CHAPTER 105 SKIN CHANGES & DISEASES IN PREGNANCY.pdf

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