Specific dermatoses of pregnancy

The specific dermatoses of pregnancy represent a heterogeneous group of pruritic skin diseases that have been recently reclassified and include pemphigoid (herpes) gestationis, polymorphic eruption of pregnancy (syn. pruritic urticarial papules and plaques of pregnancy), intrahepatic cholestasis of pregnancy, and atopic eruption of pregnancy. They are associated with severe pruritus that should never be neglected in pregnancy but always lead to an exact work-up of the patient. Clinical characteristics, in particular timing of onset, morphology and localization of skin lesions are crucial for diagnosis which, in case of pemphigoid gestationis and intrahepatic cholestasis of pregnancy, will be confirmed by specific immunofluorescence and laboratory findings. While polymorphic and atopic eruptions of pregnancy are distressing only to the mother because of pruritus, pemphigoid gestationis may be associated with prematurity and small-for-date babies and intrahepatic cholestasis of pregnancy poses an increased risk for fetal distress, prematurity, and stillbirth. Corticosteroids and antihistamines control pemphigoid gestationis, polymorphic and atopic eruptions of pregnancy; intrahepatic cholestasis of pregnancy, in contrast, should be treated with ursodeoxycholic acid. This review will focus on the new classification of pregnancy dermatoses, discuss them in detail, and present a practical algorithm to facilitate the management of the pregnant patient with skin lesions.

The specific dermatoses of pregnancy represent a heterogeneous group of inflammatory skin diseases related to pregnancy and/or the postpartum period. The most recent classification includes pemphigoid gestationis, polymorphic eruption of pregnancy, intrahepatic cholestasis of pregnancy, and atopic eruption of pregnancy. The hallmark of all four entities is severe pruritus that is accompanied by characteristic skin changes. While some of these dermatoses are distressing only to the mother because of pruritus, others may be associated with significant fetal risks. Early diagnosis and prompt treatment are therefore essential. In this review, we will discuss the various pregnancy dermatoses in detail and present an algorithm for diagnosis and management of pruritus in pregnancy.

The specific dermatoses of pregnancy revisited and reclassified: Results of a retrospective two-center study on 505 pregnant patients

27 - Pregnancy Dermatoses

27 - Pregnancy Dermatoses

Specific dermatoses of pregnancy are skin disorders that occur specifically during or immediately after pregnancy and cannot be found in non-pregnant patients. According to the current consensus, they include atopic eruption of pregnancy (AEP), polymorphic eruption of pregnancy (PEP), pemphigoid gestationis (PG), and intrahepatic cholestasis of pregnancy (ICP). The diagnosis of specific dermatoses of pregnancy can be challenging due to their variation in clinical presentation; moreover, the tests currently available do not always provide the clue for the diagnosis. However, some distinctive features may be helpful to differentiate between such entities. Accordingly, the knowledge of specific dermatoses of pregnancy and of their management is critical, since their early recognition may allow to provide care for the mother and prevent potential increased fetal risk. In fact, while AEP and PEP do not affect maternal and fetal prognosis, PG and, mainly, ICP are associated to maternal complications as well as the risk of fetal loss. In this paper, the epidemiology, pathogenesis, clinical features as well as management of AEP and PEP are reviewed in detail, while PG is described in another article of this issue. Moreover, the main features of ICP, which cannot be considered a primarily skin disease but may be managed first by dermatologists, are reported.

Pruritus in pregnancy – is it always obstetric cholestasis?

The specific dermatoses of pregnancy represent a recently reclassified heterogeneous group of pruritic inflammatory skin diseases unique to pregnancy that include pemphigoid gestationis, polymorphic eruption of pregnancy (PEP), intrahepatic cholestasis of pregnancy, and atopic eruption of pregnancy (AEP). Among them, PEP and AEP are the most frequent ones. We performed a histopathological study of a series of PEP and AEP patients (n = 41). Twenty-two patients had PEP that started in the third trimester in 16 (73%) patients and postpartum in 6 (27%) patients. Histopathology revealed a superficial or superficial and deep perivascular dermatitis with eosinophils in all biopsies and signs of a lymphocytic vasculitis in 5 (23%) cases. Epidermal changes, including epidermal hyperplasia, spongiosis, and parakeratosis, occurred in 8 cases, in particular in elder lesions. Nineteen patients had AEP that started earlier [less than third trimester, 14 (74%) patients; third trimester, 5 (26%) patients]. Clinically, 5 (26%) patients showed eczematous lesions, 7 (37%) papular lesions, 3 (16%) presented both eczematous and prurigo lesions, and 4 (21%) experienced exacerbation of preexisting atopic dermatitis. Histopathologically, AEP was characterized by a perivascular lymphohistiocytic infiltrate with frequent eosinophils (74%) and epidermal changes in all but most of P-type biopsies. No definitive differential histopathological criteria between PEP and AEP were found. Only lymphocytic vasculitis with a mixed infiltrate with eosinophils was more frequent in PEP patients. Timing of onset, morphology of skin lesions, and a detailed clinicopathologic correlation are essential for diagnosis.

