SKIN

and PREGNANCY
By

Dr M. Y.Abd El-Mawla,MD
Zagazig Faculty of
Medicine,Zagazig ,EGYPT

Introduction

Changes in the Skin Due to

Pregnancy
Skin Conditions Influenced by
Pregnancy
Pregnancy and Immune-Mediated
Disorders
Skin Conditions Specific to
Pregnancy
The Use of Drugs for Dermatologic

Changes in the Skin Due to

Pregnancy

1.

2.

Hyperpigmentation
Generalized or increase in pigment
at specific areas such as the areolae,
genitals, inner thighs, or axillae
Melasma : In most cases, the
hyperpigmentation : epidermal
melanin deposition due to a
combination of light exposure and
elevated hormones (estrogen,
progesterone, and melanocytestimulating hormone.

Melasma


1.

2.

3.

Changes in the Skin Due to

Pregnancy
Hair& Nail Changes

Hirsutism & frontoparietal

thinning of male-pattern alopecia :
increase in androgens
Postpartum: hirsutism resolves
and hair may enter the telogen
phase, resulting in the diffuse
shedding of telogen effluvium
Nail changes : transverse grooving,
brittleness, distal onycholysis, and
subungual hyperkeratosis

Telogen effluvium

Androgenic aalopecia

Vascular Changes
in Pregnancy

Erythema (most
women)

Spider
telangiectases

Chest

(66%)

Vagina
(JacquemierChadwick sign)
Cervix (Goodell's
sign -- bluish)
Palms
Gingiva

Legs
Face

Vascular Changes
in Pregnancy

Varicosities (40% of
women)
Purpura
Vasomotor
instability

Legs &Hemorrhoids

Lower extremities
Facial flushing ,Pallor
Cutis marmorata
,Raynaud'sphenomena
Face,lids &extremities

Non pitting edema

(50% of women
Pyogenic granuloma

Gingiva and other

sites

Pyogenic granuloma

Glandular Changes

Increased Eccrine glands

function:
Miliaria ,Hyperhidrosis
&Dyshidrotic eczema
Decreased Apocrine function:
Increased Sebaceous function in
third trimester:
Acne (variant-pruritic folliculitis
of pregnancy) &Sebaceous glands
on the areolae (Montgomery's
glands)

Connective Tissue
Changes in Pregnancy

Striae distensae (90%) on the

abdomen, on the breasts, thighs,
and inguinal areas.

Mechanical stretch & increased

hormones (adrenocortical,
estrogen, and relaxin) are the
most significant factors in the
development of striae,

Striae distensae

Skin Conditions Influenced

by Pregnancy

Melanomas :no increased risk of

melanoma in pregnancy .When
diagnosed during pregnancy may be
thicker and therefore have a worse
prognosis
Nevi: may develop, enlarge, or
darken.& show mild cytologic atypia.
Dermatofibromas Leiomyomas Keloids
Dermatofibrosarcoma: may develop
or grow rapidly in pregnancy

Other Skin Conditions

Influenced by Pregnancy

Atopic dermatitis

1.

More likely to worsen

than improve
May present for the first
time during pregnancy with
keratosis pilaris
Irritant hand dermatitis
due to washing postpartum &nipple
dermatitis due to nursing

2.

3.

Other Skin Conditions

Influenced by Pregnancy

1.
2.
3.

Psoriasis:

More likely to improve than

worsen
Psoriatic arthritis may worsen
Impetigo herpetiformis (generalized
pustular psoriasis) : during last trimester,
but may present earlier &persists until
delivery or long after
Associated with decreased calcium
and/or vitamin D
Severe malaise, fever, nausea , vomiting,
tetany, seizures
Grouped pustules at the margins of
symmetric erythematous patches

Impetigo herpetiformis

Impetigo
herpetiformis 2

Pregnancy &Autoimmune
Disorders

Changes in hormones including the

increase in estrogen affect the course
of autoimmune diseases.
The fetoplacental unit directs maternal
immunity toward humoral responses by
favoring certain cytokines and other
inflammatory mediators
Enhanced humoral immunity &
weakened cellular immunity lead to
variable effects that are dependent on
the specific disease process .

Systemic lupus
erythematosus

SLE may worsen and may flare postpartum.

Lupus patients are advised to avoid trying
to conceive when their disease is active
Underlying lupus renal disease may worsen
during pregnancy.
There is a significant risk of eclampsia;
Active disease in the mother, maternal use
of potentially teratogenic medications, and
pathogenic antibodies (anti-Ro-- )
transmitted from the mother may present
risks to the fetus.

Ro(SS-A) &Foetal risk

Neonatal lupus in mothers
with circulating anti-Ro(SSA) antibodies
Increased risk of prematurity
and spontaneous abortion
Congenital heart block

Nonatal lupus

Antiphospholipid
syndrome(aPLs)in pregnant
with SLE

Approximately one third of patients

who have SLE also have aPLs..
aPLs : heterogeneous group of
autoantibodies that bind
phospholipids, proteins, or a
phospholipidprotein complex on
platelets and or vascular endothelium.
Two best characterized : the lupus
anticoagulant (LA) and anticardiolipin
antibodies (aCL)
.

