What skin diseases occur during pregnancy and how to treat them

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Skin diseases during pregnancy

The content of the article

Types and reasons for changes:

1. Dark spots
   . Due to an increase in the level of pigment - melanin, dark spots appear on the skin.
2. Melasma
   . A form of hyperpigmentation, also known as "mask of pregnancy".
3. Stretch marks
   . They can appear by the third trimester and sometimes remain for life.
4. Pimples.
   Even those with clear skin can develop acne during pregnancy, but some forms of treatment for this problem should be avoided by using medications prescribed exclusively by a gynecologist.
5. Phlebeurysm
   . Pathology can develop, but varicose veins often go away after childbirth.

What is acne?

The term “acne” often refers to diseases of different nature. Most often we are talking about acne (common acne). Acne can manifest itself with a variety of elements, both inflammatory and non-inflammatory.

Non-inflammatory elements include:

• Open comedones, commonly referred to as “blackheads.” The appearance of comedones is caused by stagnation of sebum in the pores, the formation of “sebaceous plugs”. When exposed to air, sebum oxidizes and the pigment melanin is formed, which gives a dark color to the contents of the pores.
• Closed comedones (milliums) resemble white subcutaneous nodules. This is an accumulation of sebum in a pore that is not in contact with oxygen.

The inflammatory elements of acne are:

• Papules are small red nodules that protrude above the surface of the skin.
• Pustules are cavities with purulent contents, in the center of each of which there is a hair.
• Nodules are a complex form of acne that has a chronic course.

Blackheads are large, deep, painful, purplish-red lesions.

Hyperpigmentation

This is the appearance of dark spots on the face or other parts of the body. The phenomenon is caused by an increase in melanin production and goes away after childbirth, but can persist for several years.

An example of hyperpigmentation during pregnancy is melasma, known as “mask of pregnancy,” which is characterized by brown patches on the face, cheeks, nose, and forehead. To solve this problem, you need to consult a dermatologist.

To reduce stains, it is recommended to follow simple rules:

• limit your stay on the street during the period of solar activity from 10:00 to 14:00;
• in hot weather, use sunscreen with a factor of 30 or higher;
• wear a wide-brimmed hat.

Inflammation and itching

Itchy papules and plaques cause significant itching, burning or tingling. They vary in size and location. Most often the rash occurs on the stomach, legs, arms, chest or buttocks. They go away after childbirth.

Antihistamines or topical corticosteroids are used to treat inflammation and itching. In everyday life, it is necessary to use warm water when washing, apply cool compresses, wear loose and light clothing and avoid getting soap on skin that has rashes and age spots.

All medications are prescribed by a dermatologist, but they can be taken only after consultation with a gynecologist.

Will my breasts continue to grow?

Yes, breasts grow at the same intensity in the second trimester due to an increase in the volume of the mammary glands and fat deposition. It is these changes that prepare the expectant mother for feeding her baby.

The skin on and around the nipples will become darker. A woman may notice the appearance of peculiar tubercles around her nipples. These are glands that secrete a special substance that prevents the skin of the nipples from drying out.

A yellowish liquid may also begin to be released - an intermediate form of milk (colostrum), which plays an important role in the first days of the baby’s life. Having a laxative property, colostrum helps the newborn get rid of meconium (original feces), which consists of epithelial cells, prenatal hair, mucus, amniotic fluid, bile and water digested in the prenatal period.

Pimples

During pregnancy, hormonal changes occur that lead to acne. There are many ways to treat this problem.

It is necessary to follow general hygiene rules, such as washing your face with warm water and a mild product twice a day, treating the skin with non-aggressive products to prevent clogged pores.

During this period, you can use drugs that include benzoyl peroxide or salicylic, azelaic or glycolic acids.

During pregnancy it is prohibited:

1. Carry out hormonal therapy
   due to the increased risk of congenital pathologies of the fetus;
2. Use Isotretinoin
   (a form of vitamin A, also known as Retinol). This can lead to disturbances in the mental and physical development of the unborn child.
3. Use Tetracycline
   because it affects the formation of the fetal bone skeleton.

Sebaceous glands: great dryness

While you are carrying a baby under your heart, the body is actively stocking up on estrogens, which are responsible for the normal course of pregnancy.

