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Dermatoses of pregnancy are a heterogeneous and distinct group of skin disorders that are specific to the pregnancy and postpartum periods. These dermatoses result from the interaction of multiple factors within the body and skin during pregnancy and include pemphigoid gestationis, polymorphic eruption of pregnancy, intrahepatic cholestasis of pregnancy, pustular psoriasis of pregnancy, and atopic eruption of pregnancy. This activity reviews the evaluation and management of pregnancy-specific dermatoses, including key clinical features, diagnostic approaches, and treatment strategies. This activity provides insight into the maternal and fetal implications of these conditions, particularly severe pruritus and potential pregnancy complications. This activity also highlights the role of the interprofessional healthcare team in managing these conditions and emphasizes accurate recognition and differentiation of pregnancy-related dermatoses in patients with skin of color. With a focus on distressing symptoms, particularly severe pruritus, this activity emphasizes a holistic approach to the physiological and cutaneous changes during pregnancy. Objectives: Identify the common physiological skin changes of pregnancy and distinguish them from pregnancy-specific dermatoses. Differentiate among pemphigoid gestationis, polymorphic eruption of pregnancy, intrahepatic cholestasis of pregnancy, atopic eruption of pregnancy, and pustular psoriasis of pregnancy based on clinical presentation. Implement evidence-based treatment, monitoring, and follow-up for dermatoses of pregnancy while considering gestational stage and potential implications for maternal and fetal well-being. Collaborate with the interprofessional healthcare team to provide multidisciplinary care, improve maternal comfort, reduce complications, and optimize fetal outcomes. Access free multiple choice questions on this topic.

Three main factors contribute to the skin changes commonly observed during pregnancy: increased hormone levels, intravascular volume expansion, and compression of the skin by the growing uterus. Melasma, venous congestion, varicosities, spider telangiectasias, palmar erythema, cutis marmorata, acrochordons, and striae are common skin changes observed during pregnancy.[1] In addition to these normal changes, several pathological dermatoses are specific to pregnancy. These specific skin conditions may occur during pregnancy or the postpartum period and range from benign, transient conditions to more severe, chronic diseases.[2] These dermatological manifestations can cause significant discomfort and distress, and pose potential risks to both the mother and the developing fetus. The dermatoses specific to pregnancy include: Pemphigoid gestationis Polymorphic eruption of pregnancy Intrahepatic cholestasis of pregnancy Atopic eruption of pregnancy Pustular psoriasis of pregnancy [3]

Pemphigoid Gestationis Pemphigoid gestationis involves the formation of autoantibodies against bullous pemphigoid antigens BP180 and BP230.[4] The disease process is believed to originate within the placenta, where abnormal antigen expression triggers a maternal immune response. This stimulates maternal antibody production to the abnormal placental antigens. These antibodies bind not only to the placental antigen but also to the antigen in the basement membrane of the skin. The inflammatory cascade in the skin is subsequently activated, leading to the splitting of the epidermis and dermis. This results in the formation of tense bullae on the skin, which is a distinct feature of pemphigoid gestationis.[5] Polymorphic Eruption of Pregnancy Polymorphic eruption of pregnancy is the updated or preferred term for pregnancy dermatosis, formerly called pruritic urticarial papules and plaques of pregnancy, in the United States.[6] This condition commonly begins in the abdominal striae. Although the exact etiology is unclear, it has been suggested that damage to the underlying collagen and connective tissue from abdominal distention may play a role in the development of this pregnancy-specific dermatosis. An inflammatory response is activated in the abdominal skin, which may spread to the skin's collagen in other areas of the body.[5] This condition is more commonly observed in women with multiple gestations or those who experience significant weight gain during pregnancy. Another proposed etiology is a maternal immune response to fetal antigens circulating in maternal blood.[5] Intrahepatic Cholestasis of Pregnancy Intrahepatic cholestasis of pregnancy is caused by the accumulation of bile acids within hepatocytes, resulting in elevated levels of bile salts in the blood. The underlying cause of this phenomenon during pregnancy is poorly understood.[7] This is likely due to a combination of genetic, environmental, and endocrine factors.

