Pregnancy dermatoses



Pregnancy dermatoses


Wolfgang Jurecka


Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports


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Skin changes during pregnancy may range from normal (physiologic) changes that occur with almost all pregnancies through common or pre-existing skin diseases that are not associated with, but are influenced by, the pregnancy, to eruptions that appear to be specifically associated with pregnancy and the puerperium. This group of well-defined dermatoses of pregnancy has recently been reclassified and include: pruritic urticarial papules and plaques of pregnancy (PUPPP), pemphigoid gestationis, pruritus gravidarum (cholestasis of pregnancy), and atopic eruption of pregnancy (AEP).



Pruritic urticarial papules and plaques of pregnancy


Pruritic urticarial papules and plaques of pregnancy (PUPPP) is a common, intensely pruritic dermatosis that usually begins in the third trimester of the first pregnancy, but may be delayed until a few days postpartum. It occasionally recurs, albeit less severely, in subsequent pregnancies.



Management strategy


Most women who have PUPPP are relieved to learn that the condition is not serious, that all should be well with them and their baby, and that the rash will disappear at or within a few days after delivery. However, treatment is usually demanded to provide relief from the intense itching. The skin lesions may closely resemble the very early (urticarial) stage of pemphigoid gestationis. Direct and/or indirect immunofluorescence microscopy of perilesional skin or serum should be performed if pemphigoid gestationis is suspected. All similar eruptions that occur in non-pregnant women may also occur in pregnancy and should not be confused with those dermatoses that are pregnancy specific. Thus erythema multiforme, drug eruptions, contact dermatitis, urticaria, and insect bites should be considered.


In women with localized disease, frequent (several times daily) application of mid-strength topical corticosteroids provides symptomatic relief after a few days in almost all cases. Ointments containing substances such as betamethasone, mometasone, or methylprednisolone can be regarded as safe during pregnancy. New lesions usually stop appearing within 2 or 3 days, and the frequency of applications can be tapered. As the pregnancy continues many patients require therapy only once a day, or can even stop treatment before delivery. Topical antipruritic preparations are normally not useful. Oral H1 antihistamines (first generation: chlorpheniramine, cyproheptadine, tripelennamine; second generation: loratidine, levocetrizine) may offer some benefit in severely pruritic patients at bedtime. In more widespread or generalized cases and those that do not respond adequately to topical corticosteroids, a systemic corticosteroid treatment may need to be considered. Oral methylprednisolone 20–40 mg daily or its equivalent for 5 days, tapered over the following 2 weeks is very effective. For systemic treatment during pregnancy, prednisone, prednisolone, and methylprednisolone are regarded as safer than betamethasone, dexamethasone, cortisone, and hydrocortisone, which may be associated with some risk of malformation.


One striking clinical feature of PUPPP is its onset in the third trimester in association with severe striae. It usually affects first pregnancies, in which striae are more common. There have been conflicting reports questioning whether PUPPP is associated with fetal weight and maternal weight gain, resulting in excessive abdominal distension. Some patients have therefore been delivered early, with the expectation that this will terminate the PUPPP. This has appeared to be the outcome in some cases, but the resolution of PUPPP is not necessarily related to delivery.



Specific Investigations














First-line therapies












image Topical corticosteroids B
image Antihistamines C











Second-line therapies









image Systemic corticosteroids D










Third-line therapies









image Early delivery E









Pemphigoid gestationis


Pemphigoid gestationis (herpes gestationis) is a rare, intensely itchy, urticarial or polymorphic or vesiculobullous eruption. It affects approximately 1 in 60 000 pregnancies and usually appears in the second or third trimester, but it may also be associated with hydatidiform mole or choriocarcinoma. The term pemphigoid gestationis is preferable because this condition shows many clinical and immunologic similarities with bullous pemphigoid and has no relationship to herpes virus infection.



