Chapter 56: DERMATOLOGICAL

DISORDERS
Dr. Teresita R. Tablizo MD, FPOGS,
FPSUOG, FPSMS
 Physiological Skin Changes in Pregnancy

• Hyperpigmentation
– skin darkening d/t melanin deposition into epidermal
and dermal macrophages;
– exact cause unknown, prob elevated serum levels of
MSH;
– 90% of pregnant women
– More pronounced in naturally pigmented areas
(areolae, perineum, umbilicus, axillae and upper
thighs) i.e. linea alba linea nigra
– Acquired dermal melanocytosis – non-palpable
brown-blue gray patches of skin that contains spindle-
shaped melanocytes
– Chloasma/melasma – mask
of pregnancy;
• usu regress postpartum but
may persist upto 10 yrs in a
third of cases;
• OCP – aggravates melasma
• Topical tx: 2-5%
hydroxyquinone or 0.1%
tretinoin gel or cream or
20% azelaic cream
• Nevi – histologically w/
enlarged melanocytes and
inc melanin deposition in
preg; no evidence to
suggest that they undergo
malignant transformation
• Changes in hair growth
– Anagen phase – increased growing hair phase
compared to Telogen phase (resting hair phase)
– Telogen effluvium – abrupt hair loss; 1-4 mos
post-partum and hair restored by 6-12 mos; self-
limiting condition
– mild hisutism – common
• Vascular changes
– Spider angiomas – 2/3 of white women; regress
postpartum
– Palmar eythema - 2/3 of white women, 1/3 of black
women
– Pregnancy gingivitis/epulis of pregnancy - growth of
gum capillaries
– Pyogenic granuloma of pregnancy/granuloma
gravidarum –found in the oral cavity, often arising fr
the gingival papillae; arising in a “port-wine stain “
 Dermatoses in Pregnancy
3 conditions universally accepted as unique to
pregnancy:
• 1. Pruritus Gravidarum
• 2. Pruritic Urticarial Papules and
Plaques of Pregnancy (PUPPP)
• 3. Prurigo of Pregnancy
 Dermatoses in Pregnancy
3 conditions universally accepted as unique to
pregnancy:
• 1. Pruritus Gravidarum
– mild variant of intra-hepatic cholestasis of
pregnancy;
– assoc w/ bile salt retention and deposition in the
dermis  pruritus  skin lesions /excoriat’ns
– hormonal, genetic or envi’tal factors
• 2. Pruritic Urticarial Papules and
Plaques of Pregnancy –(PUPPP)
– most common
– also PEP (polymorphic eruption
of pregnancy)
– Erythematous, intensely pruritic,
initially dev on the abd, around
the striae w/ likely spread to
buttocks, thighs and extremities;
facial-sparing
– 40% predominantly urticarial,
45% - erythematous pattern,
15% combination
– late in pregnancy, nulliparas;
seldom recurrent in subsequent
preg
– resembles herpes gestationis
– Pathophysio: unknown
– Biopsy: mild non-specific lymphohistiocytic
perivasculitis w/ an eosinophilic component; no Ig or
complement deposition on staining; no linear band C3
on dermis
– Tx: oral antihistamines & skin emollients; topical
corticosteroid creams or ointments; oral
corticosteroids for severe itching
– Resolves before or within several days/4 weeks post-
partum
• 3. Prurigo of
Pregnancy
– “papular eruptions of
pregnancy”, Variants are:
prurigo gestationis and papular
dermatitis (non-specific)
– char by small pruritic, rapidly
excoriated lesions on forearms
and trunks; bite-like papules
resembling scabies or insect
bites
– 25-30 wks AOG to 3 mos PP
– Tx: oral antihistamines and
topical corticosteroid creams
• Herpes Gestationis
– (Grk: “to creep”) non-infectious,
autoimmune; rare (1:50,000)
– “pemphigoid gestationis” bec
immunologically similar to
bullous pemphigoid
– Pruritic, blistering skin eruption;
erythematous and edematous
papules to large, tense vesicles
and bullae; abdomen and
extremities; may resemble
PUPPP
– Early preg or a wk PP; may be
assoc w/ Trophoblastic dse
– May reccur in subsequent pregs;
usu earlier and more severe
– May be assoc w/ PT births,
stillbirths and IUGRs; neonates
affected - 10%
– Pathophysio: caused by devt of IG G1 antibody to BM in the epidermis;
inc predisposition among women w/ HLA-DR3 & HLA-DR4 Ags (these
are maternal Ags assoc w/ other autoimmune d/o e.g. SLE, Addison’s,
DM1)
– Autoantibody quantification: immunoblotting or ELISA
– Histopath: subepidermal edema w/ perivascular infiltrates of
lymphocytes, histocytes, eosinophils
– Confirmatory Dx: immunoflourescent skin biopsy
– Tx: topical corticosteroid and oral antihistamines;
– Prednisone 0.5 to 1 mg/kg/day PO;
– Immunosuppressants for refractory cases PP: cyclophosphamide,
methotrexate, cyclosporine
• Pruritic folliculitis of Pregnancy
– Rare (24 cases), also called “impetigo
herpetiformis”
– Hallmark lesions: sterile pustules around the
margin of erythematous patches, beginning at
flexures and extending peripherally;
– Spongiform pustule Kojog- char lesion of a
spongelike cavity filled w/ neutrophils
– Tx: systemic corticosteroids w/ antimicrobials (if w
secondary infection or sepsis)
– Resolution: several wks to mos PP
 Pre-existing Skin Disease
• Acne
– Isotretinoin, etretinate, tretinoin – strictly CI in
pregnancy
– Topical Benzoyl peroxide + Clinda or Erythro gel –
severe dse
– Topical tretinoin – no fetal risk
• Psoriasis – improves in 50% during pregnacy
– Stepwise tx:
– Localized: Topical corticosteroid
Topical calcipotriene
Anthralin
Tacrolimus
– Generalized, mild : UV-B phottherapy
Oral cyclosporine
– Gen mod/severe : topical or oral corticosteroids
• Hidradenitis suppurativa
– Chronic, progressive, inflammatory and
suppurative skin lesion
– Char by plugging of the apocrine gland 
anhydrosis  bact infxn
– Tx: systemic antimicrobials or Clindamycin
ointment
• Pemphigus- mortality 10% 2˚ to sepsis/2˚
bacterial infection
• Neurofibromatosis and Hansen dse – worsen
during preg