Dermatoses of pregnancy - clues to diagnosis, fetal risk and therapy

Abstract

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.

Keywords: Atopic eruption of pregnancy; Dermatoses of pregnancy; Intrahepatic cholestasis of pregnancy; Pemphigoid gestationis; Polymorphic eruption of pregnancy; Pruritus.

Fig. 1

Comparison of the two most common dermatoses of pregnancy: polymorphic eruption of pregnancy and atopic eruption of pregnancy. Polymorphic eruption of pregnancy in a primigravida at 40 weeks gestation: Severely itchy, dark red, urticated striae distensae are present on the abdomen, typically sparing the umbilical region (A, B). Small urticated papules with a perilesional vasospastic halo also spread to the adjacent thighs (C).

Fig. 2

Comparison of the two most common dermatoses of pregnancy: polymorphic eruption of pregnancy and atopic eruption of pregnancy. Atopic eruption of pregnancy in a primigravida at 22 weeks gestation: A discrete small papular rash involves the abdomen (A) as well as other common atopic sites such as the neck (B) and the flexural aspects of the upper extremities (C). Presence of severe xerosis and other atopic minor features as well as absence of striae distensae are clues to diagnosis.

Fig. 3

Algorithm for the management of pruritus in pregnancy. ICP: intrahepatic cholestasis of pregnancy, AEP: atopic eruption of pregnancy, PEP: polymorphic eruption of pregnancy, PG: pemphigoid gestationis, AD: atopic dermatitis, IMF: immunofluorescence, H&E: histopathology, LAB: laboratory findings, DEJ: dermo-epidermal junction.