|Year : 1992 | Volume
| Issue : 2 | Page : 84-88
Skin in pregnancy
Sujata Raj, Uday Khopkar, Akila Kapasi, SL Wadhwa
Source of Support: None, Conflict of Interest: None
Screening for cutaneous disorders was undertaken in 1,175 pregnant women attending ante-natal clinic. Skin disease or STD being encountered in 114 (9.7%). Pruritus was present in 7.1 percent and was mostly due to candidiadis. The physiological skin changes were frequently observed. Candidiasis was by far the commonest infection with a 2.9 percent incidence. Syphilis was the commonest STD followed by Donovanosis and condyloma acuminata. Specific pregnancy dermatoses were seen in 1.5 percent and included prurigo gestationis, pruritic urticarial papules and plaques (PUPPP) and pruritus gravidarum.
Keywords: Pregnancy, Dermatoses
|How to cite this article:|
Raj S, Khopkar U, Kapasi A, Wadhwa S L. Skin in pregnancy. Indian J Dermatol Venereol Leprol 1992;58:84-8
| Introduction|| |
The pregnant woman is vulnerable not only to all the dermatoses occurring in the non pregnant state but also an heir to certain eruptions related to the physiologic burden of gestation. In addition to these are those skin changes that most pregnant women exhibit and are considered to be physiological. This study was undertaken to ascertain the incidence and clinical characteristics of mucocutaneous changes in pregnancy and also to observe the effect of pregnancy on various common or preexisting dermatological conditions.
| Materials and Methods|| |
This clinical study was conducted in 1,175 pregnant women attending the antenatal clinic of a central hospital in Bombay. The study comprised mainly of women in the last two trimesters of pregnancy. Skin complaints, particularly their relation with obstetric history were noted. A detailed examination to note any physiological changes, as well as any infections, tumours or inflammatory dermatoses was performed in patients with skin complaints. Investigations like liver function tests and skin biopsies were performed wherever necessary.
| Results|| |
Of the 1,175 patients screened, 114 (9.7%) had skin or STD complaints. Their age ranged from 16 to 30 years, 74 (64.9%) of them being multigravidas.
Pruritus was the commonest complaint noted in 84 (7.1%). Fungal infections & scabies accounted for almost 65 percent of the pruritus and pregnancy dermatoses 16.3 percent. However, in 4.8 percent the pruritus could not be ascribed to any cause.
The physiological changes observed are enumerated in [Table - 1]. Of the total 1,175 patients, 16 (1.4%) were found to have STDs of which Donovanosis and condyloma acuminata accounted for 0.3 percent each. Syphilis was encountered in 11 (0.9%) of which 3 (0.3%) had secondary syphilis. One patient was sero positive for HIV.
Other infections were present in 84 (7.1%), candidiasis was predominant with a 2.9 percent incidence and specific pregnancy dermatoses were present in 1.5 percent. Dermatoses like acne vulgaris, eczema, angular cheilitis, geographic tongue and vitiligo were observed in a minority.
| Discussion|| |
Pruritus was by far the commonest presenting complaint with a 7.1 percent incidence. Withon et al  reported that upto 2 percent of pregnant women itch without any cause, which has been corroborated by this study. However, fungal infections and scabies account for most of the patients thereby emphasizing the need for a careful search for these infections in such a patient. Other causes of pruritus in pregnancy include the pregnancy dermatoses.
Pigmentation of the nipple and areola was found in 100 percent of multigravidas and in 95 percent of primigravidas in this study. This pigmentation develops after the eighth week of gestation, thus accounting for its absence in 5 percent primigravidas who were in the first eight weeks of their pregnancy. In addition, melasma was observed in 8.8 percent whereas Winton et al have reported an incidence as high as 50 percent which may possibly be due to the fact that milder pigmentary changes are more discernable in the fair skinned. 
Striae distensae were found in 75 percent, thus conforming to earlier findings.  Abdominal striae were commoner in multigravidas, but the prevalence of striae at other sites was approximately equal in multi and primigravidas.
The prevalence of palmar erythema was found to be 33.3 percent in this study. Bean et al reported it in 62.5 percent of pregnant whites and 35 percent of blacks.  This may be due to erythema being readily appreciated in the light skinned. A similar discrepancy was found in the observation of spider naevi.  Venous varicosities have been reported in about 40 percent.  The lower incidence of 6.1 percent in the present study can be attributed to the lower average weight of Indian babies,  sub leading to lesser pressure on the veins draining the vulva and lower limbs.
Candidiasis (3.8%) was observed to regress spontaneously postpartum in many. Because of the asymptomatic carrier state being taken into account, a higher incidence of 30 percent was noted in other studies. 