Management strategy


Although pemphigoid gestationis is a rare disorder, correct diagnosis and optimal management are essential. It occurs only in the presence of paternally derived tissue (fetus, hydatidiform mole, or choriocarcinoma). Once it has manifested, its course may be significantly modulated by changes in estrogen and progesterone levels. Exacerbations may occur postpartum, with oral contraceptives, and during the menstrual cycle post partum, and is commonly more severe in subsequent pregnancies. Circulating autoantibodies are directed against the same target antigens as in bullous pemphigoid, more commonly against BP180 than BP230 antigen. The autoantibodies react with the basement membrane of amnion placenta, resulting in the findings of immune activation in the placenta and evidence of placental insufficiency. Thus skin biopsies for dermatohistopathology and direct immunofluorescence, and serum for indirect immunofluorescence investigations or ELISA to confirm the diagnosis and to differentiate non-bullous pemphigoid gestationis from PUPPP are recommended. This is especially important because most patients with pemphigoid gestationis need treatment with systemic corticosteroids, at least for a while, and are therefore at risk of side effects from this treatment. Most cases resolve within a few months postpartum, with just a few urticarial eruptions during the year after delivery. However, some cases have been reported with recurrences more than 10 years postpartum. Even more important is the fetal prognosis. The current view is that pemphigoid gestationis is associated with premature delivery and a risk of low birth weight. Thus pregnancies of mothers with pemphigoid gestationis should be carefully followed in special units.


The goal of treatment is to suppress blister formation and to give the patients relief from the intense pruritus. In mild cases of pemphigoid gestationis, topical potent corticosteroids combined with a systemic antihistamine may be sufficient. First-generation antihistamines are favored over second-generation antihistamines. Chlorpheniramine, cyproheptadine, tripelennamine, loratidine, and levocetrizine may be used (see also discussion above about the use of antihistamines in PUPPP). However, most patients require systemic corticosteroid treatment during the course of their disease. Initially doses of prednisolone or its equivalent in the range of 20–40 mg daily may be tried, and then adjusted depending on the response. In severe cases 1 mg/kg body weight or even higher doses of prednisolone may be necessary to prevent blister formation. If the eruption resolves well the prednisolone can be reduced fairly rapidly in steps, initially twice weekly, later once a week, to a much lower maintenance dose. Some patients then respond to doses of prednisolone of 5–10 mg daily or every second day. Frequently the eruption flares immediately postpartum, and then a temporary increase in prednisolone treatment can be anticipated (for the use of systemic corticosteroids during pregnancy see also the discussion of their use in PUPPP above).


Newborns of mothers suffering from pemphigoid gestationis may develop bullous lesions similar to those of their mother by passive transfer of the antibasement membrane zone antibody across the placenta. These lesions are transient and require no therapy. If the mother has received high doses of prednisolone for a longer time the infant should be carefully examined by a neonatologist for evidence of adrenal insufficiency.


In severe cases of pemphigoid gestationis that do not respond satisfactorily to prednisolone alone or in cases where prolonged treatment with corticosteroids is contraindicated, plasmapheresis or intravenous immuneglobulins may be considered. Postpartum treatment may cause difficulties for several reasons:



image If the mother wishes to breastfeed, the drugs pass into the breast milk. Antihistamines may cause drowsiness in the baby, and corticosteroids may cause adrenal suppression. The pediatrician should therefore be informed in this situation


image In general, pemphigoid gestationis tends to improve postpartum: however, it may take weeks, months, or even years until there is complete remission. In those cases alternative drugs that are contraindicated during pregnancy or while the mother is breastfeeding may be used. Owing to its close relationship to bullous pemphigoid, in this situation the full range of immunosuppressive treatment may be tried as adjunctive therapy either with oral corticosteroids or alone. Other drugs that may be used are goserelin and ritodrine. High-dose intravenous immune globulin alone or in combination with cyclosporine or cyclophosphamide has been tried with success in rare cases for its corticosteroid-sparing effect


image Pemphigoid gestationis tends to exacerbate with menstruation. There may also be dramatic flares with oral contraceptives. Thus, patients should be recommended to avoid oral contraceptives as long as the disease is still active.

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Aug 7, 2016 | Posted by in Dermatology | Comments Off on Pregnancy dermatoses

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