And these hormones inhibit the work of the sebaceous glands, which begin to become lazy and produce less secretion. If your skin is naturally oily or problematic, consider yourself lucky, because at least for the next nine months, you can finally forget about greasy shine and annoying pimples. But if you have dry or normal skin, then the period of waiting for the baby will present several unpleasant surprises. The epidermis will become drier, peeling, itching and even allergic rashes may appear on it.

If your skin begins to peel, forget about alcohol lotions and under no circumstances try to remove dead particles with a scrub. This may have the opposite effect. For daily care, use a moisturizer and make nourishing masks every two weeks. Be sure to buy a humidifier or at least regularly wet clean your home. During the heating season, the air in the apartment becomes very dry and unceremoniously draws moisture from already dehydrated skin.

Vein changes

Varicose veins often develop during pregnancy.

Spider veins are small red vessels that most often appear on the face, neck and arms. These skin changes occur due to changing hormones and increased stress on the legs, vagina and rectum. They go away after childbirth.

To minimize the risk of developing pathology and alleviate symptoms, you need to take the following precautions:

• do not sit or stand for a long time, combine feasible physical activity with rest;
• spread your legs when forced to sit for a long time;
• Perform seated leg raises whenever possible;
• consult with your doctor to select a set of physical exercises to prevent blood stagnation in the vessels;
• monitor digestion, avoiding constipation.

There are three main categories of pregnancy-related skin conditions: (1) benign skin conditions caused by natural hormonal changes, (2) pre-existing skin conditions whose course changes during pregnancy, and (3) pregnancy-specific dermatoses. In some cases, these categories may overlap.

KEY RECOMMENDATIONS FOR PRACTICAL APPLICATION

Benign skin diseases

Skin conditions caused by natural hormonal changes during pregnancy include striae gravidarum, hyperpigmentation, and changes in hair, nails, and blood vessels.

STRIPS IN PREGNANT

Striae gravidarum (stretch marks) occur in 90 percent of pregnant women by the third trimester (Figure 1) (1, 2). Striae appear as pink-purple atrophic lines or stripes on the abdomen, buttocks, breasts, thighs, or arms. They are more common in young women, women with large pregnancies, and women with higher body weights (3).

Women with dark skin who have a history of stretch marks on the chest or thighs, or a family history of stretch marks of pregnancy, are also at higher risk (4).

The cause of striae is multifactorial and includes physical factors (eg, actual stretching of the skin) and hormonal factors (eg, the effect of adrenal hormones, estrogen and relaxin on the elastin fibers of the dermis).

Numerous creams, emollients, and oils (eg, vitamin E cream, cocoa butter, aloe vera lotion, olive oil) are used to prevent stretch marks; however, there is no evidence that these treatments are effective. Limited evidence suggests that two topical medications may help prevent striae (5).

One contains Centella Asiatica extract plus alpha-tocopherol and collagen and elastin hydrolysates. Another product contains tocopherol, essential fatty acids, panthenol, hyaluronic acid, elastin and menthol.

However, none of these drugs are widely available, and the safety of using centella asiatica during pregnancy and the components responsible for their effectiveness are unclear (6).

Further research is needed before these treatments and commonly used creams and emollients can be recommended for widespread use.

Most stretch marks regress to pale or flesh-colored lines and improve after childbirth, although they usually do not disappear completely. Treatment is nonspecific and there is a limited evidence base.

Postpartum treatment includes topical tretinoin therapy (Retin-A) or oral tretinoin therapy (Vesanoid) (U.S. Food and Drug Administration pregnancy categories C and D, respectively; safety unknown in breastfeeding women) and laser therapy (585 nm, pulsed dye laser) (7, 8).

HYPERPIGMENTATION

Almost all women experience some form of hyperpigmentation during pregnancy. These changes are usually more pronounced in women with darker skin.

The areas most commonly affected are the nipple areola, armpits, and genitals, although scars and nevi may also become pigmented. The linea nigra is a line that often forms when the linea alba darkens during pregnancy.

Melasma (chloasma or mask of pregnancy) may be the most cosmetically problematic skin condition associated with pregnancy (Figure 2). Up to 70 percent of pregnant women have this condition (1), and it can also occur in women taking oral contraceptives.

