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REFERATE GENERALE
GENERAL REPORTS
DERMATOZE DE SARCINÃ
DERMATOSES OF PREGNANCY
C. STOIAN, RALUCA ANDREEA VLÃDUÞÃ, ELENA DINA, IONELA MANOLE, MARIA MAGDALENA CONSTANTIN, CARMEN CUREA, G.-S. ÞIPLICA Sarcina poate fi insotita de modificari fiziologice sau The pregnancy can be adjoined by physiological or patologice la nivelul pielii. Unele dintre ele sunt influentate pathological changes in the skin. Some of them are de profilul hormonal diferit la femeia gravida. Modificarile determined by particular hormonal profile of pregnancy. fiziologice pot fi pigmentare, vasculare, modificari ce tin de Physiologic changes can be pigmentary, vascular, hair and fanere sau modificari structurale ale pielii. Dermatozele nails changes and structural changes of the skin. The care pot afecta femeia gravida se impart in doua categorii. dermatoses that can appear in the pregnant women fall in Prima categorie este cea a bolilor care apar pentru prima two categories. The firs category is that of diseases that oara in sarcina si sunt specifice sarcinii. A doua categorie appear for the first time in pregnancy and are specific to este cea a bolilor preexistente sarcinii, care isi modifica pregnancy. The second category is that of preexisting conditions, that get better or worse during pregnancy. Cuvinte cheie: sarcina, melasma, herpes gestationis,
Key-words: pregnancy, melasma, herpes gestationis,
impetigo herpetiformis, prurigo de sarcina. impetigo herpetiformis, prurigo of pregnancy Introduction
A. Physiologic changes (2)
moments in a woman’s life. In this period occurs reactions. Because of this variations, pregnant women experiences different changes and some of this can induce cutaneous disorders known as pathogenesis is unknown. This skin changes can be divided in: physiologic changes, dermatoses specific to pregnancy and diseases exacerbated or * Clinica Dermatologie II, Spitalul Clinic Colentina, Bucureºti.
Dermatology Clinic II Colentina, Clinical Hospital, Bucharest.
estrogen hormones are implicated in progress Pyogenic granuloma is a tumor consisting of
vascular tissue most frequent in trauma areas . It can affect the pregnant women. The clinical appearance is a red-purple sesile or pedun- culated tumor located on the face, mucous membranes or digits, soft on palpation, coveredwith crusts. The treatment consists in surgical Melasma, named also the mask of pregnancy,
excision deep enough (to prevent the recurence) is a specific hypermelanosis more pronounced in darker-skinned women which usually appears in the second trimester of pregnancy. It is localized Varicose veins affect up to 40% of pregnant
more often over the forehead, chicks and upper women. Venous dilation can appear on the calf, lip. There is a clear hormonal influence as in the rectum or vagina. They are caused by melasma can be produced or exacerbated by oral contraceptives. The exposure to ultraviolet pressure. When venous dilations occur, legs radiation worse the hyperpigmentation. It must be elevated. Usually, the varicosities remits usually regresses by one year after delivery but in after delivery, but in some cases, sclerotherapy is persistent forms it needs treatment (topical: hidroxicloroquine, tretinoin, non-ablative laser Cutis marmorata is a transitory blushing as a
response to cold because of the increased Palmar erythema develops in the first
trimester of pregnancy. It is caused by hyper- estrogenemia which characterizes the pregnancy.
instability. It is localized on the lower extremities Clinically it’s characterized by erythema of the and usually regresses after delivery (7).
thenar and hypothenar eminences. It usually Telogen effluvium can appear as a
consequence of pregnancy. A great number of Spider nevi appears more common in white
hairs enter in telogen phase, so the hair shedding women at the end of first trimester of pregnancy.
