SKIN and Pregnancy.ppt

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SKINand PREGNANCY

• By
• Dr M. Y.Abd El-Mawla,MD
• Zagazig Faculty of Medicine,Zagazig ,EGYPT

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Introduction

• Changes in the Skin Due to Pregnancy
• Skin Conditions Influenced by Pregnancy
• Pregnancy and Immune-Mediated Disorders
• Skin Conditions Specific to Pregnancy
• The Use of Drugs for Dermatologic

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Changes in the Skin Due to Pregnancy

• Hyperpigmentation
• Generalized or increase in pigment at specific
  areas such as the areolae, genitals, inner
  thighs, or axillae
• Melasma In most cases, the hyperpigmentation
  epidermal melanin deposition due to a
  combination of light exposure and elevated
  hormones (estrogen, progesterone, and
  melanocyte-stimulating hormone.

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Melasma
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Changes in the Skin Due to Pregnancy

• Hair Nail Changes
• Hirsutism frontoparietal thinning of
  male-pattern alopecia increase in androgens
• Postpartum hirsutism resolves and hair may enter
  the telogen phase, resulting in the diffuse
  shedding of telogen effluvium
• Nail changes transverse grooving, brittleness,
  distal onycholysis, and subungual hyperkeratosis

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Telogen effluvium
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Androgenic aalopecia
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Vascular Changesin Pregnancy

• Erythema (most women)
• Spider telangiectases (66)

• Vagina (Jacquemier-Chadwick sign)Cervix
  (Goodell's sign -- bluish)PalmsGingiva
• Chest
• Legs
• Face

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Vascular Changesin Pregnancy

• Varicosities (40 of women)
• Purpura
• Vasomotor instability
• Non pitting edema (50 of women
• Pyogenic granuloma

• Legs Hemorrhoids
• Lower extremities
• Facial flushing ,Pallor Cutis marmorata
  ,Raynaud'sphenomena
• Face,lids extremities
• Gingiva and other sites

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Pyogenic granuloma
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Glandular Changes

• Increased Eccrine glands function
• Miliaria ,Hyperhidrosis Dyshidrotic
  eczema
• Decreased Apocrine function
• Increased Sebaceous function in third trimester
• Acne (variant-pruritic folliculitis of
  pregnancy) Sebaceous glands on the areolae
  (Montgomery's glands)

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Connective Tissue Changes in Pregnancy

• Striae distensae (90) on the abdomen, on the
  breasts, thighs, and inguinal areas.
• Mechanical stretch increased hormones
  (adrenocortical, estrogen, and relaxin) are the
  most significant factors in the development of
  striae,

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Striae distensae
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Skin Conditions Influenced by Pregnancy

• Melanomas no increased risk of melanoma in
  pregnancy .When diagnosed during pregnancy may
  be thicker and therefore have a worse prognosis
• Nevi may develop, enlarge, or darken. show mild
  cytologic atypia.
• Dermatofibromas Leiomyomas Keloids
  Dermatofibrosarcoma may develop or grow
  rapidly in pregnancy

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Other Skin Conditions Influenced by Pregnancy

• Atopic dermatitis
• More likely to worsen than improve
  
• May present for the first time
  during pregnancy with keratosis pilaris
• Irritant hand dermatitis due to
  washing postpartum nipple dermatitis due to
  nursing

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Other Skin Conditions Influenced by Pregnancy

• Psoriasis More likely to improve than worsen
• Psoriatic arthritis may worsen
• Impetigo herpetiformis (generalized pustular
  psoriasis) during last trimester, but may
  present earlier persists until delivery or long
  after
• Associated with decreased calcium and/or
  vitamin D
• Severe malaise, fever, nausea , vomiting, tetany,
  seizures
• Grouped pustules at the margins of symmetric
  erythematous patches

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Impetigo herpetiformis
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Impetigo herpetiformis 2
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Pregnancy Autoimmune Disorders

• Changes in hormones including the increase in
  estrogen affect the course of autoimmune
  diseases.
• The fetoplacental unit directs maternal immunity
  toward humoral responses by favoring certain
  cytokines and other inflammatory mediators
• Enhanced humoral immunity weakened cellular
  immunity lead to variable effects that are
  dependent on the specific disease process .

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Systemic lupus erythematosus

• SLE may worsen and may flare postpartum.
• Lupus patients are advised to avoid trying to
  conceive when their disease is active
• Underlying lupus renal disease may worsen during
  pregnancy.
• There is a significant risk of eclampsia
• Active disease in the mother, maternal use of
  potentially teratogenic medications, and
  pathogenic antibodies (anti-Ro-- ) transmitted
  from the mother may present risks to the fetus.

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Ro(SS-A) Foetal risk

• Neonatal lupus in mothers with circulating
  anti-Ro(SS-A) antibodies
• Increased risk of prematurity and spontaneous
  abortion
• Congenital heart block

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Nonatal lupus
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Antiphospholipid syndrome(aPLs)in pregnant with
SLE

• Approximately one third of patients who have SLE
  also have aPLs..
• aPLs heterogeneous group of autoantibodies that
  bind phospholipids, proteins, or a
  phospholipidprotein complex on platelets and or
  vascular endothelium.
• Two best characterized the lupus anticoagulant
  (LA) and anticardiolipin antibodies (aCL)
• .

