section name header

Information

Editors

AlexanderSalava
JukkaUotila

Skin Problems during Pregnancy

Essentials

  • 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.
  • Nail lesions Nail Lesions and Disorders
    • Lines on the nail plate, detachment or splitting of nails, longitudinal dark lines being typical

The most common skin problems

Rarer skin problems

  • Erythema nodosum Erythema Nodosum
    • Acute eruption of blueish red nodules tender on palpation on both legs, possibly with mild general symptoms and fever
  • Psoriasis Psoriasis
    • May occur for the first time or be aggravated during pregnancy.
  • Seborrhoeic eczema Seborrhoeic Dermatitis in the Adult
    • Erythematous, scaly patches in the area of the eyebrows, nasolabial folds, on the face, scalp, in the ear area
  • Herpes simplex Genital Herpes
  • Lupus erythematosus Discoid Lupus Erythematosus
    • 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
  • Itchy, erythematous plaques covered with clear vesicles Ehttp://www.dynamed.com/condition/pemphigoid-gestationis#CHIEF_CONCERN__CC_
  • Usually heals within a few months.
  • Usually starts around the navel.
  • Predominantly on the trunk and proximal parts of the limbs; may spread quite widely.
  • Requires regular follow-up by a dermatologist and a gynaecologist.
  • Often recurs in subsequent pregnancies.
  • The mother may have an increased risk of hyperthyroidism after delivery.
  • The baby may also have a transient bullous dermatosis.
  • Any risk to the fetus is low but possible; association with preterm birth and low birth weight Ehttp://www.dynamed.com/condition/pemphigoid-gestationis#COMPLICATIONS.
  • Systemic glucocorticoid therapy may cause complications during pregnancy (hypertension, diabetes).

Hepatic cholestasis of pregnancy (hepatosis)

Skin tumours during pregnancy

  • Pyogenic granuloma
    • 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.
  • The diagnosis of gestational pemphigoid is based on positive immunofluorescence of skin biopsy Ehttp://www.dynamed.com/condition/pemphigoid-gestationis#BIOPSY_AND_PATHOLOGY and positive serum antibodies Ehttp://www.dynamed.com/condition/pemphigoid-gestationis#BLOOD_TESTS.
  • If a skin tumour is suspected of being malignant, perform histological examination PAD (by punch biopsy, for example).

Treatment

  • Physiological itching can usually be alleviated by non-medicated ointments.
  • For pregnancy-induced eczemas, use mid- to high potency topical glucocorticoids in courses of 2-3 weeks, for example.
  • Antihistamines, such as 10 mg loratadine or cetirizine once daily, can be used for symptomatic treatment of itching Ehttp://www.dynamed.com/management/treatments-of-common-complaints-in-pregnant-women#PRURITUS.
  • In severe eczemas not responding to topical treatment (e.g. atopic eczema, psoriasis), phototherapy (e.g. narrowband UVB phototherapy) has been used Ehttp://www.dynamed.com/condition/psoriasis#PSORIASIS_IN_PREGNANCY.
  • 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.
  • Benzoyl peroxide gel / skin wash or azelaic acid ointment/gel can be used for the treatment of acne. For inflamed lesions (pimples) clindamycin emulsion or solution can be used.
  • Topical vitamin A products or oral tetracycline are not recommended for use during pregnancy.
  • Topical products containing metronidazole, azelaic acid or clindamycin can be used for the treatment of perioral dermatitis and rosacea.
  • 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.
  • Recurrent herpes in the genital area can be treated by oral aciclovir or valaciclovir Ehttp://www.dynamed.com/condition/genital-herpes#TREATMENT_DURING_PREGNANCY. If herpes infections recur frequently, long-term preventive medication should be considered during late pregnancy Antenatal Clinics and Specialist Care: Consultations, Referrals, Treatment Guidelines.
  • 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]
    • Tyler KH. Dermatologic therapy in pregnancy. Clin Obstet Gynecol 2015;58(1):112-8. [PubMed]
    • Vaughan Jones S, Ambros-Rudolph C, Nelson-Piercy C. Skin disease in pregnancy. BMJ 2014;(348):g3489. [PubMed]
    • Chi CC, Kirtschig G, Aberer W ym. Evidence-based (S3) guideline on topical corticosteroids in pregnancy. Br J Dermatol 2011;165(5):943-52. [PubMed]