increase. The excessive hair shedding usually It is localized on the draining areas of the stops in a few months and hair density comes superior vena cava, meaning especially on the face, and upper limbs. They usually disappear Hirsutisme is observed early in pregnancy,
after delivery but when they persist a treatment by electrocauterysation or laser ablation can be more pronounced on the face and arms. It usually disappears at six months after delivery (2). Pigmentations of the nipples, areolae and
Nails become more fragile and soften, with
linea alba appears early during pregnancy and an increased growth, distal onycholysis and they are sometimes adjoined by slight hyper- pigmentation of others areas such as axilae and Striae gravidarum
inguinal region. Linea alba becomes linea nigra problem in pregnancy and is localized on the and also the secondary areolae appears. After abdomen, breast, arms, buttocks and thighs. It delivery, the hyperpigmentations tends to seems to be related more with genetic factors and disappear, but usually the skin does not return to Darkening of nevi and ephelides can
Molluscum fibrosum is a soft tisue fibroma,
become more intense in pregnancy, may enlarge skin-colored, or hiperpigmented, can reach a few or can appear new ones. It’s recommended a centimeters in size and appears frequently strict surveillance concerning this nevus because during pregnancy. The treatment consists in we don’t know for sure in what measure the B. Dermatoses specific to pregnancy
many women have increased titers of immuno-globulin E. This prurigo of pregnancy is often confused with scabies, but does not respond to inflamatory dermatoses: pemphigoid (herpes) antiscabetic agents. In order to treat this gestationis, polymorphic eruption of pregnancy, condition, topical steroids are administered in prurigo of pregnancy and pruritic folliculitis of association with antihistamines (12).
A particular form of prurigo is represented by Herpes gestationis appears especially in the
cholestasis of pregnancy. Cholestasis of preg-
late period of pregnancy. The pathophysiology of nancy is a disease chararcterized by cholestasis this bullous disease consists in appearance of that appears during second or third trimester of autoantibodies (Ig G1) against NC 16 segment of BP 180, which are meet in a genetic predisposed hormonal changes that appear during pregnancy women. The placenta may play a major role.
in one organism which is predisposed can lead to There are important associations with other cholestasis. The clinical presentation is with autoimmune diseases such as: Grave’s disease, pruritus that begins usually in second or third Hashimoto thyroiditis, pernicious anemia. The trimester. The pruritus can be accompanied by patients present severe pruritus followed by jaundice or others systemic manifestations. In the urticaria-like and bullous lesions eruption first place the pruritus is localized on palms and located on the abdomen, palms and soles. The soles. The symptoms disappears after birth, but they can appear during contraceptives intake. In fluorescence. The autoantibodies can be detected in serum with indirect immunofluorscence. Thisdisease can predispose to premature delivery andsmall for gestational age child. The treatment isused in order to ameliorate pruritus and preventnew blister formation. It includes glucocorticoidsin small doses (prednisone 20-60 mg/orally) (11).
Polymorphic eruption of pregnancy (figure
1) is known also as pruritic urticarial papules andplaques of pregnancy (PUPPP). It appears in thethird trimester and affects mainly the primi-gravidae. It is considered to appear as aconsequence of damage to connective tissuecaused by abdominal distension or by fetalantigens. The tegumentary eruption is re-presented by erythematous papules whichevolves into urticarial plaques. It is located on theabdomen, buttocks, thighs and rarely involvesthe face, breast or palms. In general, thisdermatose does not require any treatment. Insome cases, a high-potency topical steroid mayrelieve the pruritus. Only the severe cases need ashort course of oral prednisone (12).
Prurigo of pregnancy (prurigo Besnier) is a
disorder which appears in the second trimester ofpregnancy. It is characterized by pruritic, ery-thematous papules that are seen in symmetric Figure 1. Pruritic urticarial papules of pregnancy appeared distribution, especially on the trunk and extensor surfaces of the extremities. It is suspected to be Figura 1. Papule urticariene pruriginoase ale sarcinii au associated with atopy, taking into account that apãrut 5 zile înainte de livrare vitamin K deficiency. Fetal complications are (the most important are IL23, IL22, IL17, TNF-α, prematurity and fetal death. The laboratory tests IFN-γ) and proinflamatory molecules such as show elevation of serum bile acids, bilirubin and eicosanoids. Hormonal changes may play an AST. The symptomatic treatment consist of important role in the pathological process. In a cholestiramine and the pathogenic treatment genetically predisposed person, at one time of (which ameliorate the symptoms to) is the her life, may act one aggressive factor like stress, medication or infection, which determine the Pruritic folliculitis of pregnancy is charac-
lesions to occur. The lesions remit but usually terized by an follicular, papular eruption, which they appear again. This disease can present in the on skin biopsy shows evidence of follicular involvement. Pruritic folliculitis of pregnancy - Psoriasis vulgaris (red plaques, presenting pregnancy. It resolves spontaneously within 2 to 3 weeks after delivery. Pruritic folliculitis of develop from other forms and manifests as pregnancy is typically treated like mild acne.