Intrahepatic cholestasis of pregnancy is caused by the accumulation of bile acids within hepatocytes, resulting in elevated levels of bile salts in the blood. The underlying cause of this phenomenon during pregnancy is poorly understood.[7] This is likely due to a combination of genetic, environmental, and endocrine factors. Mutations in biliary transporter proteins may contribute to the genetic basis of cholestasis. Environmental factors, including low vitamin D levels and reduced dietary selenium intake, have also been implicated, as suggested by the increased incidence of cholestasis of pregnancy during the winter months. Endocrine factors include elevated levels of estrogen and progesterone metabolites during pregnancy, which can disrupt bile acid influx and efflux across liver cells.[8] Atopic Eruption of Pregnancy Atopic eruption of pregnancy is usually seen in pregnant women with a history of atopy.[9] This condition most likely results from changes in the maternal immune response during pregnancy, including downregulation of T-helper 1 cytokine production and cell-mediated immune function, along with upregulation of T-helper 2 cytokine production and humoral immune response. This shift in the immune response, which is specific to pregnancy, exacerbates the immune imbalance already seen in people with atopy, resulting in the itching and skin lesions characteristic of atopic eruption of pregnancy.[5][10] Pustular Psoriasis of Pregnancy Pustular psoriasis of pregnancy, also known as impetigo herpetiformus, is likely a variant of pustular psoriasis observed outside of pregnancy.[5]

Dermatoses of pregnancy are skin conditions that occur in reproductive-aged females worldwide. Almost 90% of patients report skin changes during pregnancy.[11] Pemphigoid Gestationis Pemphigoid gestationis is a rare skin disease that occurs during pregnancy. The incidence of pemphigoid gestationis is 1 in 50,000 to 1 in 60,000 pregnancies.[5] The most significant risk factor is a history of pemphigoid gestationis in a prior pregnancy. Polymorphic Eruption of Pregnancy Polymorphic eruption of pregnancy affects approximately 1 in 200 pregnancies and typically occurs in the third trimester, particularly in primigravid women. This condition is a self-limiting dermatosis of the skin that may also present in the postpartum period. The condition is more frequently observed in pregnancies with a male fetus, and approximately 75% of affected patients are primiparous.[5] Intrahepatic Cholestasis of Pregnancy The incidence of intrahepatic cholestasis of pregnancy varies widely by population. The highest reported rates occur among Araucanian Indian women, indigenous to the South American country of Chile, who have the highest incidence of up to 28%. In Europe, the incidence is 1.5% or less, whereas in the United States, it ranges from 0.32% in White populations to as high as 5.6% in Hispanic groups.[5] Risk factors for developing intrahepatic cholestasis of pregnancy include a personal or family history of intrahepatic cholestasis of pregnancy, underlying hepatobiliary disease, and advanced maternal age. Risks for severe disease include smoking, previous cholecystectomy, a history of intrahepatic cholestasis of pregnancy in a previous pregnancy, and pregestational diabetes.[12] Atopic Eruption of Pregnancy Atopic eruption of pregnancy is the most common dermatosis of pregnancy, accounting for approximately 50% of cases. Most cases present early in pregnancy, often during the first trimester. In about 75% of patients, atopic eruption of pregnancy begins before the third trimester, which is earlier in pregnancy than the other dermatoses specific to pregnancy.[13] Pustular Psoriasis of Pregnancy Pustular psoriasis of pregnancy, also known as impetigo herpetiformis, is a rare dermatosis that most commonly occurs during the third trimester.[5] This condition is observed more frequently in primigravidas.[1]