Syphilis was encountered in 0.9 percent hence the need for routine serological screening of all pregnant women. Condyloma acuminata were seen in 0.3 percent and were florid due to the increased vascularity.
Prurigo gestationis had a 1.2 percent incidence in this study with the onset between the 18 to 35 weeks which is consistent with prior descriptions. , From this study it appears that the eruption may not be confined to the extensors of the limbs, upper back and chest as described  as in majority of the studied Individuals the eruption was seen on the abdomen and flexural areas [Figure - 1]. History of similar episodes in prior pregnancy was obtained in 21.4 percent, with most having history of a severer rash suggestive of urticarial lesions. It is possible that these patients probably had pruritic urticarial papules and plaques of pregnancy (PUPPP) in prior pregnancies and that these two disorders belong to the same group of diseases only with varying severity. The severity probably reduces with increasing gravidity. The 0.2 percent occurrence of PUPPP is supported by Lawley et al  [Figure - 2] Onset usually occurs after the 34 week,  which is at variance with that observed in this study where the onset was between the 24 to 28 weeks of gestation. Biopsy findings established the diagnosis. [Figure 3].
Pruritus gravidarum has been reported to have an incidence of 0.02 to 2.4 percent.  This study noted it in 0.1 percent with the onset in the third trimester. The patient included had raised serum alkaline phosphatase without hyperbilirubinaemia and history of similar disease in 3 prior pregnancies.
Acne vulgaris was observed to have arisen mainly in the last trimester when the progesterone levels are maximal. Eczema was seen in 0.9 percent which is similar to that reported by Crawford et al,  Vitiligo is known to behave variably in pregnancy.10 Of the 3 patients included in our study 1 had the onset during pregnancy whereas 2 remained static.
Thus in this study the normal physiological cutaneous changes were found to share a similar incidence with those of earlier studies. The specific pregnancy dermatoses which bear a poor prognosis were fortunately rare.
| References|| |
|1.||Winton G B, Lewis C W. Dermatoses of pregnancy. J Amer Acad Dermatol 1982; 6 : 977-98. |
|2.||Sharma SC, Dhall K, Sharma R, et al. Dermatoses of Pregnancy, Incidence and clinicohistopathological featuers. Abstract of paper presentation at XVIII National Conference, IADVL, Jaipur, 1990. |
|3.||Bean WB, Cogswell R, Dexter M, et al, Vascular changes in pregnancy. Surgery, Gynecology and obstetrics, 1949; 88 : 739-52. |
|4.||Scoggins R B. Skin changes and diseases in pregnancy. In : Dermatology in General Medicine, (Fitzpatrick TB, Eisen AZ, Wolff K,et al, eds), 2nd edn. NewYork : McGraw Hill Book company, 1979; 1363-70. |
|5.||Krishnan L, Chakladar BK. Maternal risk factors and low birth. Indian J Obstet Gynaec, 1989; 1 : 52-7. |
|6.||Odds FC. Candida and candidiasis, University Park Press, Baltimore, 1970 quoted by, Hammer GS, Hirschman SZ. Infections in Pregnancy. In: Rovinsky & Guttmacher's Medical, Surgical and Gynaecologic Complications of pregnancy (Cherry SH, Berkowitz RL, Kase NG, ads), 3rd edn. Baltimore : Williams and Wilkins, 1985; 15-6. |
|7.||Nurse DS. Prurigo of pregnancy. Australian J of Dermatol 1968; 9: 258. quoted by Burton JL and Rook A. The ages of Man and their Dermatoses. In : Textbook of Dermatology (Rook A, Wilkinson DS, Ebling FJG, al, et, eds), 4th edn. Bombay : Oxford University press, 1987; 265-83. |
|8.||Besnier E, Brocq L, Jacquet L . La pratique dermatologique. Masson, Paris, 1904, Tome IV, p 74 quoted by Dotz W, Berman B. Guttmacher's Medical, Surgical and Gynaecologic Complications of pregnancy, (Cherry SH, Berkowitz RL, Kase NG, ads), 3rd edn. Baltimore : Williams and Wilkins, 1985;452-73. |
|9.||Crawford G, Leeper R. Diseases of skin in pregnancy. Arch Dermatol 1950;61:753-71. |
|10.||Mosher DB, Fitzpatrick TB, Ortonne JP, et al. Disorders of pigmentation. In : Dermatology in General Medicine (Fitzpatrick TB, Eisen AZ, Wolff K,et al, eds), 3rd edn. NewYork McGraw-Hill Company, 1979; 811. |
[Figure - 1], [Figure - 2]
[Table - 1], [Table - 2]
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