Benzoyl peroxide (10%) and hydrocortisone acetate 1% have been used with some success.
pustules that develop in multiple annularerythematous lesions. It resembles C. Diseases that modify their evolution
during pregnancy
There are a few dermatological conditions
that can improve during pregnancy. However,this improvement is not present in every case,there are situations when the disease can even getworse or remain unchanged. One example ofdisease that can improve during pregnancy ispsoriasis and one example of disease that usuallyget worse is lupus erythematosus. Diseases thatusually get worse are also the viral and fungalinfections14.
Psoriasis is one of the dermatological
diseases that can get better during pregnancy14.
Psoriasis is a disease characterized by papulo-scuamous lesions distributed in areas ofextension (knees, elbows). The pathophysiologyof this disease is very complex and poorlyunderstood, but it is known that reflects aninterplay between genetic predisposition,immunologic factors, nervous system functionand environmental factors. The immune systemseems to play the major role in pathogeny; it wasfound that both innate and adaptive immunesystem interact and develop a complicated chainof events, which leads to psoriatic lesions. Thedendritic cells, which probably lose theirtolerance inductive capacity, activates a T-cell Figure 2. Impetigo herpetiformis (week 28 of pregnancy) response, characterized by secretion of cytokines Figura 2. Impetigo herpetiforma (sãptãmâna 28 de sarcinã) impetigo herpetiformis, but it persist after the newborn can occur independently of the rout of delivery. In pregnancy podophillotoxin is - Impetigo herpetiformis (figure 2) appears contraindicated, the electrocautery is the in the third trimester of pregnancy and then disappear after delivery. There are pustules Lupus erythematosus is one of the most
distributed in an annular pattern, similar to young women in the reproductive years. For most women with lupus a successful pregnancy - Gutatte psoriasis ( papules on the trunk)15 is possible. During pregnancy or several weeks to Psoriasis can manifest as arthritis and the months after delivery, women may experience clues for the diagnosis are enthesitis, onyco- lupus for the first time or may experience a dystrophy, distal interphalangeal involvment, sacroilitis or spondyloartritis, isolated involve- chances to end in miscarriage and if it occurs in ment of the joints and enthesitis (16).
the first trimester of pregnancy the cause can be There are some improvements in 30-40 % of due to active lupus and if it occurs later the cause cases, the rest is distributed between unimproved is antiphospholipid antibody syndrome, in spite cases and worsened cases. During pregnancy the of treatment with heparin and aspirin. All systemic treatment is best to be avoided, the best women with lupus, even if they do not have a choice is topical treatment, using topical cortico- previous history of miscarriage, should be steroids, topical calcipotriene, topical anthralin screened for antiphospholipid antibodies, both the lupus anticoagulant and anticardiolipin Erythema nodosum is an inflammatory
antibody. Another risk is the preterm birth due to disease that affects the subcutaneous tissue. It is associated with many other conditions such as membranes, active lupus, high dose prednisone, infections, systemic illnesses and drug admi- and renal disease. The most important maternal nistration. Is useful to emphasize that in category risk, that of a lupus flares, it’s an excess of renal of drugs that produce erythema nodosum are the and hematologic flares, and fewer arthritis flares.
contraceptives. For this reason and because About 3% of babies born to mothers with lupus erythema nodosum can appear during menses is will have neonatal lupus. This lupus consists of a believed that hormonal changes during preg- temporary rash and abnormal blood counts.
nancy can be a trigger for this illness. Clinical Neonatal lupus usually disappears by the time presentation is with erythematous nodules on the the infant is 3-6 months old and does not recur.
anterior surface of shins. The lesions are tender About one-half of babies with neonatal lupus are and usually lasts weeks. Systemic symptoms and born with a heart condition. This condition is signs can appear. Erythema nodosum appear in permanent, but it can be treated with a pace- the first or second trimester of pregnancy. The maker. A pregnant women with lupus can be treatment is represented by NSAIDs, but not in treated with prednisone, azathioprine, heparin, hydroxychloroquine (Plaquenil) (18, 19). Human papiloma viruses infections.
