Rashes of pregnancy

Background

  • First rule out life-threatening causes 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)

Differential Diagnosis

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 [1] but often also affects abdomen
    • Pruritic folliculitis of pregnancy
      • Scattered follicle-based papules & pustules usually start on abdomen
  • Treatment: emolients 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
  • Pruritis 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)

  • Most common pregnancy-specific dermatosis
  • Onset in last weeks of pregnancy
  • Intense pruritis, 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

  • 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

Disposition

See Also

External Links

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

References

  1. 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