Pemphigoid Gestationis Pemphigoid gestationis is an autoimmune disease similar to bullous pemphigoid. This condition may rarely occur with hydatidiform moles and choriocarcinoma. The immune response originates in the placenta and stimulates maternal antibody production. These antibodies subsequently cross-react with antigens in the skin. Autoantibodies target collagen XVII in the skin, leading to splitting of the dermis and epidermis and resulting in the formation of tense bullae. Initially, bullae form in the periumbilical region, but subsequently spread to other parts of the trunk and extremities. Extreme itching is very common. Pemphigoid gestationis most commonly develops during the second and third trimesters of pregnancy (approximately 34% of cases), but it may also occur in the first trimester (18%) or during the postpartum period (14%). Skin lesions often resolve in the last few weeks of pregnancy; however, 10% of women have a recurrence of lesions with the use of oral contraceptives, and 75% of women have recurrences postpartum.[5] Polymorphic Eruption of Pregnancy Polymorphic eruption of pregnancy most commonly occurs in primiparous patients during the third trimester, although it may also present in the second trimester. Lesions initially appear as pruritic, erythematous papules and plaques arising within the abdominal striae and may subsequently spread to the breasts, back, arms, and thighs. Sparing of the periumbilical region, as well as the face, palms, and soles, is characteristic.[5] Recurrence in subsequent pregnancies is rare. Approximately 15% of cases have an onset in the postpartum period.[14] Intrahepatic Cholestasis of Pregnancy Intrahepatic cholestasis of pregnancy typically presents with pruritus in the absence of primary skin lesions. Pruritus classically involves the palms of the hands and soles of the feet. Secondary skin lesions, such as linear excoriations, erosions, and scabbing, may be present. The condition frequently recurs in subsequent pregnancies, with reported recurrence rates ranging from 45% to 70%.[5] Atopic Eruption of Pregnancy

Intrahepatic cholestasis of pregnancy typically presents with pruritus in the absence of primary skin lesions. Pruritus classically involves the palms of the hands and soles of the feet. Secondary skin lesions, such as linear excoriations, erosions, and scabbing, may be present. The condition frequently recurs in subsequent pregnancies, with reported recurrence rates ranging from 45% to 70%.[5] Atopic Eruption of Pregnancy Atopic eruption of pregnancy encompasses a group of dermatoses with shared clinical features. In atopic eczema, eczematous lesions may appear for the first time during pregnancy, most commonly in the first or second trimester. Lesions typically involve flexural or other atopic sites, although in approximately one-third of cases, they are distributed over the trunk and limbs. Prurigo of pregnancy presents with grouped, excoriated papules on the limbs and trunk. Pruritic folliculitis of pregnancy, which usually occurs in the second or third trimester, is characterized by erythematous follicular papules resembling steroid-induced acne.[15] The underlying pathophysiology is thought to involve an exaggerated shift in the maternal immune response during pregnancy, favoring a T-helper 2–dominant profile that helps prevent fetal rejection.[5] Pustular Psoriasis of Pregnancy Pustular psoriasis of pregnancy may be associated with underlying hypocalcemia, vitamin D deficiency, hyperparathyroidism, genetic factors, or hormonal changes. However, the overall pathophysiology remains poorly understood.[5]