Exposure to sunlight and other types of ultraviolet radiation worsens melasma; Therefore, using highly effective broad-spectrum sunscreens (against UVA and UVA) and avoiding overexposure to sunlight may prevent the development or worsening of melasma (1, 2).

Although no specific treatment is prescribed during pregnancy, doctors can reassure patients that melasma in most cases goes away after childbirth. However, it may not resolve completely and may recur in future pregnancies or with the use of oral contraceptives (1, 2).

Severe postpartum epidermal melasma is usually treated with combinations of topical tretinoin, hydroquinone (Eldoquin Forte), and corticosteroids (9, 10).

CHANGES IN HAIR AND NAILS

An increase or decrease in hair growth is common during pregnancy (1, 2, 11). Many women have manifestations of hirsutism on the face, limbs and back, caused by endocrine changes during pregnancy.

Hirsutism usually resolves after childbirth, although cosmetic correction may be considered if the condition persists. Pregnant women may also notice a slight thickening of the hair on their scalp. This is caused by the prolonged active (anagen) phase of hair growth.

After childbirth, scalp hair enters a long resting phase (telogen) of hair growth and increased shedding (telogen hair loss) occurs, which can continue for several months or more than a year after pregnancy (12).

A few women prone to androgenetic alopecia may notice frontoparietal hair loss, which may not go away after pregnancy.

Nails usually grow faster during pregnancy. Pregnant women may experience increased fragility, transverse grooves, onycholysis, and subungual hyperkeratosis (1, 2, 11). Most of these conditions resolve after delivery, and doctors can explain this to patients and recommend adequate nail care.

VASCULAR CHANGES

Natural changes in estrogen production during pregnancy can cause dilation, instability, proliferation, and blockage of blood vessels. Most of these vascular changes resolve after delivery (1).

Spider telangiectasias (spider nevi or spider angiomas) occur in approximately two-thirds of pregnant women with light skin phototypes and 10 percent of pregnant women with dark skin phototypes, mainly on the face, neck and arms. This condition most often occurs in the first and second trimesters of pregnancy (1, 2, 11).

Palmar erythema occurs in approximately two thirds of pregnant women with light skin phototypes and up to one third of pregnant women with dark skin phototypes. Subcutaneous, vulvar, or hemorrhoidal varicose veins occur in approximately 40 percent of pregnant women (1, 2, 11).

Vascular changes combined with increased blood volume can cause increased “outflow,” leading to persistent swelling of the face, eyelids, and extremities in up to half of pregnant women (1, 11).

Increased blood flow and pelvic vascular instability can cause vaginal erythema (Chadwick's sign) and a bluish discoloration of the cervix (Goodell's sign) (1).

Vasomotor disturbances can also cause facial flushing; dermatographism; sensations of heat and cold; and manifestations of marbled skin, a condition characterized by a bluish tint to the skin due to an excessive reaction to cold (2).

All pregnant women experience hyperemia and swelling of the gums, which can cause gingivitis and bleeding, especially in the third trimester (1, 11).

Pyogenic granulomas may appear late in the first trimester or in the second trimester as dark red or purple nodules on the gums or, less commonly, on other areas of the skin.

In most patients, observation is advisable because these lesions usually regress after delivery. However, if bleeding occurs, surgical treatment and possible excision may be indicated (1, 2, 11).

Previously existing skin diseases

Pre-existing skin conditions (eg, atopic dermatitis; psoriasis; candidiasis and other fungal infections; skin tumors, including malignant melanoma) may change during pregnancy.

Atopic dermatitis and psoriasis may worsen or improve during pregnancy. Atopic eruptions may be associated with prurigo gravidarum and usually worsen over time but may improve during pregnancy (13).

Psoriasis often improves as it progresses. Fungal infections usually require a longer course of treatment during pregnancy (14).

Soft tissue fibroids can occur on the face, neck, upper chest, and under the breasts during late pregnancy. These fibroids usually disappear after childbirth (1).

The impact of pregnancy on the development and prognosis of malignant melanoma has been widely debated; however, a recent retrospective cohort study of pregnant women with melanoma provided no evidence that pregnancy affects survival (16).

