregnancy-induced eczema is suspected or if the patient has a severe skin problem resistant to treatment.
A gynaecologist should be consulted if gestational pemphigoid is diagnosed (fetal monitoring) or a primary Herpes simplex infection or particularly problematic recurrent infection in the genital area is suspected during pregnancy.
If hepatic cholestasis of pregnancy is suspected, the patient should be referred as an emergency case to a maternity hospital.
References
Bechtel MA. Bechtel MA. Pruritus in Pregnancy and Its Management. Dermatol Clin 2018;36(3):259-265. [PubMed]
Wood AM, Livingston EG, Hughes BL ym. Intrahepatic Cholestasis of Pregnancy: A Review of Diagnosis and Management. Obstet Gynecol Surv 2018;73(2):103-109. [PubMed].
Kushner CJ, Concha JSS, Werth VP. Kushner CJ, Concha JSS, Werth VP. Treatment of Autoimmune Bullous Disorders in Pregnancy. Am J Clin Dermatol 2018;19(3):391-403. [PubMed].
Chien AL, Qi J, Rainer B ym. Treatment of Acne in Pregnancy. J Am Board Fam Med 2016;29(2):254-62. [PubMed].
Bechtel MA, Plotner A. Dermatoses of pregnancy. Clin Obstet Gynecol 2015;58(1):104-11. [PubMed]