Skin Changes & Diseases in Pregnancy - Chapter 105 PDF

Summary

This chapter discusses various skin changes and diseases associated with pregnancy. It covers topics like pigmentary disturbances, structural changes, and dermatoses related to fetal risk. The content is geared towards medical professionals.

Full Transcript

SKIN CHANGES & DISEASES IN PREGNANCY– CHAPTER 105 CHANGES COMMONLY ASSOCIATED WITH DERMATOSES ASSOCIATED WITH FETAL RISK N PREGNANCY PREGNANCY PEMPHIGOID (HERPES GESTATIONIS) o Characterized by...

SKIN CHANGES & DISEASES IN PREGNANCY– CHAPTER 105 CHANGES COMMONLY ASSOCIATED WITH DERMATOSES ASSOCIATED WITH FETAL RISK N PREGNANCY PREGNANCY PEMPHIGOID (HERPES GESTATIONIS) o Characterized by altered endocrine, metabolic, and immunologic milieus Epidemiology o Pigmentary disturbances are the most common physiologic o Rare, seen in 1 in 50,000 pregnancy changes o This is a pruritic, vesiculobullous eruption of mid-to-late pregnancy & immediate postpartum. Begins § Pigmentary disturbances during second or third trimester. Linea Nigra- reversible darkening of the o Manifest as abrupt appearance of severely pruritic urticarial lesions on a background of normal skin linea alba (hypopigmented linear patch o Associated by small-for-gestational age & premature delivery extending from the pubis symphysis to the Etiology & Pathogenesis sternal xiphoid process) o Immunologically mediated Melasma/Chloasma – irregular, blotchy, o DIF: linear deposition of C3 with or without immunoglobulin IgG at the dermal-epidermal junction facial hyperpigmentation that occurs in o Can occur in abnormal pregnancies (hydatidiform mole, choriocarcinoma) 70% of the patients. Clinical manifestations o Aggravated by sun exposure & CUTANEOUS FINDINGS oral contraceptive intake in o Urticarial followed by vesicular lesions on the trunk & extremities nonpregnant woman o Melasma may regress postpartum but often persists Changes in melanocytic nevi o Normal during pregnancy o In most studies found out does not appear be a feature in most pregnancies o Dermoscopy: widening in diameters and structure changes most especially in front of the body § Most common structural changes Striae distensae/ striae gravidarum/ stretch mark- mostly affecting the areas prone to stretch including abdomen, hips, Diagnosis buttocks & breast Strongest predictors: family history, Ø Histopathology personal history and race o Same with classic BP: Subepidermal blister with predominantly eosinophilic Ø DIF Spider angiomas : most common vascular o Gold standard lesion o linear deposition of C3 with or without immunoglobulin IgG at the dermal-epidermal junction Ø ELISA o Has 96% specificity o For BP 180 & 230 SKIN CHANGES & DISEASES IN PREGNANCY– CHAPTER 105 Differential Diagnosis o Initially begins as nocturnal pruritus only and gradually becomes severe pruritus at night o Polymorphic eruption of pregnancy, drug eruptions or urticaria o Constitutional symptoms: fatigue, nausea, vomiting or anorexia o Harmful effects on fetus: premature births, intrapartum fetal distress & fetal deaths Course and Prognosis Diagnosis o Associated with premature delivery & risk of low birth weight o Risk of these fetal complications correlates with maternal disease severity Ø Laboratory tests o Maternal prognosis is very good but resolving within weeks, months or years until complete remission o Elevated serum bile acids – single indicator of ICP o 75% will flare during postpartum & require treatment o Common features of ICP o Anti-basement membrane zone antibodies can be transferred via passive transmission § Total serum bile acid levels - >11UM/L o If treated with high doses of prednisolone, adrenal insufficiency § Cholic acid-to-chenodeoxycholic acid ratio>1.5 or cholic acid proportion of total bile acids > 42% § Glycine conjugates-to-taurine conjugates of bile acids ratio less than 1 Treatment/management o Degree of pruritus & disease severity correlate with bile acid concentration o Initiated with topical steroids & first-generation antihistamines o Liver function tests o Second line: plasma-pheresis or IV immunoglobulins § Not a sufficient basis for diagnosis of ICP § Alanine transaminase – sensitive in ICP and healthy pregnancy is not a feature of this § Y-glutamyl transferase – normal or slightly elevated in ICP; low in normal late gestation INTRAHEPATIC CHOLESTASIS OF PREGNANCY § Direct or conjugated fractions of bilirubin- commonly elevated in ICP § Albumin slightly reduced Epidemiology § Alpha globulins & B-globulins are elevated o Rare, reversible