Pemphigoid Gestationis Pemphigoid gestationis is characterized by eosinophilic spongiosis, eosinophilic epitheliotropism, and a dense superficial dermal infiltrate rich in eosinophils. Diagnosis is confirmed by skin biopsy with histopathologic evaluation and direct immunofluorescence staining.[4] Polymorphic Eruption of Pregnancy Histopathologic findings in polymorphic eruption of pregnancy are nonspecific. Common features include dermal edema, scattered stromal mast cells, and a polymorphous mononuclear infiltrate with eosinophils. In approximately half of cases, superficial and deep perivascular mononuclear infiltrates with eosinophils are observed. Epidermal changes, present in about one-third of biopsies, may include parakeratosis, focal spongiosis, and acanthosis. Direct immunofluorescence studies are consistently negative.[1] Additional findings may include superficial or deep perivascular dermatitis and lymphocytic vasculitis. In some cases, nuclear dust may be present, without evidence of fibrin deposition.[6] Intrahepatic Cholestasis of Pregnancy Intrahepatic cholestasis of pregnancy may demonstrate abnormal placental histopathology, including increased terminal villous and capillary surface area, an increase in the number of syncytial knots, as well as decidual arteriopathy, delayed villous maturation, choriangiosis, and decidual arteriopathy.[16] No primary skin lesions are present in intrahepatic cholestasis of pregnancy. Atopic Eruption of Pregnancy Atopic eruption of pregnancy may demonstrate subepidermal pustules and perifollicular neutrophilic infiltration on microscopic examination.[9] Histopathologic findings can also include epidermal hyperplasia, spongiosis, and parakeratosis.[6] Pustular Psoriasis of Pregnancy Pustular psoriasis of pregnancy is typically diagnosed based on clinical findings rather than histopathology. The condition is characterized by multiple tender, sterile pustules noted on the skin. Blotchy erythema is found underneath these pustules. If a biopsy is performed, histopathologic features include neutrophilic infiltrates in the dermis and epidermal micropustules.[17]

When a new rash develops during pregnancy, prompt evaluation is necessary to identify potential risks to both the mother and fetus. A thorough medical history, including personal, family, and obstetric histories, is essential because some dermatoses may recur in subsequent pregnancies. Specifics about the timing of onset and associated symptoms should be obtained, followed by a comprehensive skin examination. A skin biopsy may be indicated in select cases. Laboratory evaluation should be guided by the clinical presentation and history. Pemphigoid Gestationis Pemphigoid gestationis most commonly develops during the second or third trimester of pregnancy and is characterized by severe itching. Skin papules and plaques involving the abdomen and back are characteristic symptoms. The urticarial papules, plaques, and vesicles appear first in the periumbilical region. Lesions may subsequently spread to the trunk and extremities, while the face, scalp, palms, soles, and mucous membranes are usually spared.[18] The initial skin rash evolves into vesicles or tense bullae on an erythematous base, with the interval between initial rash formation and bulla formation ranging from days to up to 4 weeks. Bullae that develop during pregnancy typically regress spontaneously in the final weeks of pregnancy, before delivery. However, many patients develop flares immediately postpartum. Pemphigoid gestationis may recur in subsequent pregnancies, and approximately 10% of patients experience recurrence with oral contraceptive use.[5] Polymorphic Eruption of Pregnancy Polymorphic eruption of pregnancy typically presents during the third trimester. Urticarial lesions initially involve the abdominal striae and characteristically spare the periumbilical region. The erythematous lesions may be surrounded by pale halos, giving a target-like appearance. This condition is one of the most common dermatoses of pregnancy.[15] Intrahepatic Cholestasis of Pregnancy

Polymorphic eruption of pregnancy typically presents during the third trimester. Urticarial lesions initially involve the abdominal striae and characteristically spare the periumbilical region. The erythematous lesions may be surrounded by pale halos, giving a target-like appearance. This condition is one of the most common dermatoses of pregnancy.[15] Intrahepatic Cholestasis of Pregnancy Intrahepatic cholestasis of pregnancy typically presents in the late second or third trimester with generalized pruritus, often beginning on the palms and soles. Pruritus is frequently worse at night. Primary skin lesions are absent; however, secondary changes such as excoriations, erosions, and scabbing may be present. Associated symptoms may include jaundice, pale stools, and steatorrhea, although these are not always observed. The condition may recur in subsequent pregnancies.[5] Atopic Eruption of Pregnancy Atopic eruption of pregnancy is characterized by intense itching and is usually present in the first or second trimester of pregnancy. This is a clinical diagnosis that is confirmed by ruling out other diagnoses. The 2 clinical patterns of skin eruptions are diagnoses: P-type and E-type. P-type typically consists of grouped, erythematous papules on the extensor surfaces of the extremities and the trunk. The E-type consists of eczematous lesions involving the face, neck, upper chest, and flexural areas, which are commonly affected by eczema. Many patients have a personal or family history of atopy, asthma, or seasonal allergies.[5] Pustular Psoriasis of Pregnancy Pustular psoriasis of pregnancy, also known as impetigo herpetiformis, is a rare dermatosis that most commonly occurs during the third trimester of pregnancy. This condition is characterized by circumferential rings of erythematous plaques covered with sterile pustules along the periphery that occur in flexural areas. The lesions do not typically itch, and these plaques may spread to the trunk and extremities. The hands, feet, and face are generally spared. The plaques may become centrally crusted and eroded. Although rare, this disorder may be associated with systemic symptoms, including nausea, vomiting, diarrhea, fever, anorexia, lymphadenopathy, malaise, and, in severe cases, seizures. Onycholysis may also occur. Lesions can spread to involve the trunk and extremities while typically sparing the hands, feet, and face.[5]