Scleroderma is an autoimmune affection
Human papiloma viruses can infect the genital including systemic and localized forms. Because apparent and subclinical evolution because of the complications do occur women with diffuse capacity of the virus to persist in the basal layer scleroderma are at greater risk for developing of the skin. Some of the viral subtypes (16 and 18) serious cardiopulmonary and renal problems are associated with the risk of malignant genital early in the disease. However they should be tumors. Genital warts presents as smooth, pale, encouraged to delay pregnancy until the disease pink, papules or tumors in the genital or anal stabilizes. All patients who become pregnant area. They have irregular surface and can during this high-risk time should be monitored coalesce to form bigger masses. The infection of extremely carefully. The main problem which Pitiriazis rosea is a papulosquamous
preeclampsia in the third trimester that must be disorder of a viral etiology. There are multiple treated aggressively with ACE inhibitors.
eythemato-squamous patches that involves the Another risks are maternal death, or miscarriage, trunk (parallel with skin lines). Usually this or high risk of premature and small infants (small appearance is preceded by a large erythemato- squamous patch. The evolution is usually self Dermatomyositis is one of the most common
limited. The therapy is represented by mid- forms of the idiopathic inflammatory myopathy, potency topical corticosteroids. The pregnancy with an incidence of 1-9 cases per million peryear. The disease is rare during pregnancy, and dose not affect the evolution of this disease (24).
there are no available epidemiological data on In pregnancy the medication must be very
pregnancy and dermatomyositis. Anyway, there carefully chosen. The number of the drugs are described two types of pregnancy-related DM. In the first type, the disease is provoked reduced. The topical agents are preferred, as they during pregnancy and tends to improve after have a diminished absorption. If systemic delivery .In the second type, the onset is in the therapy is used, oral administration is preferred.
postpartum period. The symptoms and signs are The drugs that can not be used during pregnancy usually non-specific: slight fatigue and periungal are retinoids, estrogens, danazol, finsateride, erythema. The risks in pregnancy are premature methotrexate, thalidomide. The drugs that can delivery and fetal mortality. The recommended damage and must be avoided as far as possible treatment is corticotherapy, but it can have are azathioprine, colchicine, cyclophosphamide, adverse effects. Therefore, the pregnant patients busulfan, penicilamine and NSAIDs (22). The lists above presented are not exhaustive.
If during pregnancy appears a infection that Pemfigus vulgaris is a bullous disease
must be treated with antibiotics, then penicilins characterized by intraepidermal formation of are the first choice. From macrolides, the drugs blisters on the skin or mucous membranes. Thedisease is characterized by the presence of of choice are spiramicyn and erythromycin. Anti- antibodies against desmoglein 1 and 3 and biotics that must be avoided are: sulfonamides in clinical manifestations are mucosal erosions, the third trimester, metronidazole (especially in flaccid blisters and erosions in the skin. The treat- systemic administration), tetracyclines ( can pro- ment consists of corticotherapy, but treatment duce dental and bone malformations), amyno- with intravenous immunoglobulins seems to be a glicosides, fluroquinolones and chloramphenicol.
In topical administration neomicin, bacitracin Acne during pregnancy can be mild, mode-
and fusidic acid can be used. Antifungal therapy rate or severe. It can be induced, pronounced or is best to be topic and the substances used are attenuated by the pregnancy. The increased imidazoles and nystatin. Antiviral therapy using levels of androgens are responsible for acne acyclovir is controversial, but when needed is breakouts, which can appear any time in these applied. Podophilin is best to be avoided.
nine months. Usually, the acne associated with Antiparasite medication consist of dithranol , pregnancy resolves on its own a few months later permetrin and benzoil benzoate. Corticosteroid or after delivering. Treatments considered safe therapy can be used during pregnancy, but if are and recommended include: azelaic acid, benzoyl used big doses the best is to have a pediatrician peroxide, salicylic acid (in low concentrations consult before delivery. The antihistamines can only) and erythromycin. A series of treatments be used in pregnancy in topical administration.
