Skin symptoms of pregnancy

The cutaneous manifestations of pregnancy are various physiological changes that are an expression of adaptive processes and responses to hormonal influences within the skin and its appendages. The most common cutaneous symptoms of pregnancy include:

• increased sweating
• increased skin tone
• an increase in the thickness of the fat pad, especially on the face (facies acromegalica gravidarum), neck and hips
• faster growth of hair and nails
• hirsutismof pregnancy (hirsutismus gestationis) - the appearance of hair in the face, abdomen and lower abdomen (usually disappears after delivery)
• pigmented lesions:

1. an increase in the amount of pigment in the skin and mucous membranes (dyschromia gravidarum) manifested by increased pigmentation of the white crease, areolae of the nipples, skin of the umbilicus, axillary pits, genital area and blue-violet colouration of vulvar mucous membranes
2. an increase in the skin's sensitivity to sunlight with hyperpigmentation of freckles and pigmented lesions and often, especially on the face, the so-called chloasma gravidarum - irregular yellowish to dark-brown spots ("butterfly", "eyeglasses", "moustache")

• reddening and overgrowth of the gums
• stretch marks during pregnancy (striae gravidarum) resulting from a rapid increase in the circumference of the abdomen, thighs, nipples
• swelling (especially in the second half of pregnancy), especially of the skin on the lower legs and hands, but in the morning can also cover the whole skin in a traceable manner
• enlargement of the superficial veins in the nipples, abdomen, lower legs; tendency to varicoseveins of the lower limbs and anus
• soft fibromas, which often spread on the neck, neck and armpit pits.

Dermatoses in pregnancy, photo panthermedia

Skin diseases modified by pregnancy

The course of many skin diseases that existed before pregnancy undergoes significant changes during pregnancy, in some cases exacerbation, in others significant improvement. Here are some examples:

• acne - most often improves significantly during pregnancy
• alopecia are ata - progression of the disease is halted, often permanent regrowth begins
• vitiligo - generally progress slows down, often repigmentation begins
• condylomata - lesions grow rapidly during pregnancy, sometimes to enormous size
• pigmentedmoles - become more pigmented, often enlarged, there is an increased tendency to malignant transformation of pigmented moles (moles that enlarge or are exposed to irritation should be removed)
• stellate hemangiomas - like nevi they can grow and sometimes become malignant
• psoriasis: the course is difficult to predict: about half of the patients improve, about 20% worsen, the others do not observe any change in the intensity of the course of the psoriasis; in the postpartum period, the vast majority of patients observe worsening
• collagenosis:

1. SLE - if the course is stable, maintained with low doses of steroids, pregnancy does not necessarily induce exacerbations and the woman can give birth to a healthy baby; however, there is a significant risk of congenital lupus in the neonate
2. Scleroderma - if the lesions involve the abdominal integuments, they endanger the normal development of the foetus
3. Dermatomyositis - the course of the disease may worsen during pregnancy.

Dermatoses of pregnancy

These are skin diseases directly related to pregnancy and specific to this period of a woman's life. They include:

• Lichen herpetiformis (impetigo herpetiformis) - a life-threatening maternal and foetal variant of pustular psoriasis occurring in pregnant women. They have psoriasis vulgaris before pregnancy or are clinically healthy. The seeding of sterile pustular lesions on an erythematous-inflammatory base begins in the second or third trimester of pregnancy. The evolution of the lesions is typical of pustular psoriasis. The most characteristic localisation involves all skin folds, the lower abdomen and the inner surface of the thighs, but generalisation of the lesions may also occur. The general condition of the pregnant woman is usually severe, often the skin lesions are accompanied by high fever, headache and arthralgia, nausea and vomiting, diarrhoea, disturbances in calcium (hypocalcaemia leading to tetany symptoms) and phosphorus metabolism, hypoalbuminaemia and oedema. The disease can end in maternal death. There is also an enormous risk of complications for the foetus, including placental failure and intrauterine death. There is often spontaneous improvement after delivery. The disease recurs in each subsequent pregnancy and therefore its occurrence is an absolute contraindication to the next pregnancy.
  
• Herpes gestationis - a blistering dermatosis starting in the second or third trimester of pregnancy, sometimes also in the puerperium. The lesions are initially multiform, erythematous and papular, rapidly progressing to subepidermal, well-circumscribed vesicles and blisters without a tendency to rupture and to meet the lid. The lesions are usually located on the abdomen, thighs and buttocks, sometimes also on the hands, feet and face. They are accompanied by severe pruritus. Immunofluorescence examination reveals the presence of IgG and complement deposits at the dermal-epidermal interface, and serum antibodies to basement membrane (BMOH) are often found. The disease is not life-threatening to the mother and usually resolves by 3 months postpartum. There is an increased tendency to preterm births. The baby is born healthy or with similar changes. In women who have had this dermatosis during pregnancy, subsequent rashes can also be induced by contraceptive pills containing gestagens.
  