The hands, feet, and face are generally spared. The plaques may become centrally crusted and eroded. Although rare, this disorder may be associated with systemic symptoms, including nausea, vomiting, diarrhea, fever, anorexia, lymphadenopathy, malaise, and, in severe cases, seizures. Onycholysis may also occur. Lesions can spread to involve the trunk and extremities while typically sparing the hands, feet, and face.[5] Notably, in individuals with skin of color (SOC), the clinical presentation of pregnancy-associated dermatoses may differ from that observed in patients of European or Arab ancestry. Erythema may be less apparent, while postinflammatory hyperpigmentation is often more prominent. Additionally, inflammatory conditions, including autoimmune blistering disorders, may exhibit a violaceous or purplish hue in SOC, which can be mistaken for the coloration seen in interface dermatoses.[19]

Pemphigoid Gestationis Pemphigoid gestationis is diagnosed by skin biopsy for histopathologic examination and direct immunofluorescence, which demonstrates linear C3 deposition along the perilesional or basal membrane lamina lucida. More recently, enzyme-linked immunoassay testing has been used to detect circulating maternal antibodies in serum.[5] Patients may also present with fever and malaise, and laboratory evaluation may reveal leukocytosis and eosinophilia.[18] Polymorphic Eruption of Pregnancy Polymorphic eruption of pregnancy is usually diagnosed based on the clinical presentation and history. Skin biopsy is rarely required.[5] Bullae are not present on the skin with polymorphic eruption of pregnancy.[20] Pemphigoid gestationis and polymorphic eruption of pregnancy can be difficult to distinguish clinically because both may present with urticarial papules and plaques. Accurate differentiation and evaluation are important because polymorphic eruption of pregnancy is not associated with pregnancy complications, but pemphigoid gestationis may be associated with placental insufficiency. In settings where direct immunofluorescence and enzyme-linked immunoassay testing are unavailable, a scoring system may help differentiate pemphigoid gestationis and polymorphic eruption of pregnancy.[20] Intrahepatic Cholestasis of Pregnancy Intrahepatic cholestasis of pregnancy is associated with elevated serum total bile acid levels higher than 11 µmol/L. Serum bile acid levels greater than 40 µmol/L are generally considered indicative of severe disease. Direct or indirect bilirubin levels and liver transaminases may also be elevated. Ultrasound of the liver may help exclude other causes of transaminitis.[5] Atopic Eruption of Pregnancy Atopic eruption of pregnancy is usually diagnosed based on the clinical presentation, although a skin biopsy may be performed to rule out other conditions.[5] Reliable diagnostic criteria for atopic eruption of pregnancy do not exist.[13] Pustular Psoriasis of Pregnancy Pustular psoriasis of pregnancy is often diagnosed by a skin biopsy.[5] Histology shows spongiform pustules and intraepidermal microabscesses formed by neutrophils. On average, approximately 56% of the body surface area is affected.[21] Distinct diagnostic studies are available only for cholestasis of pregnancy and pemphigoid gestationis.[6]

