Rashes of pregnancy

Background

• First rule out life-threatening causes of rash such as SJS or TEN
• Multiple pruritic rashes associated with pregnancy including:
  • Atopic eruption of pregnancy
  • Intrahepatic cholestasis of pregnancy
  • Pemphigoid gestationis
  • Pruritic urticarial papules and plaques of pregnancy (PUPPP)
  • Pustular psoriasis of pregnancy (previously Impetigo herpetiformis)
• Non-pathologic skin changes in pregnancy:
  • Melasma (facial rash)
  • Hyperpigmented Linea Alba
  • Striae gravidarum (stretch marks)

Rash Red Flags

• Fever
• Toxic appearance
• Hypotension
• Mucosal lesions
• Severe pain
• Very old or young age
• Immunosuppressed
• New medication

Differential Diagnosis

Melasma: pigment changes to the face due to pregnancy.

Linea nigra in a woman at 22 weeks pregnant.

Atopic eruption of pregnancy

• Onset usually 1st/2nd trimester
• Types:
  • Eczema
    • Flexural surface distribution
  • Prurigo of pregnancy
    • Erythematous papules and nodules on the extensor surfaces of the extremities but often also affects abdomen
  • Pruritic folliculitis of pregnancy
    • Scattered follicle-based papules & pustules usually start on abdomen
• Treatment: emollients and topical corticosteroids
• No known risk to fetus

Intrahepatic cholestasis of pregnancy

• Onset in 2nd/3rd trimesters
• LFT abnormalities
• Rash non-specific but often pruritis of hands/feet
• Pruritus distinguishes it from HELLP syndrome
• Treatment: consider starting ursodiol in consultation with OB/GYN
• Risk to fetus: prematurity, neonatal respiratory distress

Pruritic urticarial papules and plaques of pregnancy (PUPPP)

PUPPP on gravid abdomen.

PUPPP on gravid abdomen.

• Most common pregnancy-specific dermatosis
• Onset in last weeks of pregnancy
• Intense pruritus, often associated with striae
• Rash usually begins on abdomen
• Treat with mid- to high-potency topical steroids (e.g. Betamethasone or Triamcinolone)
• No associated risk to fetus
• Only occurs in 1st pregnancy
• Also called Polymorphic Eruption of Pregnancy (PEP)

Pemphigoid gestationis

• Autoimmune disorder
• Onset: 2nd/3rd trimester
• Rash: pruritic papules and vesicles with bullae, usually starts periumbilical
• Treatment: High-potenecy topical steroids +/- prednisone (0.5mg/kg/day) and oral antihistamines
• Risk: fetal prematurity

Pustular Psoriasis of Pregnancy

Severe pustular psoriasis.

• Onset: 3rd trimester
• Rash: painful pustules, usually start on thighs
• Management: admit to OB/GYN for fetal monitoring
• Risk: fetal morbidity
• No recent exposure to meds distinguishes it from AGEP

Evaluation

Workup

If concern for Pemphigoid gestationis, ICP, or Pustular psoriasis based on exam:

• CBC
• Electrolytes
• LFTs

Management

• Based on suspected condition

See Also

• Pregnancy (main)
• General approach to rashes

External Links

https://www.uptodate.com/contents/dermatoses-of-pregnancy