Dermatoses of pregnancy: Understanding, managing gestational risks

Key Points

During gestation, a woman's body undergoes profound endocrine and metabolic changes. These changes can result in numerous physiological skin alterations, including pigmentary and vascular, as well as mucosal, hair, nail and glandular changes, according to George Kroumpouzos, M.D., Ph.D., F.A.A.D., clinical assistant professor of dermatology, Brown Medical School, Providence, R.I.

While many of these changes are not associated with any risks for the mother or fetus and are expected to resolve postpartum, others can pose serious maternal and fetal risks, he says.

"With quick recognition and correct classification of skin problems, the risks are minimal when the dermatoses are treated promptly," he says.

Dermatologists should be particularly attuned to a number of skin conditions in pregnant patients. These are categorized into:

- Physiologic skin changes in pregnancy (which do not require treatment);

- Pre-existing skin diseases and tumors affected by pregnancy;

- Pruritus in pregnancy (often secondary to intrahepatic cholestasis of pregnancy);

- Specific dermatoses of pregnancy, including PUPPP (pruritic urticarial papules and plaques of pregnancy), herpes (pemphigoid) gestationis, pruritic folliculitis of pregnancy and prurigo of pregnancy.

Immunosuppression

Pregnant females often develop a flare of certain inflammatory dermatoses as a result of high estrogen levels and endocrine changes during gestation, Dr. Kroumpouzos says.

"Also, pregnancy induces a state of immunosuppression, so pregnant females may develop infectious diseases more easily, such as warts, fungal infections and candida vaginitis.

"In addition, skin diseases such as acne, eczema and systemic lupus are more likely to worsen than remit during pregnancy," he says.

Cholestasis

A more serious pruritic condition and one that should not be overlooked by the dermatologist is intrahepatic cholestasis of pregnancy. This pregnancy-induced liver disorder is associated with fetal risks.

Cholestasis can be ruled out by ordering postprandial levels of bile salts, which are elevated in cholestasis.

If a pregnant woman is diagnosed with cholestasis, fetal monitoring is mandatory, Dr. Kroumpouzos says, and the obstetrician needs to be consulted about intensive fetal monitoring until delivery.

"The pregnant woman should be counseled about the nature of her skin condition, possible maternal or fetal risks associated with it, and management options," he says.

"She also needs to be advised about the chances of recurrence of the dermatosis in future pregnancies," Dr. Kroumpouzos says.