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Pregnancy Related Dermatoses

A Presentation About "Pregnancy Related Dermatoses".

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Pregnancy Related Dermatoses

  1. 1. PREGNANCY RELATED DERMATOSES Dr. Nobody X student, Y Hospital
  2. 2. PRAGNANCY :  Pregnancy is a physiological condition.  It is characterised by altered endocrine,metabolic and immunologic milius.  This dramatic alteration result in multiple cutaneous changes, both physiologic and pathologic
  3. 3. DERMATOSES IN PREGNANCY  Physiologic changes associated with pregnancy  Preexisting dermatoses affected by pregnancy  Dermatoses specific to pregnancy
  5. 5. PIGMENTARY CHANGES  Melasma(Cholasma)  Hyperpigmentation around areolae  Linea nigra on abdomen  Darkening of nevi
  6. 6. VASCULAR CHANGES  Spider angiomas  Palmar erythema  Varicosities  Non-pitting edema  Pyogenic granulomas
  7. 7. STRUCTURAL CHANGES  Striae gravidarum: most common structural change during pregnancy is striae distensae, also known as Striae gravidarum.
  8. 8. HAIR CHANGES  Thickning of Scalp hair  Hypertrichosis (prolongation of anagen phase)  Postpartum telogen effluvium (synchronized transition into telogen phase)  Androgenetic alopecia
  9. 9. NAIL CHANGES  Onycholysis  Brittleness  Subungual hyperkeratosis  Transverse grooving
  10. 10. DISEASES POTENTIALLY WORSENED DURING PREGNANCY Infections  Candida vaginitis  Condyloma acuminate  Human papilloma virus  Herpes simplex infection  Leprosy  Trichomoniasis  Varicella  Immune-mediated diseases • Systemic lupus erythematosus (SLE)  Dermatomyositis and polymyositis  Metabolic diseases • Acrodermatitis enteropathica • Porphyria cutanea tarda  Connective tissue disorders • Ehlers-Danlos syndrome Type 1 and 4 • Excessive bleeding, wound gaping and uterine laceration • Pseudoxanthoma elasticum
  12. 12. WELL-DEFINED DERMATOSES ASSOCIATED WITH PREGNANCY  Pemphigoid (Herpes) Gestationis  Pruritic Urticarial Papules and Plaques of Pregnancy  Recurrent Cholestasis of Pregnancy (Prurigo Gravidarum)  Impetigo Herpetiformis INCOMPLETELY DEFINED ERUPTIONS ASSOCIATED WITH PREGNANCY  Prurigo Gestationis (Besnier) ATOPIC ERRUPTION  Pruritic Folliculitis of Pregnancy OF PREGNANCY  Miscellaneous Disorders
  13. 13. PEMPHIGOID GESTATIONIS (HERPES GESTATIONIS)  Incidence: approximately 1 in 50,000 pregnancies  Usually begins with urticarial papules and plaques around the umbilicus and extremities.  Bullous lesions tend to develop as the disease progresses, and are often not present on first presentation.  Lesions of PG tend to spare the face, palms, and soles.  Mucosal surfaces are involved in fewer than 20% of cases.
  14. 14. CONTINUE-  Mean onset at 21 weeks; postpartum in 20% of cases  In about 75% of cases, PG flares around the time of delivery, regressing spontaneously after the baby is born.  Recurrence in subsequent pregnancies: 8%  May be provoked by subsequent menstrual periods or OCPs
  15. 15. PATHOPHYSIOLOGY  An autoimmune bullous disorder  Involves IgG immune response directed at a 180-kDa hemidesmosome transmembrane glycoprotein  IgG Abs bind to the lamina lucida and fix compliment  Activated eosinophils, neutrophils, T- cells (Th2 predominant) involved in blister formation  Increased frequency of HLA- DR3, DR4 and C4 null alleles in PG patients  Black women rarely manifest PG (possibly due to low incidence of HLA- DR4)  May be associated with menstruating women, those taking OCPs  May be associated with hydatidiform mole and choriocarcinoma
  16. 16. LABORATORY STUDIES  Histology: papillary dermal edema resulting in subepidermal bulla with eosinophil-rich infiltrate, ± keratinocyte necrosis, perivascular infiltrate  DIF: linear C3 deposition ± IgG at basement membrane (c.f. PUPPP)  IIF: epidermal base (roof of blister like BP)
  17. 17. TREATMENT  Oral corticosteroids: 20 to 60 mg/d of prednisone  Severe PG have required treatment with rituximab, cyclophosphamide, MTX  Intravenous immunoglobulin (IVIG)  Cyclosporine in refractory cases
  18. 18. PRURITIC URTICARIAL PAPULES AND PLAQUES OF PREGNANCY  Incidence: 1 in 120 to 1 in 240 pregnancies  Itchy, erythematous papules that coalesce into plaques  Classically found on the abdomen, sparing the umbilical area, and are found primarily in the abdominal striae
  19. 19. CONTINUE  Onset : Late in third trimester  Resolves with delivery and rarely recurrence with subsequent pregnancy  Fetus and mother are not effected by this eruption. Rarely manifested transient lesion of PUPPP
  20. 20. INTRAHEPATIC CHOLESTASIS OF PREGNANCY  Onset after 30th week in 80% of patients  Steatorrhea often noted by the patient, followed by vitamin K deficiency  Resolves after delivery  Recurs with subsequent pregnancies  Increased fetal complication
  21. 21. CONTINUE-  No primary skin lesions  Present with sudden onset of severe pruritus on palms and soles which quickly becomes generalized  Itching is often so severe that it leads to chronic insomnia  Secondary skin lesions: erythema and excoriations  Observable jaundice occurs 10% to 20% of patients