Pemphigoid Gestationis The primary goals of treatment are to minimize itching and decrease blister formation. Nonpharmacologic measures such as cool compresses, maintaining a cool environment, and wearing light, breathable clothing may help alleviate symptoms. Oral antihistamines, such as loratadine 10 mg daily, may also be used.[18] First-line medical therapy consists of topical corticosteroids, including fluocinonide 0.05% cream or ointment and clobetasol propionate 0.05% cream or ointment. If topical treatment does not achieve an adequate response, systemic corticosteroids such as prednisolone 20 to 40 mg orally daily may be required. Prednisolone has minimal placental transfer to the fetus.[18] Additional therapies that have been used include intravenous immunoglobulin, azathioprine, and dapsone. Systemic corticosteroids are the first-line therapy for moderate to severe pemphigoid gestationis, but they are also associated with maternal and fetal risks. Dupilumab, an IL-4Rα antagonist approved by the US Food and Drug Administration (FDA), suppresses type 2 inflammation and has demonstrated efficacy in bullous pemphigoid, although data in pemphigoid gestationis remain limited. Existing reports, including pharmacovigilance data, suggest dupilumab is well tolerated during pregnancy, with a small number of published cases describing its use in pemphigoid gestationis.[22] Rituximab has also been used for the treatment of postpartum flares.[5] Polymorphic Eruption of Pregnancy The main goal of treatment is to decrease itching. The lesions frequently resolve on their own in 4 to 6 weeks. Oral antihistamines and topical steroids are commonly used for treatment. Topical hydrocortisone 2.5% ointment or cream, desonide 0.05% ointment or cream, triamcinolone acetonide 0.1% ointment or cream, mometasone furoate 0.1% cream, or fluocinolone acetonide 0.025% ointment may be used. Systemic corticosteroids may be used as a short course if topical treatment is not satisfactory. Common regimens include prednisolone or prednisone 0.5 mg/kg daily for a week, followed by a taper over the subsequent 1 to 2 weeks.[5] Intrahepatic Cholestasis of Pregnancy

The main goal of treatment is to decrease itching. The lesions frequently resolve on their own in 4 to 6 weeks. Oral antihistamines and topical steroids are commonly used for treatment. Topical hydrocortisone 2.5% ointment or cream, desonide 0.05% ointment or cream, triamcinolone acetonide 0.1% ointment or cream, mometasone furoate 0.1% cream, or fluocinolone acetonide 0.025% ointment may be used. Systemic corticosteroids may be used as a short course if topical treatment is not satisfactory. Common regimens include prednisolone or prednisone 0.5 mg/kg daily for a week, followed by a taper over the subsequent 1 to 2 weeks.[5] Intrahepatic Cholestasis of Pregnancy Ursodeoxycholic acid (UDCA) is currently the most effective pharmacologic treatment for intrahepatic cholestasis of pregnancy and has the most benefits. However, the Society for Maternal-Fetal Medicine states that UDCA therapy does not improve fetal outcomes with intrahepatic cholestasis of pregnancy, although it significantly reduces maternal pruritus. A starting dose of UDCA of 10 to 15 mg/kg/d can be divided into 2 or 3 daily doses. After 1 week, the dose can be increased to a maximum of 21 mg/kg/d to control symptoms. Doses ranging from 450 to 1200 mg per day have been shown to reduce total bile acid levels in cord blood, colostrum, and amniotic fluid.[23][3] Alternative treatment options include oral antihistamines, S-adenosyl-l-methionine, and rifampin. Cholestyramine has a high adverse-effect profile and does not improve itching; however, it does reduce bile acid resorption.[5] Delivery is recommended at 36 weeks of gestation when bile acid levels are greater than or equal to 100 µmol/L due to the increased risk of stillbirth. Delivery between 36 and 39 weeks of gestation is recommended when bile acid levels are less than 100 µmol/L.[5] Atopic Eruption of Pregnancy Topical therapies to relieve itching and dryness, including urea and 1% to 2% menthol, are recommended as initial treatments. Adequate skin hydration is critical as fundamental therapy. Antihistamines such as chlorpheniramine, loratadine, and cetirizine may also be used.[5] Topical medium to high potency steroids in the amount of 200 mg per month are considered safe in pregnancy.