can induce fetus malformations and need to be The recommendation in systemic administration avoided: isotretinoin, topical retinoids, tetra- cycline and its derivatives (doxycycline and Bibliografie/Bibliography
1. Hung N. W., Hobbins C. J. Clinical Maternal fetal medicine.2000; 385.
2. Warrel D. A., Cox T. M, Firth J. D., Benz E. J . Oxford textbook of Medicine .2005. 440.
3. Parish L.C., MD; Parish J.L.,MD, Dermatologic Diseases in Pregnancy, Pigmentary Changes. 4. Ingber A., Obstetric Dermatology A Practical Guide, Chapter 2, Section 1, Disorders of Pigmentation (Pg.7,8). 5. Forsea D. , Compendiu de Dermatologie ºi Venerologie, 1998, Capitolul 25, pg.313.
6. Parish L.C., MD; Parish J. L., MD, Dermatologic Diseases in Pregnancy, Vascular Changes.
7. Ingber A., Obstetric Dermatology A Practical Guide, Hair and Nails, pg.19-21.
8. Fitzpatrick’s Dermatology in General Medicine, 7-th edition, Chapter 86, Paus R., Olsen E. A., Messenger A. G.pg.
9. Fitzpatrick’s Dermatology in General Medicine, 7-th edition, Chapter 107 Skin Changes and Diseases in pregnancy, Karen J.K.,Pomeranz M. K., K. Wolf, L. A. Goldsmith, S. I. Katz, Barbara A. Glichrest, A. S. Paller, D.
10. J. P. Callen MD, J. L. Jorrizo MD, J. L. Bolognia, W. W. Piette MD, J. J. Zone MD, Bolognia’s Dermatology,
Dermatological Signs of Internal Diseases 4 th edition Chapter 35 Pregnancy, Cutaneous Tumors affected by 11. Rapini R. P., Jorizzo J. L.,. Bolognia J. L, Dermatology 2003, 1-st edition,. Shornik J. K, Chapter 29, Diseases of 12. Fitzpatrick’s Dermatology in General Medicine, 7-th edition, Chapter 107, Skin Changes and Diseases in Pregnancy, Karen J.K.,Pomeranz M. K.,Lowell K. W, A. Goldsmith, S. I. Katz, B. A. Glichrest, A. S. Paller, D. J.
13. Fitzpatrick’s Dermatology in General Medicine 7 th edition, Chapter 107, Skin Changes and Diseases in Pregnancy, Karen J.K.,Pomeranz M. K, Lowell K. W., A. Goldsmith,, S. I. Katz, B. A. Glichrest, A. S. Paller, D. J.
14. W. Sterry, R. Paus, W. Burgdorf, Dermatology (Chapter 39, Diseases in pregnancy-pg. 569-570).
15. Fitzpatrick’s Dermatology in General Medicine 7 th edition, Chapter 18, Gudjonsson J. E.,Elder J. T., Psoriasis (pg.
16. Fitzpatrick’s Dermatology in General Medicine 7 th e dition, Chapter19, Winchester R., Psoriatic Arthritis (pg.
17 Habif T. P .Clinical dermatology,., Fourth Edition, Chapter 11, Sexually transmitted viral infections.
18. Wallace D. J , Hahn B., Dubois E. L. Dubois’ Lupus Erythematosus. 2006. 996.
19. Lahita. R. G Systemic lupus erythematosus .2004. 670.
20. Evans A.T. Manual of obstetric. 2007. Pg. 466.
21. W. Sterry, R Paus, W. Burgdorf, Dermatology, Chapter 14, pg.(229-231.) 22. Ahmed A., Gurcan H., Use intravenous immunoglobulin during pregnancy in patients with pemphigus vulgaris, Journal of European Academy of Dermatology and Venerology, 12 dec. 2010.
23. W. Sterry, R Paus, W. Burgdorf, Dermatology, Chapter 44 (pg. 647-650).
24. W. Sterry, R. Paus, W. Burgdorf, Dermatology, Chapter 16 (pg. 279-280).
Clinica Dermatologie II, Spitalul Clinic Colentina, Bucureºtiªos. ªtefan cel Mare nr. 19-21 Dermatology Clinic II, Clinical Hospital Colentina, Bucharestªtefan cel Mare street no. 19-21

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