  22. 22.  ICP is a disease of late pregnancy corresponding to the period of highest placental hormone level  ICP spontaneously remits at delivery when hormone concentration normalized  Twin and triplet pregnancy characterize by greater rise in hormone concentration ETIOLOGY
  23. 23. LABORATORY STUDIES  Gold standard: serum bile acid level >11 μmol/L (N: 6.6-11 μmol/L)  Recent study: ↑ urine bile acids have 100% sensitivity and 83% specificity for ICP.  55% to 60% of cases: mildly ↑ aspartate aminotransferase and alanine aminotransferase
  24. 24. TREATMENT  Reduction of serum bile acid levels in order to prolong pregnancy and reduce both fetal risks and maternal symptoms  Ursodeoxycholic acid: reduces maternal pruritus and improves fetal prognosis  Dose: 15 mg/kg/day or, independent of body weight, 1 g/day either as a single dose or divided into two to three doses until delivery  Antihistamines  Close obstetric surveillance and weekly fetal cardiotocographic (CTG) registration at least from 34 weeks’ gestation  Interdisciplinary management by dermatologists, hepatologists, gynecologists, and pediatricians absolutely mandatory
  25. 25. PRURITIC FOLLICULITIS OF PREGNANCY  Prevalence: 1 in every 10,000 pregnancies  Presents as papules and pustules concentrated around hair follicles  Often, lesions begin on the abdomen and spread to the extremities.  May be pruritic
  26. 26. CONTINUE  Onset most often in third trimester  Resolves after 2/3 weeks of delivery  Increased incidence of (fetal) low birth weight  No associated fetal morbidity or mortality
  27. 27. PAPULAR DERMATITIES OF PREGNANCY  Pruritic generalised eruption of 3-5 mm erythematous papule surmounted by a small,firm,central crust.  May erupt anytime during pregnancy  Resolves with delivery  Recurrence in subsequent pregnancy
  28. 28. IMPETIGO HERPETIFORMIS/ PUSTULAR PSORIASIS OF PREGNANCY  Impetigo herpetiformis is a form of pustular psoriasis that occurs during pregnancy and may be life-threatening  Many of the affected women have had no personal or family history of psoriasis.  Recurrences in subsequent pregnancies have been reported.  There may be an increased risk of fetal morbidity and mortality associated with placental insufficiency with risk of still birth.  The disease tends to remit promptly after delivery
  29. 29. CONTINUE-  The earliest lesions are erythematous patches occurring in the groin, axillae, and anterior as well as posterior neck. At their margins these erythematous patches are studded with tiny superficial pustules  As plaques enlarge, the center becomes eroded and crusted.  Mild pruritus, painful lesions
  30. 30. LABORATORY STUDIES Most Common Laboratory dearangemant includes  Leucocytosis  Neutriphillia  Elevated ESR  Hypoferric anemia  Hypoalbuminemea  Calcium, phosphate ,Vit-D level is decreased
  31. 31. HISTOPATHOLOGY  Neutrophilc inflammatory infiltrate, epidermal acanthosis and papillomatosis with focal parakeratosis  Neutrophils collections, forming intraepidermal multilocular microabscesses, called spongiform pustules of Kogoj
  32. 32. TREATMENT:  Systemic corticosteroids, 30-60mg of prednisolone per day  Cyclosporin may be used in refractory cases  Even if the pustules are sterile, some authors recommend adjuvant treatment with cephalosporin  Replacement of calcium, fluids and electrolytes due to ↓ Levels of calcium, phosphate and albumin
  33. 33. PRURIGO GESTATIONIS  ONSET : Between 20th and 34th weeks of gestation  Resolution : Post-purtum period  Recurrence: Usually not occur.  Site : Proximal limb and upper trunk
  34. 34.  This eruption may symply be an expression of atopic dermatities of pregnancy  2/3rd present with widespread eczematous changes (so-called E-type AEP) often affecting typical atopic sites such as face, neck, upper chest, and the flexural surfaces of the extremities.
  35. 35. CONTINUE-  1/3rd have papular lesions (P-type AEP).  Small erythematous papules disseminated on trunk and limbs, as well as typical prurigo nodules, mostly located on the shins and arms.  Extreme dryness of the skin
  36. 36. TREATMENT:  Symptomatic treatment  Topical corticosteroids  Antihistamines  Severe cases  Short course of systemic corticosteroids and antihistamines  Phototherapy (UVB) is a helpful additional measure and considered safe in pregnancy
  37. 37. MISCELLANEOUS DISORDERS Other eruptions thought to be associated with pregnancy have been described. Examples include :  Spangler's papular dermatitis,  autoimmune progesterone dermatitis of pregnancy, and  linear IgM dermatosis of pregnancy. These entities have neither been substantiated nor elucidated. Accordingly, their existence is in doubt.
  38. 38. References ANDREWS’ disease of skin: clinical dermatology FITZ PATRICKS dermatology in general medicine  James WD, Elston DM. 2011. Andrews’ Diseases of The Skin: Clinical Dermatology. (11th edn). Elsevier Inc: London  Jain S. 2012. Dermatology: Illustrated Study Guide and Comprehensive Board Review. Springer Science: New York   A Study on Dermatoses of Pregnancy. Our Dermatol Online. 2013; 4(1): 56-60  A Dermatoses of pregnancy- clues to diagnosis, fetal risk and therapy. Ann Dermatol. 2011 Aug; 23(3):265-75.  Recent developments in the specific dermatoses of pregnancy. Clin Exp Dermatol. 2012 Jan; 37(1):1-4