Topical therapies to relieve itching and dryness, including urea and 1% to 2% menthol, are recommended as initial treatments. Adequate skin hydration is critical as fundamental therapy. Antihistamines such as chlorpheniramine, loratadine, and cetirizine may also be used.[5] Topical medium to high potency steroids in the amount of 200 mg per month are considered safe in pregnancy. Fluticasone propionate should not be used in pregnancy because the placenta does not metabolize it and can, therefore, reach the fetus in higher concentrations.[13] Oral corticosteroids may be needed when initial treatment is not successful. Prednisone or prednisolone at a maximum dose of 0.5 mg/kg/d for 2 to 3 weeks may be necessary to control symptoms. Broad and narrowband UVB and UVA-1 light therapy have also been utilized.[5][13] Cyclosporin A and azathioprine (off-label use) may be used in pregnancy when the benefits to the mother are deemed to outweigh any potential risk to the fetus. Methotrexate and mycophenolate mofetil use is contraindicated during pregnancy. Janus kinase inhibitors, baricitinib, upadacitinib, and abrocitinib are also contraindicated for use in pregnancy.[13][5] Pustular Psoriasis of Pregnancy Prednisolone 15 to 30 mg daily, a systemic corticosteroid, is the most common treatment for pustular psoriasis of pregnancy. The dose may be increased to prednisolone 60 to 80 mg daily if needed.[5] Topical betamethasone 0.05% at a dose of 15 to 30 grams per day has also been used. Dapsone, H1-receptor antagonists, and colchicine have been tried. Acitretin has been successfully used in postpartum women.[21] Cyclosporine or tumor necrosis inhibitors, such as infliximab and adalimumab, may be used in very severe cases. Several other medications have been used in pregnancy to treat pustular psoriasis of pregnancy, but because the condition is rare, data regarding efficacy and safety during pregnancy remain limited. Delivery is considered curative and may be appropriate in refractory cases, particularly when the pregnancy is near term.[5]

The differential diagnoses for dermatoses of pregnancy include: Acute urticaria Contact dermatitis Chronic urticaria Drug eruptions Erythema multiforme Insect bites Gallstones Biliary disease (cholecystitis and cholangitis) Hepatitis Acute fatty liver of pregnancy Atopic dermatitis Scabies pregnancy Folliculitis

Pemphigoid Gestationis Pemphigoid gestationis frequently recurs in subsequent pregnancies, affecting approximately 50% to 70% of patients. Recurrent disease in subsequent pregnancies is often associated with earlier-onset and more severe disease. Preterm birth and fetal growth restriction are infrequently associated with pemphigoid gestationis. Pemphigoid gestationis usually regresses after delivery; however, a postpartum recurrence may occur in approximately 75% to 85% of patients.[1] Pruritic Eruption of Pregnancy Pruritic eruption of pregnancy usually resolves within 3 to 6 weeks postpartum.[1] Intrahepatic Cholestasis of Pregnancy Intrahepatic cholestasis of pregnancy is unique to pregnancy and typically resolves spontaneously postpartum.[12] Adverse neonatal effects may be seen, including intrauterine fetal death. Atopic Eruption of Pregnancy Atopic eruption of pregnancy is not associated with any adverse fetal or maternal outcomes. However, the itching may be intense and disruptive. Pustular Psoriasis of Pregnancy Pustular psoriasis of pregnancy may be associated with fetal death due to placental ischemia. Maternal convulsions may occur due to elevated calcium levels. Recurrences in subsequent pregnancies may start earlier, and the use of oral contraceptive pills may trigger a flare.[1]

