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
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
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
, 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
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
is a transitory blushing as a
response to cold because of the increased
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
can appear as a
consequence of pregnancy. A great number of
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
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,
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
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
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
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
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
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
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.
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
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
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
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
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
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
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
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
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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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