Suggested clinical and

laboratory criteria for the
diagnosis of APS

Pregnancy Loss
Recurrent spontaneous abortion &
Unexplained fetal death
Thrombosis: Venous thrombosis &
Arterial thrombosis, stroke
Autoimmune thrombocytopenia&
hemolytic anemia
Transient ischemic attacks
Chorea gravidarum &Livedo reticularis
Laboratory criteria
Lupus anticoagulant, Anticardiolipin
antibodies , >1520 IgG binding units&
activated partial thromboplastin time .

Conditions Specific to
Pregnancy

Herpes gestationis (HG) (also known

as "pemphigoid gestationis") .
Pruritic and urticarial papules and
plaques of pregnancy (PUPPP).
Intrahepatic cholestasis of
pregnancy (ICP) may present with
intense pruritus.
Prurigo of pregnancy
Pruritic folliculitis of pregnancy

Herpes Gestationis H G
(pemphigoid gestationis)

The incidence 1 in 50,000 pregnancies

Developing during the second or third
trimester (mean onset, 21 weeks) &
reported in the first trimester.
Intensely pruritic, urticarial lesions on
the abdomen in half of the cases
especially periumbilically, with a rapid
progression to multiple, generalized
bullae. Face, mucous membranes, palms,
and soles : spared.

Improving during the later part of

pregnancy, only to flare at delivery or
postpartum in about 75% of patients
Histopathology : a subepidermal vesicle
with perivascular infiltration
(lymphocytes & eosinophils).
Direct immunofluorescence :C3 with or
without IgG in a linear band along the
basement membrane zone (BMZ). The
antibody localizes to the roof of the
blister.
A mismatch of HLA antigens between the
mother and father, manifested by an
immunologic response against the
paternal class II antigens at the placental
BMZ with cross-reaction at the skin BMZ.

Foetal Risk in in HG
The

newborn shows
signs of HG in less
than 10% of cases.
The foetal risk :
prematurity and low
birthweight,

Urticarial plaques &

vesiculations

Pruritic and Urticarial

Papules and Plaques of
Pregnancy(PUPPP)

Occuring in approximately 1 in 240

pregnant women, typically in the third
trimester in first pregnancy
The urticarial papules begin within
striae on the abdomen and thighs
and, sparing the periumbilical
region, face, palms, and soles.
The lesion may be also vesicles or
targetoid.
Not to recur in subsequent
pregnancies

Biopsy : a spongiotic epidermis with a

perivascular inflammatory infiltrate:
increased numbers of eosinophils.

Immunofluorescence : negative
Poseing no risk to the mother
(except pruritus) or fetus, resolveing
postpartum.

Aetiology :

1.

Abdominal distention: eliciting an

inflammatory response by damaging
the connective tissue &
A substance released from placenta
into the maternal circulation
triggers fibroblast proliferation

2.

Intrahepatic Cholestasis of
Pregnancy (ICP)

In the third trimester of pregnancy

(mean, 31 weeks) with a mild form of
intrahepatic bile secretory dysfunction.
Features :1-generalized pruritus with or
without jaundice 2-absence of primary
skin lesions, (3) biochemical
abnormalities consistent with
cholestasis,(elevated serum bile acids
(mean, 1349 mug/100 mL) and (4)
resolution after delivery.
Recurrence with subsequent pregnancy

Pathophysiology

Estrogens interfere with the diffusion of

fluid across the canalicular membrane
of the hepatocyte and subsequently
with hepatic bile acid secretion.
Inhibition of hepatic glucuronyltransferase
Altered estrogen metabolism in the
liver, resulting in reduced biliary
volume and excretion of these
compounds

Prurigo of pregnancy
(PP )

The incidence : 1 in 300

pregnancies.
In all trimesters of pregnancy
Erythematous papules and nodules
on the extensor surfaces of the
extremities and occasionally on the
abdomen
Recurrence during subsequent
pregnancies is variable
Related to an atopic background

Pruritic folliculitis of
pregnancy (PFP)

Generalized, pruritic erythematous,

follicular papules, developing from the
fourth to the ninth month of
gestation .
A form of steroid acne, with no
evidence of any immunologic or
hormonal abnormalities.
Some authors[ have suggested that
PFP and PP should be included within
the spectrum of "polymorphic eruption
of pregnancy.

The Use of Drugs for

Dermatologic Conditions
in Pregnancy

FDA Pregnancy Categories

A
B

Controlled studies show no fetal risk

No risk to human fetus despite

possible animal risk.

Risk cannot be ruled out; human

studies are lacking.

Positive evidence for risk to human

fetus, but benefits may outweigh risks of
drug

Contraindicated in pregnancy; there is

no reason to risk use of drug in pregnancy

Undetermined No pregnancy
category yet assigned

Topical corticosteroids during

pregnancy :with a low risk to the

fetus( Category C risk) as the risk
cannot be ruled out because no human
studies have been done.
Topical povidone-iodine and
podophyllin place a fetus at risk. : not
recommended for use during
pregnancy

Analgesics: associated with minimal

risk to the fetus or infant.
Indomethacin::associated with
problems in infants .

Retinoids and antineoplastic:

isotretinoin (used to treat acne

vulgaris) & antineoplastic eg
methotrexate: category X.
Antipruritic agents. : doxepin:
avoided during pregnancy and
lactation. Hydroxyzine : risk in the first
trimester of pregnancy and is
associated with a risk of congenital
abnormality.
Antibiotics:including tetracycline &
ciprofloxacin--pose potential risks
during pregnancy.. Penicillins are
considered comparatively safe during
pregnancy

THANK
YOU