Pemphigoid Gestationis Pemphigoid gestationis may be associated with fetal growth restriction and preterm delivery.[4] Neonatal pemphigoid gestationis occurs in 10% to 13% of neonates as a result of the transplacental passage of maternal IgG autoantibodies. The mild blistering seen resolves spontaneously within several weeks of birth. As the lesions heal, they leave hyperpigmented areas of skin.[5][4][18] Pruritic Eruption of Pregnancy Pruritic eruption of pregnancy is not associated with any adverse maternal or fetal outcomes and rarely recurs in subsequent pregnancies. Intrahepatic Cholestasis of Pregnancy Intrahepatic cholestasis of pregnancy is associated with poor outcomes for the fetus. Prematurity, respiratory distress, and meconium-stained amniotic fluid are all fetal risks associated with intrahepatic cholestasis of pregnancy. Stillbirth is an additional fetal risk, especially when bile acid levels are higher than 100 µmol/L.[5] Atopic Eruption of Pregnancy Atopic eruption of pregnancy commonly occurs in subsequent pregnancies, and there are no maternal or fetal risks associated.[5] Pustular Psoriasis of Pregnancy Pustular psoriasis of pregnancy is associated with maternal electrolyte imbalances, especially low calcium, which can lead to delirium, seizures, or tetany. Fluid losses, dehydration, and sepsis from infections may also be associated. Pustular psoriasis of pregnancy may recur in subsequent pregnancies at an earlier stage of pregnancy and with a more severe clinical presentation. Pustular psoriasis of pregnancy can also recur during menstruation or when taking birth control pills. Other complications include preterm labor, neonatal demise, fetal growth restriction, premature rupture of membranes, and intrauterine fetal death due to placental insufficiency.[5]

The first steps in achieving the best possible outcomes in patients with specific dermatoses of pregnancy are prompt recognition, accurate diagnosis, and adequate treatment of symptoms. Improving symptoms and educating patients about their specific diagnosis will result in better outcomes for those affected by pregnancy-related dermatoses. Consultation with a dermatologist may provide additional expertise and evaluation to optimize treatment strategies and outcomes. Proper treatment strategies are crucial for reducing and preventing disruptive itching and potential adverse pregnancy and neonatal outcomes. Patient education about the risk of recurrence in future pregnancies will help with family planning decisions.

Healthcare professionals involved in managing dermatoses of pregnancy should possess diagnostic skills to accurately identify both common physiological skin changes and specific pathological dermatoses related to pregnancy. Appropriate treatment selection is essential, particularly given the unique considerations and limitations associated with pregnancy. Patient education is also critical so that patients understand their diagnosis, treatment plan, and the potential implications for maternal and fetal well-being. Primary care physicians, advanced practice clinicians, nurse-midwives, and obstetricians should consider consultation with a maternal-fetal medicine specialist or dermatologist when the diagnosis is uncertain or when treatment recommendations are complex or unsuccessful. Developing a comprehensive strategy involves a collaborative and multidisciplinary approach. Physicians, advanced practitioners, nurses, pharmacists, and other health professionals share responsibilities in delivering patient-centered care. This includes formulating evidence-based protocols for the evaluation and treatment of dermatoses of pregnancy. Ensuring patient safety is paramount, and interprofessional healthcare team members should identify and mitigate potential risks associated with dermatoses and their treatments during pregnancy. Establishing clear communication channels supports a cohesive management strategy. Regular case discussions and multidisciplinary meetings can improve coordination and promote more comprehensive, patient-centered care. Ongoing education and training are also important for keeping clinicians up to date on the latest advances in managing these dermatological conditions. Coordinated efforts contribute to improved patient outcomes, reduced healthcare disparities, and enhanced overall healthcare experiences for individuals affected with dermatoses of pregnancy.