Rashes of pregnancy: Difference between revisions

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==Background==
==Background==
*First rule out life-threatening causes such as [[Stevens-Johnson syndrome and toxic epidermal necrolysis|SJS or TEN]]
*First rule out life-threatening causes of [[rash]] such as [[Stevens-Johnson syndrome and toxic epidermal necrolysis|SJS or TEN]]
*Multiple pruritic rashes associated with [[Pregnancy (main)|pregnancy]] including:
*Multiple pruritic rashes associated with [[Pregnancy (main)|pregnancy]] including:
**Atopic eruption of pregnancy  
**Atopic eruption of pregnancy  
**Intrahepatic cholestasis of pregnancy
**Intrahepatic [[cholestasis of pregnancy]]
**Pemphigoid gestationis
**Pemphigoid gestationis
**Pruritic urticarial papules and plaques of pregnancy (PUPPP)
**Pruritic urticarial papules and plaques of pregnancy (PUPPP)
**Pustular psoriasis of pregnancy (previously Impetigo herpetiformis)
**Pustular [[psoriasis]] of pregnancy (previously Impetigo herpetiformis)
*Non-pathologic skin changes in pregnancy:
*Non-pathologic skin changes in pregnancy:
**Melasma (facial rash)
**Melasma (facial rash)
**Hyperpigmented Linea Alba
**Hyperpigmented Linea Alba
**Striae gravidarum (stretch marks)
**Striae gravidarum (stretch marks)
{{Rash red flags}}


==Differential Diagnosis==
==Differential Diagnosis==
[[File:Melasmablemish.jpg|thumb|Melasma: pigment changes to the face due to pregnancy.]]
[[File:Linea nigra.jpg|thumb|Linea nigra in a woman at 22 weeks pregnant.]]
===Atopic eruption of pregnancy===
===Atopic eruption of pregnancy===
*Onset usually 1st/2nd trimester
*Onset usually 1st/2nd trimester
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**Pruritic folliculitis of pregnancy
**Pruritic folliculitis of pregnancy
***Scattered follicle-based papules & pustules usually start on abdomen
***Scattered follicle-based papules & pustules usually start on abdomen
*Treatment: emolients and topical corticosteroids
*Treatment: emollients and topical corticosteroids
*No known risk to fetus
*No known risk to fetus


===Intrahepatic cholestasis of pregnancy===
===Intrahepatic [[cholestasis of pregnancy]]===
*Onset in 2nd/3rd trimesters
*Onset in 2nd/3rd trimesters
*LFT abnormalities
*[[LFTs|LFT]] abnormalities
*Rash non-specific but often pruritis of hands/feet
*Rash non-specific but often pruritis of hands/feet
*Pruritis distinguishes it from [[HELLP syndrome]]
*[[Pruritus]] distinguishes it from [[HELLP syndrome]]
*Treatment: consider starting [[ursodiol]] in consultation with OB/GYN
*Treatment: consider starting [[ursodiol]] in consultation with OB/GYN
*Risk to fetus: prematurity, neonatal respiratory distress
*Risk to fetus: prematurity, neonatal respiratory distress


===Pruritic urticarial papules and plaques of pregnancy (PUPPP)===
===Pruritic urticarial papules and plaques of pregnancy (PUPPP)===
[[File:PUPPP 2007-05-06 front2.jpg|thumb|PUPPP on gravid abdomen.]]
[[File:PUPPP 2007-05-06 left.jpg|thumb|PUPPP on gravid abdomen.]]
*Most common pregnancy-specific dermatosis
*Most common pregnancy-specific dermatosis
*Onset in last weeks of pregnancy
*Onset in last weeks of pregnancy
*Intense pruritis, often associated with striae
*Intense pruritus, often associated with striae
*Rash usually begins on abdomen
*Rash usually begins on abdomen
*Treat with mid- to high-potency [[Topical steroids|topical steroids]] (e.g. Betamethasone or Triamcinolone)
*Treat with mid- to high-potency [[Topical steroids|topical steroids]] (e.g. Betamethasone or Triamcinolone)
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*Autoimmune disorder
*Autoimmune disorder
*Onset: 2nd/3rd trimester
*Onset: 2nd/3rd trimester
*Rash: pruritic papules and vesicles with bullae, usually starts periumbilical
*[[Rash]]: pruritic papules and vesicles with bullae, usually starts periumbilical
*Treatment: High-potenecy [[Topical steroids|topical steroids]] +/- prednisone (0.5mg/kg/day) and oral antihistamines
*Treatment: High-potenecy [[Topical steroids|topical steroids]] +/- prednisone (0.5mg/kg/day) and oral antihistamines
*Risk: fetal prematurity
*Risk: fetal prematurity


===Pustular Psoriasis of Pregnancy===
===Pustular Psoriasis of Pregnancy===
[[File:Psoriasis manum.jpg|thumb|Severe pustular psoriasis.]]
*Onset: 3rd trimester
*Onset: 3rd trimester
*Rash: painful pustules, usually start on thighs
*[[Rash]]: painful pustules, usually start on thighs
*Management: admit to OB/GYN for fetal monitoring
*Management: admit to OB/GYN for fetal monitoring
*Risk: fetal morbidity
*Risk: fetal morbidity
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*CBC
*CBC
*Electrolytes
*Electrolytes
*LFTs
*[[LFTs]]


==Management==
==Management==
*Based on suspected condition


==Disposition==
==Disposition==
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[[Category:Dermatology]]
[[Category:Dermatology]]
[[Category:OBGYN]]
[[Category:OBGYN]]
[[Category:Symptoms]]

Latest revision as of 20:30, 17 March 2021

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[1]

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 [2] 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

Disposition

See Also

External Links

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

References

  1. ↑ Nguyen T and Freedman J. Dermatologic Emergencies: Diagnosing and Managing Life-Threatening Rashes. Emergency Medicine Practice. September 2002 volume 4 no 9.
  2. ↑ Tunzi, Marc et al, "Common Skin Conditions During Pregnancy" Am Fam Physician. 2007 Jan 15;75(2):211-218. http://www.aafp.org/afp/2007/0115/p211.html
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