Pregnancy Rash Treatment | Dr Joycelim Dermatologist & Skin Specialist

Pregnancy Rash

During pregnancy, there are changes in the skin. These changes can be classified into 3 main groups

Physiological skin changes (due to changes in hormones during pregnancy)
Pre-existing skin conditions that change during pregnancy
Pregnancy specific skin rash

1. Physiological skin changes in pregnancy which includes

Stretch marks
Pigmentation
Hair and nail changes
Vascular changes
Skin growths

Stretch marks in pregnancy (Striae Gravidarum)

Seen in up to 90% of pregnant women
Extremely common in the second or third trimester
Appear as pink or purple lines or bands which later become white
Seen on the abdomen, buttocks, breasts, thighs or arms
More commonly seen in
- Younger women
- Women with larger babies
- Women with higher body mass
- Women with history of breast or thigh striae
- Family history of striae gravidarum

Causes of Stretch marks in pregnancy (Striae Gravidarum)

Causes are multifactorial and include stretching, weight gain and hormonal factors

Treatment of stretch marks in pregnancy (Striae Gravidarum)

Prescription creams
Lasers to improve the appearance
- Pulse dye laser V beam: reduces red stretch marks and releases growth factors to smooth out the breaks in the skin
- Ablative and non-ablative Laser resurfacing: Fraxel Dual, YouLaser MT, ADVATx
Jet volumetric remodelling (Enerjet)
Thermo-mechanical remodelling (Tixel Pro 2.0)
Fractional radiofrequency
Dermal filler injection, Profhilo
Ultherapy
Skin Infusion

Pigmentation in Pregnancy

There is a generalized increase in skin pigmentation during pregnancy. This is more obvious in darker skin women. Increased pigmentation is seen in the nipples, areolae, genital areas and midline of the abdominal wall (linea nigra). This pigmentation usually fades after delivery

Melasma in Pregnancy (Mask of Pregnancy)

Melasma can occur for the first time during pregnancy or pre-existing melasma may worsen during pregnancy. After delivery melasma may lighten but it often persists after pregnancy

Treatment of melasma in pregnancy

Broad-spectrum sunscreen plus blue light filters
Sun avoidance such as wearing hats, shades and UV clothing
Prescription creams
Chemical peels
Laser treatments- usually perform postpartum

Hair and nail changes in pregnancy

During pregnancy there is some degree of increased hair growth on the face, limbs and back. This resolves postpartum
There is mild thickening of scalp hair due to prolonged anagen phase of hair growth in pregnancy. Postpartum there is increased shedding (telogen effluvium)
Nails grow faster during pregnancy. There may be increase brittleness, transverse grooves, onycholysis and subungual keratosis. The nail changes resolve postpartum.

Vascular changes during pregnancy

Vascular changes occur in the third trimester and usually improve or cleared after delivery. They include

Edema
Varicose veins in the legs and hemorrhoids
Spider angiomas and spider veins are common
Redness of the palm

Treatment of vascular changes

Sclerotherapy
Laser treatment: Pulse dye V beam laser, Excel V Nd-YAG laser, ADVATx laser

Skin growths during pregnancy

Most of these are benign growths and include vascular and non-vascular growths

Skin tags
Moles may increase in numbers or size
Pyogenic granuloma
Angioma

Treatment of skin growths postpartum

Surgery
Laser removal
Cryosurgery
Electrodesiccation
Incision

2. Pre-existing skin conditions that change during pregnancy

Acne during pregnancy

Acne may worsen during the third trimester as maternal androgens increased
Treatment is the same as in non-pregnant women except that oral medication is not allowed
Chemical peels and LED light treatments are safe in pregnancy

Eczema during pregnancy

Often eczema may worsen during pregnancy
Treatment includes topical steroids and moisturisers

Safety of topical steroid in pregnancy

Maternal use of topical steroid is safe. There is no association of any potency of steroid with mode of delivery, birth defects, preterm delivery, fetal death and low Apgar score (JAMA Derm Clinical Evidence Synopsis Cc Chi, et al)
Very potent topical steroids in large accumulative dose is associated with low birth weight

3. Pregnancy specific skin rash (Pregnancy Dermatosis)

There are 4 pregnancy-specific skin rash and they are

Atopic Eruption of Pregnancy (AEP): most frequent
Polymorphic Eruption of Pregnancy (PEP)
Pemphigoid gestationis (PG)
Intrahepatic Cholestasis of Pregnancy (ICP): most important

