Miscellaneous diseases affected by pregnancy
Introduction
Several dermatologic conditions are sufficiently common to occur frequently during pregnancy. Such dermatoses as psoriasis, acne, hidradenitis suppurativa, atopic dermatitis, and erythema multiforme may or may not change during the pregnant state. This review will highlight variations that could occur during pregnancy.
Some dermatoses and tumors are commonly modified by pregnancy and the puerperium, but the effects of pregnancy on psoriasis are variable, although often consistent in the same woman. The sudden eruption of acute pustular psoriasis gives rise to a distinct entity called “impetigo herpetiformis.”
The literature is replete with reports of psoriasis and pregnancy, most of which suggest an improvement.1, 2 Selected papers are detailed in (Table 1).3
In another study, 50% of psoriatic patients were reported to improve during pregnancy.4
We believe that pustular psoriasis should be considered separately from impetigo herpetiformis; however, there is disagreement among many authors regarding this issue. Impetigo herpetiformis occurs only in pregnant women, and unlike pustular psoriasis, it is associated with hypocalcemia. Impetigo herpetiformis causes a high incidence of stillbirths and fetal abnormality,5 and it is often associated with low levels of vitamin D.6 In addition, pregnant women with impetigo herpetiformis rarely report a personal or family history of psoriasis.6, 7, 8, 9
Pregnancy is associated with an increase in the levels of estrogen and progesterone, which may play a role in improving psoriasis by promoting a state of immune tolerance. It acts in stimulation of B-cell–mediated immunity but suppresses the T-cell–mediated immunity.10, 11 Progesterone has also been shown to be the key factor in uterine immunosuppression.12, 13
The number of patients with psoriasis who improve during pregnancy is double the number of patients who worsen in pregnancy. This finding may be due to increased estrogen levels relative to progesterone.2
Clinically, chronic plaque psoriasis is the most common type of psoriasis to develop or worsen in pregnancy.1 In general, chronic plaque psoriasis is more likely to improve (40%-63%) than worsen (14%).14, 15 There is some indication that that may also be a result of high levels of interleukin 10 in pregnancy.16
Psoriatic arthritis has been reported to develop or worsen during pregnancy, and 30% to 45% of the women had the onset of psoriatic arthritis either postpartum or perimenopausally (Fig. 1, Fig. 2).17
Atopic dermatitis worsens in most pregnant women and few patients improve. The exacerbation is partly due to the pruritus of pregnancy, but in spite of that, remission of the disease has been reported in only 24% of cases.18
Breast-feeding is often a problem for women with atopic dermatitis due to nipple eczematization. There is also a problem in postpartum with irritant hand dermatitis, owing to increased exposure to such common irritants as food or detergents (Fig. 3, Fig. 4, Fig. 5, Fig. 6).19
Acne may improve during pregnancy, but it is occasionally exacerbated during pregnancy. This is particularly the case with acne conglobata.20 This can cause management problems because many of the systemic antiacne agents, which range from antimicrobials to isotretinoin (13-cis-retinoic acids), are contraindicated especially in the first trimester (Fig. 7, Fig. 8).21
Hidradenitis suppurativa is a chronic relapsing inflammatory skin disease that affects the apocrine gland–bearing skin sites, in particular, the axillae and anogenital regions. It is characterized by recurrent abscess formation and draining sinus tracts due to subcutaneous extension with induration, destruction of skin appendages, and subsequent scarring. It typically begins after puberty, when there is full development of the apocrine glands. It is more prevalent in women than men (Fig. 9).