During pregnancy, the mother undergoes changes to sustain and enable normal growth and development of the fetus. Common physiological changes include linea nigra, fibroepithelial polyps, striae, spider angioma, palmar erythema and pruritis gravidarum. However, there are some changes that are purely pathological, and these are termed the pregnancy-specific dermatoses (PSDs). The PSDs occur during pregnancy or in the immediate postpartum period. They do not include the various benign conditions or pre-existing dermatoses and tumours that may present or worsen with pregnancy. They do include a number of distinct and identifiable conditions: atopic eruption of pregnancy (AEP), polymorphic eruption of pregnancy (PEP), intrahepatic cholestasis of pregnancy (ICP) and pemphigoid gestationis (PG). These are a heterogeneous group of skin conditions characterized by pruritis and inflammatory changes. In addition, pruritis gravidarum is sometimes considered pathophysiological and thus part of this group, rather than a physiological process. Each of these conditions has a distinct, but not fully understood, pathogenesis. The mechanisms leading to PSD may be a reflection on the hormonal and immunological changes associated with pregnancy. AEP and PEP are benign conditions, and although they can cause distress to the mother, they are otherwise minor. However, ICP and PG are more serious conditions, and both carry the potential for serious risks to both the mother and the fetus. Thus, the pathophysiology of these latter two conditions is considered in more detail in the following article.

Introduction and purpose: Pregnancy is a remarkable and delicate period in a woman's life, marked by significant physiological adaptations to accommodate the growing fetus. These changes affect every organ system, including the skin. The aim of this review paper is to raise awareness and assist clinicians in recognizing, diagnosing, and effectively managing these distinct skin conditions associated with pregnancy. Material and methods: An extensive examination of articles published in scientific journals was carried out through online research platforms PubMed and Google Scholar. We searched articles by entering keywords in appropriate configuration: “pregnancy dermatoses”, “pemphigoid gestationis”, “ polymorphic eruption of pregnancy”, “intrahepatic cholestasis of pregnancy”, “pustular psoriasis of pregnancy”, “atopic eruption of pregnancy”. Description of the state of knowledge: This diverse set of pregnancy-related skin conditions includes pemphigoid gestationis, polymorphic eruption of pregnancy, intrahepatic cholestasis of pregnancy, atopic eruption of pregnancy, and pustular psoriasis of pregnancy. Summary: Early diagnosis and treatment are crucial to mitigate maternal and fetal complications, and in some conditions, prevent fatalities. Improving clinicians' in-depth understanding of these disease processes can enhance patient safety and quality of life during and after pregnancy.

Pregnancy dermatoses describe a set of extremely pruritic dermatologic disorders that uniquely present in the gestational period. Those who care for pregnant women are left to try to differentiate these conditions. They are pruritic urticarial papules and plaques of pregnancy (PUPPP), pemphigoid gestationis, atopic eruption of pregnancy, and intrahepatic cholestasis of pregnancy. While the most common of these, atopic eruption of pregnancy and PUPPP, are benign, self-limiting diseases that have no implications for the fetus, pemphigoid gestationis and intrahepatic cholestasis of pregnancy both pose a risk to the fetus and are associated with adverse outcomes. A clinician’s ability to distinguish these conditions can impact both the mother and the fetus.

The specific dermatoses of pregnancy represent heterogeneous group of pruritic skin disorders that occur exclusively in pregnancy. The updated classification proposed subdividing specific dermatoses of pregnancy into four main categories: 1. atopic eruption of pregnancy; 2. polymorphic eruption of pregnancy; 3. pemphigoid gestationis; 4. intrahepatic cholestasis of pregnancy. Severe pruritius, which is the main symptom in all 4 entities, can impair maternal quality of life. Significant maternal risks are not associated with specific dermatoses of pregnancy; however, pemphigoid gestationis and intrahepatic cholestasis of pregnancy are associated with fetal risks. Pathognomonic laboratory tests are not available, except direct immunofluorescence which is diagnostic of pemphigoid gestationis and elevated serum level of bile acids of intrahepatic cholestasis of pregnancy. Characteristic clinical features provide discrimination between polymorphic eruption of pregnancy and atopic eruption of pregnancy.

Dermatoses unique to pregnancy are important to recognize for the clinician as they carry considerable morbidity for pregnant mothers and in some instances constitute a risk to the fetus. These diseases include pemphigoid gestationis, polymorphic eruption of pregnancy, intrahepatic cholestasis of pregnancy, and atopic eruption of pregnancy. This review discusses the pathogenesis, clinical importance, and management of the dermatoses of pregnancy.

Pruritus in pregnancy is a common and burdensome symptom that may be a first sign of a pregnancy-specific pruritic disease (atopic eruption of pregnancy, polymorphic eruption of pregnancy, pemphigoid gestationis, and intrahepatic cholestasis in pregnancy) or a dermatosis coinciding with pregnancy by chance. Despite its high prevalence, pruritus is often underrated by physicians, and data regarding the safety profiles of drugs for pruritus are very limited. In this review, we illustrate the epidemiology, possible pathophysiology, clinical characteristics, and diagnostic workup of various pregnancy-related diseases and discuss antipruritic treatments. The prevalence of pruritus in pregnancy demonstrates the importance of symptom recognition and the need for an holistic approach, taking into account both the potential benefits for the patient and the potential risks to the fetus.

Women with rashes or itchy skin during pregnancy will often present initially to the general practitioner. Knowledge of thespecific dermatoses of pregnancy willassist in diagnosis, management and,importantly, facilitation of timely escalation of care of conditions that canpotentially affect the fetus. The aim of this article is to provide a diagnostic framework for approaching apruritic rash during pregnancy as well asa helpful summary of management ofpregnancy-specific dermatoses. It will assist clinicians in the identification of specific dermatoses that pose fetal risks. In addition to considering non-pregnancy specific conditions when approaching pruritus or a pruritic rash in pregnancy, it is important that clinicians also consider pregnancy-specific dermatoses, which have been reclassified into four categories: polymorphic eruption of pregnancy, pemphigoid gestationis, intrahepatic cholestasis of pregnancy (ICP) and atopic eruption of pregnancy. Unlike the other dermatoses, ICP begins with pruritus, and skin changes are secondary. ICP and pemphigoid gestationis are associated with fetal riskssuch as prematurity and stillbirth.