Dermatological diseases typical for pregnant women

True dermatoses of pregnancy (Table 1) (17, 23) include pruritic urticarial papules and plaques of pregnancy (PUPPP), pruritus of pregnancy, intrahepatic cholestasis of pregnancy, pemphigoid of pregnancy, impetigo herpetiformis, and pruritic folliculitis of pregnancy.

TABLE 1 . Dermatological diseases characteristic of pregnancy

PUPPP

PUPPP (Figure 3) is the most common pregnancy-specific dermatosis, occurring in one in 130–300 pregnant women (1).

The PUPPP-associated rash, characterized by intense itching, develops in the third trimester and usually appears first on the abdomen, often along stretch marks (17).

This disorder is more common in first pregnancies and multiple pregnancies, and familial cases have also been reported (18).

Despite its frequency, the etiology of PUPPP remains unclear. A relationship has been suggested between this disease and disturbances in the interaction between the maternal immune system and fetal tissues (24).

The increased incidence in women with multiple pregnancies suggests that skin stretching may play a role in triggering an immune-mediated reaction. Histopathological findings are nonspecific (18).

There is no specific treatment for PUPPP and it is not associated with adverse pregnancy outcomes.

Antihistamines and topical steroids can be used to treat itching, and systemic corticosteroids can be used for severe itching (18). The rash usually goes away within one to two weeks after delivery.

Prurigo of pregnant women

Prurigo in pregnancy (Fig. 4.) occurs in approximately one in 300 pregnant women and is recorded in all trimesters (1). It is not uncommon for a pregnant woman to experience prolonged itching that persists for weeks or months after giving birth (1).

The cause of this disease is unclear, and there are no significant adverse effects on the mother or fetus. An association with intrahepatic cholestasis during pregnancy or a history of atopy has been suggested (18). Mild-strength topical steroids and oral antihistamines may provide symptomatic relief.

INTRAHEPATIC CHOLESTASIS IN PREGNANCY

Intrahepatic cholestasis of pregnancy has historically been called pruritus of pregnancy because its classic presentation is severe itching in the third trimester. Intrahepatic cholestasis of pregnancy occurs in one in 146 to 1293 pregnant women in the United States (1).

The diagnosis is based on the clinical picture and history: itching with or without jaundice, the absence of primary elements of a skin rash and laboratory markers of cholestasis. This condition usually resolves after childbirth (1, 18, 19).

Laboratory markers include elevated serum bile acid levels (4.08 μg per mL [10 μmol per L] or more) and alkaline phosphatase levels with or without elevated bilirubin levels (25).

However, alkaline phosphatase levels are typically elevated in pregnant women, limiting the value of this test (19).

Aspartate aminotransferase and alanaminotransferase levels and other liver function tests may be slightly altered. Cholestasis and jaundice in patients with severe or prolonged intrahepatic cholestasis during pregnancy may cause vitamin K deficiency and coagulopathy (18).

The etiology of intrahepatic cholestasis during pregnancy remains controversial. Family history of the disease is common, and there is an association with the presence of human leukocyte antigen-A31 (HLA-A31) and HLA-B8 (1, 18).

This condition tends to recur in subsequent pregnancies (1). Patients may have a family history of gallstone disease and a higher risk of gallstone formation (25, 26).

This condition is associated with a higher risk of preterm birth and rupture of meconium-stained fluid and fetal death.

A prospective cohort study demonstrated a correlation between bile acid levels and fetal complications, with a statistically significant increase in adverse fetal outcomes reported in patients with bile acid levels of 16.34 μg per mL (40 μmol per L) or more (25).

For patients with mild itching, oral antihistamines may be prescribed. Patients with more severe cases require ursodeoxycholic acid (ursodiol [Actigall]) to relieve pruritus and reduce cholestasis while reducing the risk of adverse fetal outcomes (18, 27).

Current data do not support the effectiveness of therapy with S-adenosylmethionine, anion exchange resins (eg, cholestyramine [Questran]), or corticosteroids (18, 28).

Patients should undergo in-depth prenatal care at diagnosis, and some recommendations recommend delivery before 38 weeks of pregnancy. The effect of early delivery on perinatal complications has not been proven (29).

PEMPHIGOID IN PREGNANT

Gestational pemphigoid (Figure 5), sometimes called gestational herpes, is an autoimmune skin disease that occurs in one in 50,000 mid- to late-term pregnancies (20).