cholestasis typically occurs in late pregnancy when the seym concentration os estrogen o Cutaneous biopsy does not aid in diagnosis is at peak o Prurigo Gravidarum – mild cases of ICP with pruritus & not associated with jaundice Differential Diagnosis o Presence of primary lesion points to a different diagnosis and other causes of liver derangement disease Etiology & Pathogenesis o hyperthyroidism, allergic reactions, polycythemia vera, lymphoma, pediculosis, and scabies o The interplay of hormonal, genetic, environmental & alimentary factors o Biochemical cholestasis in susceptible individuals Course and Prognosis § Disease of late pregnancy (period of highest placental hormonal level) o Hallmark of ICP (biochemical and symptoms) resolves with 2-4 weeks § Spontaneously remits at delivery when hormone concentrations normalize o Recurrence with subsequent pregnancies in 45-70% of cases § Twin & triplet pregnancies which has the highest risk of hormonal concentration o Some experience recurrence after exposure to oral contraceptives § Occurs during subsequent pregnancies o Maternal outcomes are favorable but predisposed to postpartum hemorrhage secondary to Vitamin K o Geographic variations & familial clustering of genetic predisposition § ABCB4 (multidrug resistance gene3) o With later development of cholelithiasis or gallbladder disease o Fetal risks: prematurity, fetal distress and fetal death § ABCB11 (bile salt export pump) § ATP8B1 (F1C1) o Complications correlate with higher bile acid levels & attributed to acute placental anoxia & increase in § Higher incidence during winter months & related to reduction of selenium levels meconium-stained amniotic fluid Treatment/management Clinical features o Only pregnancy dermatosis presents without primary skin lesions o Therapy aims: reduce serum bile acid levels, prolong pregnancy, ameliorate maternal symptoms o Occurs during the third trimester with moderate-to-severe pruritus localized in the palms and soles or o Bland emollients, topical antipruritic agents, UDCA generalized § UDCA – naturally occurring hydrophilic bile acid o Pruritis occurs in first trimester 10% and the second trimester 25% and precedes the onset of symptoms 450- 1200MG is well tolerated and highly effective in controlling the clinical and liver by 1-4 weeks function abnormalities reduces maternal symptoms & fetal risk SKIN CHANGES & DISEASES IN PREGNANCY– CHAPTER 105 exerts a hepatoprotective effect through augmentation of the excretion of hydrophobic bile o Rare maternal complication: tetany, delirium & convulsions acids, sulfated progesterone metabolites and other hepatotoxic compounds o Most feared complication: placental insufficiency, stillbirth or neonatal death decreases bile acids, sulfated progesterone metabolites and other hepatotoxic compounds § Early induction of labor is contemplated decreases bile acid levels in colostrum, cord blood, amniotic fluid Diagnosis PUSTULAR PSORIASIS OF PREGNANCY (IMPETIGO HERPETIFORMIS) Ø Laboratory tests o Elevated serum bile acids – single indicator of ICP Epidemiology o Common features of ICP o very rare and is generally regarded as a variant of pustular psoriasis attributable to alterations during § Total serum bile acid levels - >11UM/L pregnancy § Cholic acid-to-chenodeoxycholic acid ratio>1.5 or cholic acid proportion of total bile acids > 42% o Onset usually occurs during third trimester but can occur as early as first trimester § Glycine conjugates-to-taurine conjugates of bile acids ratio less than 1 Etiology & Pathogenesis o Degree of pruritus & disease severity correlate with bile acid concentration o Distinguishing factor from generalized pustular psoriasis o Liver function tests § Absence of a positive family history § Not a sufficient basis for diagnosis of ICP § Abrupt resolution of symptoms at delivery § Alanine transaminase – sensitive in ICP and healthy pregnancy is not a feature of this § Tendency to recur during subsequent pregnancies § Y-glutamyl transferase – normal or slightly elevated in ICP; low in normal late gestation § Lacking normal triggers (infection, exposure to drugs and others) § Direct or conjugated fractions of bilirubin- commonly elevated in ICP o Diagnosis § Albumin slightly reduced § Histopathology § Alpha globulins & B-globulins are elevated Classic pustular psoriasis o Cutaneous biopsy does not aid in diagnosis § Laboratory tests Differential Diagnosis CBC: leukocytosis, neutrophilia, elevated ESR, hypoferric anemia & hypoalbuminemia Decreased calcium, phosphate and vitamin