1. Atopic Eruption of Pregnancy (AEP)

Previously known as

Prurigo of pregnancy
Pruritic folliculitis of pregnancy

The most common skin rash in pregnancy (50%)

Occurs early, 75% before the third trimester
Often seen in primipara (44%)
Common in single pregnancies (99%)
Patients may have atopic background, in which there is a tendency to recur in subsequent pregnancies
- In 20% there is an exacerbation of pre-existing atopic eczema
- 80% may experience atopic skin changes for the first time ever or after a long remission (for example since childhood)
Up to 70% of patients have elevated serum Ig E levels

Clinical features of Atopic Eruption of Pregnancy (AEP)

2/3 will have widespread eczematous changes in the face, neck, flexure (E-Type AEP)

1/3 will have papules or prurigo on the trunk and limbs (P-type AEP)

Course and prognosis of Atopic Eruption of Pregnancy (AEP)

Maternal: good prognosis, but recurrence in subsequent pregnancies is common
Fetal: no risk. The infant may have a higher risk of developing atopic dermatitis

Treatment of Atopic Eruption of Pregnancy (AEP)

Topical steroids
Moisturisers
Oral antihistamine
Topical anti-itch medication. Menthol is safe
Phototherapy
A short course of systemic steroids in some
Close monitoring for superimposed bacterial infections

2. Polymorphic Eruption of Pregnancy (PEP)

Also known as:

Pruritic urticarial papules and plaques of pregnancy (PUPPP)
Toxic erythema of pregnancy
Late-onset prurigo of pregnancy

Cause of Polymorphic Eruption of Pregnancy (PEP)

Cause often unknown
It May be caused by increased abdominal distension or Maternal-fetal cells immune system

Clinical features of Polymorphic Eruption of Pregnancy (PEP)

It is the 2^nd commonest pregnancy-specific skin rash
Occurs in 1:160 deliveries
Seen predominantly in primigravidae
Develops in the third trimester
There are some risk factors such as
- Excessive maternal weight gain
- Multiple pregnancies
- A family history
Characteristics of Polymorphic Eruption of Pregnancy (PEP)
- Red and intensely itchy rash
- Often begin in the stretch marks
- Not seen in the umbilicus
- The face is not affected
- Take various forms (polymorphic) such as hives, bumps, red papules or patches, blisters

Course and prognosis of Polymorphic Eruption of Pregnancy (PEP)

Maternal: good, rash resolves 1-2 weeks after delivery
Fetal: no risk

Treatment of Polymorphic Eruption of Pregnancy (PEP)

No specific treatment
Oral antihistamines
Topical corticosteroids for the itch
Oral corticosteroids for severe rash

3. Pemphigoid gestationis (PG)

This is an autoimmune skin disorder
Affects 1:20,000-50,000 pregnancies
Onset in the 2^nd and 3^rd trimester but may arise at any stage during pregnancy
The rash takes a variable course
- It generally improves in late pregnancy
- It resolves after pregnancy
- Or it may get worse in the immediate postpartum period

Clinical features of Pemphigoid Gestationis (PG)

The rash is itchy
The rash looks like grouped or annular rings of red papules, plaques or blisters
The rash affects mainly the abdomen including the umbilicus but may be generalised

Course and prognosis of Pemphigoid Gestationis (PG)

Maternal

It can recur with menstruation and with oral contraceptives
It can recur in subsequent pregnancies
In subsequent pregnancies, symptoms become more serious and develop earlier

Fetal

5 – 10 % of new-borns will develop a blistering rash due to the mother’s antibodies crossing the placenta. The rash is temporary, lasting 6 weeks
Mild placental failure has been associated
Associated with premature deliveries
Newborns are small for gestational age

Treatment of Pemphigoid Gestationis (PG)

Relieve itching with antihistamine
Prevent blister formation with topical or oral steroids
In severe patients, immunosuppression may be needed
Secondary infection is treated

4. Intrahepatic Cholestasis of Pregnancy (ICP)

Also known as

Pruritus Gravidarum
Obstetic cholestasis

Affects 0.02-2.4 % of pregnancy

There is often a family history

Clinical features of Intrahepatic Cholestasis of Pregnancy (ICP)

Unexplained itch during the second or third trimester
Itch felt in the abdomen, the palms and soles or may be widespread
There is no primary skin rash
Excoriations to severe itch bumps may be seen
Jaundice occurs in 10% of patients and is often mild

Course and prognosis of Intrahepatic Cholestasis of Pregnancy (ICP)