Herpes Gestationis—This disease, more frequently known as dermatitis herpetiformis is an inflammatory superficially seated multiform herpetiform eruption, which is characterized by erythematous, vesicular, pustular, and bullous lesions.
—J. Whitridge Williams (1903)
Four dermatoses considered unique to pregnancy include intrahepatic cholestasis of pregnancy, pruritic urticarial papules and plaques of pregnancy (PUPPP), atopic eruption of pregnancy (AEP), and pemphigoid gestationis (PG). Descriptions of these are given in Table 62-1. As a group, these are diagnosed in up to 5 percent of pregnancies (Chander, 2011). Their gross appearance may be similar to each other or to other skin disorders, and pruritus is a common feature of all four. Only intrahepatic cholestasis and pemphigoid gestationis have been linked with adverse fetal outcomes.
TABLE 62-1Pregnancy-specific Dermatoses |Favorite Table|Download (.pdf) TABLE 62-1 Pregnancy-specific Dermatoses
|Disorder ||Frequency ||Characteristic Lesion ||Adverse Pregnancy Effects ||Treatment |
|Cholestasis of pregnancy ||Common ||No primary lesions, secondary excoriations from scratching ||Increased perinatal morbidity ||Antipruritics, cholestyramine, ursodeoxycholic acid |
|Pruritic urticarial papules and plaques of pregnancy (PUPPP) ||Common ||Erythematous pruritic papules or plaques; patchy or generalized on abdomen, thighs, buttocks, especially within striae, but with umbilical sparing ||None || |
|Atopic eruptions of pregnancy (AEP) || || ||None ||Antipruritics, emollients, topical corticosteroids, oral steroids if severe |
|Eczema of pregnancy ||Common ||Dry, red scaly patches on extremity flexures, neck, face || || |
|Prurigo of pregnancy ||Common ||1–5 mm pruritic red papules on extensor surfaces, trunk || || |
|Pruritic folliculitis of pregnancy ||Rare ||Small red papules, sterile pustules on trunk || || |
|Pemphigoid gestationis ||Rare ||Erythematous pruritic papules, plaques, vesicles, and bullae; abdomen often with umbilical involvement, extremities ||Preterm birth, fetal growth restriction, transient neonatal lesions || |
Intrahepatic Cholestasis of Pregnancy
Previously termed pruritus gravidarum, this condition is found in 0.5 percent of pregnancies (Wikström Shemer, 2013). In contrast to the other pregnancy-specific dermatoses, intrahepatic cholestasis of pregnancy generally has no primary skin lesions. Rarely, a rash precedes pruritus, which is usually associated with abnormally elevated serum bile acid levels and mildly increased hepatic aminotransferase levels (Chao, 2011). Adverse fetal effects have been linked to this condition, and it is discussed in detail in Chapter 55.
This rare autoimmune bullous disease is notable for its maternal and fetal effects. Initially, pruritic papules and urticarial plaques form and are then followed in most cases after 1 to 2 weeks by vesicles or bullae. Lesions are frequently distributed periumbilically, often develop on other skin surfaces, but spare mucous membranes, scalp, and face (Fig. 62-1).
Pemphigoid gestationis. A. Abdominal plaques classically involve the umbilicus. B. Blistered lesions on the wrist and forearm. (Used with permission from Dr. Kara Ehlers.)
Previously termed herpes gestationis, pemphigoid gestationis is not related to the herpesvirus. Instead, ...