D o Most likely § Cultures of pustules & PBS § Pustular drug eruption negative § Pemphigoid gestationis o Consider Clinical features § Pemphigus vulgaris § Dermatitis herpetifromis o Acute eruption can occur at first trimester § Pustular eruption in inflammatory bowel disease o Typical lesion o Always rule out § Erythematous patches whose margins § Infectious causes of pustular eruption are studded with subcorneal pustules affecting the flexural areas, spreading Course and Prognosis centrifugally with sparing of face, palms and soles o Cardinal feature: rapid resolution of symptoms after pregnancy § Accompanied by constitutional o Reports in puerperium, in nonpregnant woman taking oral contraceptives & postmenopausal symptoms such as fever, chills, o Progress throughout pregnancy malaise, diarrhea, nausea & arthralgia o Subungual lesions can result to onycholysis Treatment/management o Rare involvement of the mucous membrane o Treatment is indicated to reduce the risk of fetal & maternal complication o Life-threatening maternal complication: o Topical treatments hypocalcemia & bacterial sepsis o NBUVB o Systemic corticosteroids SKIN CHANGES & DISEASES IN PREGNANCY– CHAPTER 105 § Cyclosporine 5mg/kg – 10mg/kg/day § Infliximab Delayed administration of live vaccines o Fluid status & electrolyte monitoring o Fetal monitoring o Maternal cardiac and renal function o Induction of labor DERMATOSES NOT ASSOCIATED WITH FETAL RISK IN PREGNANCY POLYMORPHIC ERUPTION OF PREGNANCY (PRURITIC URTICARIAL PAPULES & PLAQUES OF PREGNANCY) Diagnosis Epidemiology Ø Clinically o Common benign, intensely pruritic dermatosis occurring exclusively in primagravids, third trimester, & o typical locations at the end of the pregnancy Immediate postpartum Ø Biopsy Etiology, Pathogenesis & Risk Factors o Only performed if considering PG o Unknown pathogenesis o Non-specific: parakeratosis, spongiosis, occasional exocytosis of eosinophils (eosinophilic spongiosis) o Maternal Immunoreactivity triggered o Edematous dermis, perivascular infiltrate of lymphocytes admixed with eosinophils & neutrophils § increased abdominal dissension leading to altered collagen and or elastic tissue. Ø DIF § Increased progesterone receptor in lesional PEP o Granular or or absent C3, IgM or IgA at the dermoepidermal junction around blood vessels § Risk factors o IDIF is negative Multiple gestations (twin & triplet pregnancies) Treatment/management Unexplained association with male fetuses & cesarean o Harmless to mother & fetus Increased maternal-fetal weight gain o Pruritis is intense & unremitting Clinical manifestations o Symptomatic relief CUTANEOUS FINDINGS § Topical corticosteroids o Primagravids during last § Oral antihistamine o Oral corticosteroids trimester of pregnancy (mean of § Rarely required 35 weeks) o Reassurance o Polymorphous in nature as erythematous urticarial papules § Self-limited nature of PEP surrounded by a narrow pale halo. Begins on the abdomen (in ATOPIC ERUPTION OF PREGNANCY (AEP) the striae gravidarum) with periumbilical sparing but rapidly Epidemiology spreads to the thigh, buttocks, o Most common pruritic disorder in pregnancy (50% of all pregnancies) breast and arms o o Pruritis parallels the eruption and Etiology, Pathogenesis, Risk Factors severe pruritus may disturb sleep o Pregnancy-related shift in cytokine profile expression leading to preferential expression of T-helper 2 cytokine o Risk factor include personal/family history of atopy SKIN CHANGES & DISEASES IN PREGNANCY– CHAPTER 105 Clinical manifestations o 20% of patients with a flare of preexisting atopic dermatitis o Minor features of eczema xerosis, hyper linear palms are found in both cases o E-type § Eczematous § Flexural surfaces and face o P-type § Popular § Individuals with personal and or familial atopic background/ elevated serum IgE levels § Prurigo of pregnancy § District pruritic, excoriated papules with predilection for extensor surfaces Diagnosis Ø Clinically Ø Histopathology o Nonspecific Ø Laboratory test o Total serum IgE – elevated in 20-70% Clinical course and prognosis o Onset is typically third trimester that responds to therapy quickly o Excellent maternal & fetal prognosis o Mother with history atopy, infant has increased risk for atopic dermatitis Treatment/management o Emollients o Midpotency topical o Antihistamines o Benzoyl peroxide – truncal, follicular and NVB SKIN CHANGES & DISEASES IN PREGNANCY– CHAPTER 105 SKIN CHANGES & DISEASES IN PREGNANCY– CHAPTER 105

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