• Progesterone autoimmune dermatitis of pregnancy(progesterone dermatitis) - a rare dermatosis developing in the first trimester of pregnancy, often already in the first weeks of pregnancy as a result of a delayed-type immunological reaction to endogenous progesterone (the role of progesterone has been confirmed by skin tests). It is considered one of the most severe pregnancy dermatoses, as it is accompanied by an outstanding propensity for miscarriages and premature births, with a fetal mortality rate approaching 100%. The skin lesions resemble a flare-up of acute acne. They take the form of papules, pustules, often also blackheads, and it is not uncommon for follicular keratosis to coexist. The lesions usually start on the backs of the hands, then extend to the skin of the elbows, knees, buttocks and the proximal surfaces of the thighs, but do not involve the trunk or face. The skin lesions themselves do not cause subjective complaints, but joint pains may occur. Additional examinations reveal high eosinophilia (up to 50% on smear) and increased serum IgG and IgM levels, while skin histopathology reveals eosinophil infiltrates in the epidermis, dermis and subcutaneous tissue. After miscarriage or premature birth, symptoms resolve spontaneously leaving discolouration, and may recur after progesterone-containing medication.

Dermatoses of pregnancy, photo: panthermedia

• Scabies of pregnancy(prurigo gestationis) - a dermatosis of pregnancy occurring most frequently in women prone to atopy. It usually begins in the second trimester of pregnancy (early form), less frequently in the third trimester or shortly before delivery (late form) and recurs in each subsequent pregnancy. The clinical picture is reminiscent of scabies, consisting of erythematous papulopustular eruptions and blisters accompanied by severe pruritus. The lesions predominantly occupy the joint, neck and décolletage areas, but may also become generalised. Intense scratching leads to lichenification, lichenification of papules and scarring. The disease needs to be differentiated from symptomatic scabies.
  
• Dermatitis papulosa gestationis , a dermatosis that can occur at any stage of pregnancy. The lesions are small haemorrhagic papules of several millimetres in size, do not tend to cluster and cause quite severe pruritus. The localisation of the lesions affects the trunk and limbs, sometimes also the face. The eruptions persist for about 10 days, after which they disappear leaving discolouration. General symptoms are absent. It does not pose a risk to the life of the mother or the foetus.
  
• Itchy focal papules and urticaria of pregnancy = PUPPP (pruritic urticarial papules and plaques of pregnancy) (PUP dermatosis, papulae-urticatae-pruritus dermatosis) - a dermatosis of pregnancy with a clinical picture resembling erythema multiforme. The lesions, which take the form of oedematous papules and urticarial erythematous blisters and sometimes also small vesicles, start in the areas affected by the striae of pregnancy (lower abdomen, thighs, nipples) and spread to the trunk and limbs. The face, hands, feet and mucous membranes remain free of lesions. The lesions are accompanied by severe pruritus. Onset occurs in the third trimester of pregnancy, sometimes also shortly after delivery. It more often affects pregnant women with multiple pregnancies. It poses no risk to the foetus.
  
• Itchy pregnancy folliculitis (folliculitis gravidarum) - this is a form of hormonally induced acne. Itchy follicular papules and pustules appear in the second and third trimester of pregnancy. They may be generalised or affect only the abdomen and flanks. They resolve spontaneously while still pregnant or after delivery and rarely recur in subsequent pregnancies. Lesions of lesser intensity may also occur during menstruation. The prognosis is good and the dermatosis also poses no risk to the foetus.
  
• Pruritus gestationis - can be limited or generalised. The onset is usually in the third trimester, but can also occur in the earlier months of pregnancy. Initially, the skin does not show any physical symptoms, then laxity appears as a consequence of intense scratching. Limited pruritus is usually paroxysmal, increases at night and mainly affects the genital area, groin, thighs and lower abdomen. Differential diagnosis should be made for infections (Candida albicans, Trichomonas vaginalis, gonococci), vulvar varicose veins, allergic or allergic-toxic lesions (laundry detergents, bleach, cosmetics, underwear items, etc.). The occurrence of persistent generalised pruritus requires diagnosis for diabetes mellitus, systemic disorders (lymphomas, granulomatosis), intrahepatic cholestasis of pregnancy, renal disease, psychosis. Scabies and lice should be excluded.

Pregnancy and dermatoses, photo: panthermedia

Most of the dermatoses of pregnancy, despite their often protracted and subjectively troublesome course (accompanying pruritus), do not pose a threat to mother and foetus. Antihistamines and external preparations with soothing, anti-inflammatory and antipruritic effects are usually used in the treatment of these conditions. However, the existence of gestational dermatoses with a severe course and a serious prognosis for both mother and foetus should not be overlooked. They require intensive and specialised therapeutic management.