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Suggested clinical and laboratory criteria for
the diagnosis of APS

• Pregnancy Loss
• Recurrent spontaneous abortion Unexplained
  fetal death
• Thrombosis Venous thrombosis Arterial
  thrombosis, stroke
• Autoimmune thrombocytopenia hemolytic anemia
• Transient ischemic attacks
• Chorea gravidarum Livedo reticularis
• Laboratory criteria
• Lupus anticoagulant, Anticardiolipin
  antibodies , gt1520 IgG binding units activated
  partial thromboplastin time .

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Conditions Specific to Pregnancy

• Herpes gestationis (HG) (also known as
  "pemphigoid gestationis") .
• Pruritic and urticarial papules and plaques of
  pregnancy (PUPPP).
• Intrahepatic cholestasis of pregnancy (ICP) may
  present with intense pruritus.
• Prurigo of pregnancy
• Pruritic folliculitis of pregnancy

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Herpes Gestationis H G (pemphigoid gestationis)

• The incidence 1 in 50,000 pregnancies
• Developing during the second or third trimester
  (mean onset, 21 weeks) reported in the first
  trimester.
• Intensely pruritic, urticarial lesions on the
  abdomen in half of the cases especially
  periumbilically, with a rapid progression to
  multiple, generalized bullae. Face, mucous
  membranes, palms, and soles spared.

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• Improving during the later part of pregnancy,
  only to flare at delivery or postpartum in about
  75 of patients
• Histopathology a subepidermal vesicle with
  perivascular infiltration (lymphocytes
  eosinophils).
• Direct immunofluorescence C3 with or without IgG
  in a linear band along the basement membrane zone
  (BMZ). The antibody localizes to the roof of the
  blister.
• A mismatch of HLA antigens between the mother and
  father, manifested by an immunologic response
  against the paternal class II antigens at the
  placental BMZ with cross-reaction at the skin
  BMZ.

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Foetal Risk in in HG

• The newborn shows signs of HG in less than 10 of
  cases.
• The foetal risk prematurity and low
  birthweight,

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Urticarial plaques vesiculations
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Pruritic and Urticarial Papules and Plaques of
Pregnancy(PUPPP)

• Occuring in approximately 1 in 240 pregnant
  women, typically in the third trimester in first
  pregnancy
• The urticarial papules begin within striae on the
  abdomen and thighs and, sparing the
  periumbilical region, face, palms, and soles.
• The lesion may be also vesicles or targetoid.
• Not to recur in subsequent pregnancies

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• Biopsy a spongiotic epidermis with a
  perivascular inflammatory infiltrate increased
  numbers of eosinophils.
• Immunofluorescence negative
• Poseing no risk to the mother (except pruritus)
  or fetus, resolveing postpartum.
• Aetiology
• Abdominal distention eliciting an inflammatory
  response by damaging the connective tissue
• A substance released from placenta into the
  maternal circulation triggers fibroblast
  proliferation

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Intrahepatic Cholestasis of Pregnancy (ICP)

• In the third trimester of pregnancy (mean, 31
  weeks) with a mild form of intrahepatic bile
  secretory dysfunction.
• Features 1-generalized pruritus with or without
  jaundice 2-absence of primary skin lesions, (3)
  biochemical abnormalities consistent with
  cholestasis,(elevated serum bile acids (mean,
  1349 mug/100 mL) and (4) resolution after
  delivery.
• Recurrence with subsequent pregnancy

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Pathophysiology

• Estrogens interfere with the diffusion of fluid
  across the canalicular membrane of the hepatocyte
  and subsequently with hepatic bile acid
  secretion.
• Inhibition of hepatic glucuronyl-transferase
• Altered estrogen metabolism in the liver,
  resulting in reduced biliary volume and excretion
  of these compounds

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Prurigo of pregnancy (PP )

• The incidence 1 in 300 pregnancies.
• In all trimesters of pregnancy
• Erythematous papules and nodules on the extensor
  surfaces of the extremities and occasionally on
  the abdomen
• Recurrence during subsequent pregnancies is
  variable
• Related to an atopic background

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Pruritic folliculitis of pregnancy (PFP)

• Generalized, pruritic erythematous, follicular
  papules, developing from the fourth to the ninth
  month of gestation .
• A form of steroid acne, with no evidence of any
  immunologic or hormonal abnormalities.
• Some authors have suggested that PFP and PP
  should be included within the spectrum of
  "polymorphic eruption of pregnancy.

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The Use of Drugs for Dermatologic Conditions in
Pregnancy
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FDA Pregnancy Categories

• A Controlled studies show no fetal risk
• B No risk to human fetus despite possible
  animal risk.
• C Risk cannot be ruled out human studies are
  lacking.
• D Positive evidence for risk to human fetus,
  but benefits may outweigh risks of drug
• X Contraindicated in pregnancy there is no
  reason to risk use of drug in pregnancy
• Undetermined No pregnancy category yet assigned

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• Topical corticosteroids during pregnancy with a
  low risk to the fetus( Category C risk) as the
  risk cannot be ruled out because no human studies
  have been done.
• Topical povidone-iodine and podophyllin place a
  fetus at risk. not recommended for use during
  pregnancy
• Analgesics associated with minimal risk to the
  fetus or infant. Indomethacinassociated with
  problems in infants .

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• Retinoids and antineoplastic isotretinoin (used
  to treat acne vulgaris) antineoplastic eg
  methotrexate category X.
• Antipruritic agents. doxepin avoided during
  pregnancy and lactation. Hydroxyzine risk in
  the first trimester of pregnancy and is
  associated with a risk of congenital abnormality.
  
• Antibioticsincluding tetracycline
  ciprofloxacin--pose potential risks during
  pregnancy.. Penicillins are considered
  comparatively safe during pregnancy

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• THANK YOU