Apocrine activity decreases during pregnancy, which may explain the frequent clinical improvement of preexisting hidradenitis suppurativa. Pregnancy also results in the improvement of Fox-Fordyce disease, which is a chronic disorder of the apocrine glands of the axillae, anogenital, and periareolar in women (Fig. 10).22, 23
Erythema multiforme is an acute, self-limited disease, characterized by abrupt onset of papular lesions that are symmetrical, red, and fixed. It can be precipitated by HSV I and II, histoplasma capsulatum, and, possibly, the Epstein-Barr virus. Pregnancy may also trigger erythema multiforme. It involves the mouth (lips, buccal mucosa, and tongue), the dorsa of the hands and the forearms, which are the most commonly involved skin sites, and the palms, neck, face, and trunk. Lesions can also occur on the legs. The lesions tend to be grouped, especially around the elbows and knees. It usually heals within 2 weeks. The development of respiratory signs, fever, and necrosis of oral mucosa with labial crusting indicates a diagnosis of Stevens-Johnson syndrome. There are reports of vaginal stenosis resulting from Stevens-Johnson syndrome occurring in pregnancy (Fig. 11).24, 25, 26, 27
Section snippets
Urticaria
Urticaria, particularly physical-pressure type, can occur during pregnancy and is often aggravated by pregnancy. It appears mainly on the abdomen in the second but more in the third trimester. The cause is unclear but precipitating factors may be heat, constricting clothing, or even the distension of the abdominal wall. Urticaria should be differentiated from the early pruritic urticarial lesions of herpes gestationis. Physical urticaria is frequently accompanied by dermographism.28, 29
Conclusions
Common dermatoses can occur during the pregnant state, as might be expected. The concern should be directed toward the pharmacological intervention and whether any of the agents topical or systemic might interfere with gestation.11, 30, 31, 32
References (32)
- et al.
Estrogen accelerates immune complex glomerulonephritis but ameliorates T cell–mediated vasculitis and sialadenitis in autoimmune MRL lpr/lpr mice
Cell Immunol
(1992) - et al.
Specific dermatoses of pregnancy: an evidence-based systematic review
Am J Obstet Gynecol
(2003) - et al.
Inhibitory effect of progesterone and 20 alpha-hydroxypregn-4-en-3-one on the phytohemagglutinin-induced transformation of human lymphocytes
Am J Obstet Gynecol
(1977) - et al.
Drug administration to the pregnant or lactating woman: a reference guide for dermatologists
J Am Acad Dermatol
(1990) - et al.
Use of oral and topical agents for acne in pregnancy
J Am Acad Dermatol
(1988) - et al.
Psoriasis and pregnancy: hormone and immune system interaction
Int J Dermatol
(1996) - et al.
Hormonal effect on psoriasis in pregnancy and post partum
Arch Dermatol
(2005) - et al.
Hormonal influences on women with psoriasis
Cutis
(1998) - et al.
Psoriasis. A questionnaire survey of 2,144 patients
Arch Dermatol
(1968) - et al.
Impetigo herpetiformis in two successive pregnancies
Br J Dermatol
(1966)
Impetigo herpetiformis with lowered serum level of vitamin D and its diminished intestinal absorption
Dermatologica
Impetigo herpetiformis
Dermatologica
Generalized pustular psoriasis
BMJ
Generalized pustular psoriasis. A clinical and epidemiological study of 104 cases
Br J Dermatol
Mechanism of immunosuppression of progesterone on maternal lymphocyte activation during pregnancy
J Immunol
Psoriasis: improvement during and worsening after pregnancy
Br J Dermatol
Cited by (14)
Management of Psoriasis During Preconception, Pregnancy, Postpartum, and Breastfeeding: A Consensus Statement
2021, Actas Dermo-SifiliograficasInflammatory and glandular skin disease in pregnancy
2016, Clinics in DermatologyCitation Excerpt :There are no data on whether urticaria worsens or improves in pregnancy, although anecdotally it has been reported to do both.29,31 Pressure urticaria may be aggravated by pregnancy.32 Urticaria does not affect fertility, fetal development, or delivery.31
Trends in incidence of adult-onset psoriasis over three decades: A population-based study
2009, Journal of the American Academy of DermatologyCitation Excerpt :In a survey conducted among 63 women with psoriasis, half of them reported exacerbation of psoriasis with menopause.33 In contrast to menopause, pregnancy is a state of natural immunomodulation associated with alleviation or exacerbations in the course of various inflammatory diseases, including psoriasis.34,35 Although the increase in female incidence in the sixth decade of life is consistent with previous observations regarding disease course during pregnancy and menopause, the potential role of hormonal factors in etiology of psoriasis in men is currently unknown.
Dermatologic conditions of pregnancy
2008, General DermatologyLocoregional anaesthesia and psoriasis
2007, Annales Francaises d'Anesthesie et de ReanimationDermatoses of pregnancy
2013, Orvosi Hetilap