Pemphigoid gravidarum is associated with the presence of HLA-DR3 and HLA-DR4 and is rarely associated with molar pregnancy and choriocarcinoma (18, 21). Patients with a history of this disease have an increased risk of other autoimmune diseases (eg, Graves' disease) (30).

The disease can occur in different ways, although its course usually improves in late pregnancy with exacerbations in the immediate postpartum period. Exacerbations have been associated with oral contraceptive use and are common in subsequent pregnancies (18).

Immunodiagnostic studies reveal characteristic deposits of complement C3 along the dermoepidermal junction (30). The risk to the fetus has not been confirmed, although immunoglobulin G autoantibodies cross the placenta, and 5 to 10 percent of newborns have urticarial, vesicular, or bullous lesions (30).

Mild placental insufficiency has been associated with preterm birth and small gestational age neonates. Therefore, antenatal care should be considered (22).

Patients with mild forms of pemphigoid of pregnancy may respond to oral antihistamines and systemic topical corticosteroids, while patients with more severe symptoms may require oral corticosteroids.

HERPETIFORM IMPETIGO

Impetigo herpetiformis (Figure 6), a form of pustular psoriasis, is a rare skin disease that appears in the second half of pregnancy. Whether this disorder is specific to pregnancy or simply exacerbated by it remains controversial (1).

Systemic signs and symptoms of impetigo herpetiformis include nausea, vomiting, diarrhea, fever, chills, and lymphadenopathy. There is usually no itching. Complications (eg, secondary infection, septicemia, hyperparathyroidism with hypocalcemia, hypoalbuminemia) may occur (1).

Treatment of impetigo herpetiformis includes systemic corticosteroids and antibiotics to treat secondary infected lesions. Prednisolone may be required at a dose of 15 to 30 mg to 50 to 60 mg per day, followed by a slow dose reduction (1, 22, 23).

The disease usually resolves after childbirth, although it may recur during subsequent pregnancies. The degree of risk to the fetus is somewhat controversial; however, an increase in fetal morbidity has been reported, suggesting the need for increased prenatal care (22).

ITCHY FOLLICULITIS OF PREGNANCY

Pruritic folliculitis of pregnancy occurs in the second and third trimesters and manifests as erythematous follicular papules and sterile pustules.

Contrary to its name, itching is not the main symptom. Spontaneous resolution occurs after childbirth. This condition is likely underdiagnosed because it is often misdiagnosed as bacterial folliculitis (18).

The etiology of pruritic folliculitis of pregnancy is unclear, and there are no reports of adverse fetal outcomes clearly associated with this condition. Treatment includes topical corticosteroids, topical benzoyl peroxide (Benzac), and ultraviolet B therapy (1).

Other skin diseases in pregnant women

Less common skin conditions during pregnancy are pemphigoid rash and intrahepatic cholestasis.

• Gestational pemphigoid rash
  is an autoimmune disease that appears in the second or third trimester or after childbirth. Symptoms of this condition include blisters on the abdomen or other parts of the body. Increases the risk of premature birth or having a low birth weight baby.
• Intrahepatic cholestasis of pregnancy
  is a liver condition that appears in the third trimester. It is characterized by severe itching on the palms of the hands, soles of the feet or torso, and occurs without a rash.

If unusual sensations on the skin, itching or rashes appear, you should consult a doctor to find out the cause of the phenomenon and begin treatment on time.

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Acne: ellipsis

In the second trimester of pregnancy, many mothers sadly notice that uninvited guests have appeared on their faces - acne. Even those who previously did not have such problems at all or they happily disappeared along with adolescence are not immune from this trouble. This is due to the increased concentration of testosterone. This male hormone awakens the sebaceous glands from the hibernation into which estrogens plunge them and forces them to work for wear, producing a shock portion of fatty lubricant. Mixing with dust and bacteria living on the skin, the explosive mixture clogs the pores, and nasty pimples crawl to the surface. You need to fight acne with soft cleansing cosmetics that do not contain soap and alcohol. During the day, it is useful to wipe problem skin with antibacterial wipes. But under no circumstances buy remedies for teenage acne: in your situation, they are unsafe and can negatively affect the future toddler, especially if you use them in the first trimester, when the formation of the baby’s vital systems and organs occurs.