Four dermatoses considered unique to pregnancy are pemphigoid gestationis (PG), pruritic urticarial papules and plaques of pregnancy (PUPPP), atopic eruption of pregnancy (AEP), and intrahepatic cholestasis of pregnancy. Descriptions of these are given in Table 65-1. Their gross appearance can be similar to each other or to other skin disorders, and pruritus is a common feature. Of these four, adverse fetal outcomes are linked only with PG and intrahepatic cholestasis. The latter is discussed in detail in Chapter 58 (p. 1032). It generally lacks primary skin lesions, but pruritus is usually associated with abnormally elevated serum bile acid levels and mildly increased hepatic transaminase levels.
TABLE 65-1Pregnancy-specific Dermatoses ||Download (.pdf) TABLE 65-1Pregnancy-specific Dermatoses
|Disorder ||Frequency ||Characteristic Lesion ||Adverse Pregnancy Effects ||Treatment |
|PUPPP ||Common ||Erythematous pruritic papules or plaques; patchy or generalized on abdomen, thighs, buttocks, especially within striae, but with umbilical sparing ||None ||Oral antipruritics, emollients, topical corticosteroids, and if severe, oral steroids |
|AEP || || ||None |
|Eczema in 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 || |
|Cholestasis of pregnancy ||Common ||No primary lesions, secondary excoriations from scratching ||Increased perinatal morbidity ||Oral antipruritics, cholestyramine, ursodeoxycholic acid |
In this rare autoimmune bullous disease, pruritic papules and urticarial plaques initially form. Vesicles or bullae usually follow after 1 to 2 weeks. Lesions frequently involve umbilicus and other skin surfaces but typically spare mucous membranes, scalp, and face (Fig. 65-1).
Pemphigoid gestationis. A. Abdominal plaques classically involve the umbilicus. B. Blistered lesions on the wrist and forearm. (Reproduced with permission from Dr. Kara Ehlers.)
Previously termed herpes gestationis, PG is not related to the herpesvirus. Instead, maternal immunoglobulin G (IgG) antibodies target collagen XVII found in the basement membrane of skin and amnionic epithelium (Kelly, 1988; Sadik, 2016). Collagen XVII is also termed bullous pemphigoid 180 (BP180). Autoantibody binding to BP180 activates complement to promote eosinophil chemotaxis to the antigen-antibody complexes. Eosinophilic degranulation damages the dermal–epidermal junction and leads to blistering.
In most cases, PG develops during a first pregnancy. Most subsequent pregnancies also are affected, usually earlier and more severely (Tani, 2015). Additionally, other autoimmune diseases, especially Graves disease, are frequent in affected women (Jenkins, 1999; Shornick, 1992).
PG usually begins during the ...