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Pregnancy rashes

Pregnancy rashes

Rashes in pregnancy are divided into two groups. The first group consists of rashes that are only seen in pregnant women, and includes conditions such as pruritic urticarial papules and plaques of pregnancy (PUPPP), pemphigoid gestationis (previously named herpes gestationis and bullous dermatosis of pregnancy), pruritic folliculitis of pregnancy, pruritus of pregnancy, prurigo of pregnancy and erythema nodosum of pregnancy. All of these conditions are uncommon or rare. The second group consists of pre-existing conditions that are worsened by pregnancy, eg atopic dermatitis, rosacea, psoriasis, acne, pityrosporum folliculitis, herpes simplex, vulvovaginal candidiasis and lupus erythematosus.

Treatment of all skin conditions in pregnancy is difficult. There is often a poor response to therapy, which in itself is limited. In most cases the condition is unable to be effectively treated until the pregnancy is over. Use of medication to treat benign skin conditions in pregnancy should be limited to category A drugs, Australian Categorisation of Drugs in Pregnancy, see chapter on Drug use in pregnancy and breastfeeding.

This is the most common of the rashes specific to pregnancy, presenting in primigravidae towards the end of the third trimester, with itchy plaques and papules beginning on the abdomen and spreading to the rest of the trunk, arms and legs. The eruption clears promptly after delivery and does not recur in subsequent pregnancies.

The following treatment is recommended

a potent topical corticosteroid applied twice daily under wet dressings (see Points on use of modified dressings)

AND

hydroxyzine 25 to 50mg orally, 3 times daily.

In extreme cases where the patient is unable to sleep because of itching, prednisolone 25mg orally, daily may be used. Consultation with a dermatologist and obstetrician in this situation is recommended.

This is a rare, autoimmune condition in which a rash, which may initially resemble PUPPP, occurs initially in the second to third trimester (average time of onset is 21 weeks) and resolves postpartum. The rash tends to recur earlier in each subsequent pregnancy. Onset of the rash may sometimes be in the first week postpartum, and it may not clear for several weeks. The rash is unresponsive to topical corticosteroids and if left untreated may become vesicular or bullous. This eruption should be diagnosed by skin biopsy.

Treatment is with

prednisolone 0.5 to 1mg/kg orally, daily until eruptions and itching have resolved, then gradually withdrawn over 6 weeks.

Referral to a dermatologist is recommended.

This rare condition occurs in the second or third trimester. Very itchy follicular papules and pustules occur mainly on the upper body and arms. Swabs should be taken to rule out a Staphylococcus aureus infection; however, in this condition they are negative. Treatment with potent topical corticosteroids may be used but the response can be disappointing. The condition resolves after delivery.

Itch without an observable rash or skin disease may occur in pregnancy, usually in the third trimester. This may be idiopathic or due to pregnancy-associated cholestasis. In all cases, serum bile acids and liver function tests must be checked. Both will be elevated in cholestasis and this condition is usually managed with induction at or before 38 weeks, depending on severity, as continuation of the pregnancy beyond this time is harmful to the fetus. Both conditions may be very distressing to the patient; however, therapy is ineffective. The itching resolves promptly after delivery.

Erythema nodosum may occur in pregnancy, with no other identifiable cause. Other causes of this condition, such as bacterial and other infections, sarcoidosis, enteropathies, drugs and malignancies, should be ruled out. The condition is usually not disabling. No treatment other than bedrest is usually required. It resolves after delivery.

Atopic dermatitis – may be managed in the usual way, see General treatment of dermatitis. Topical corticosteroids are considered safe in pregnancy.

Psoriasis – topical therapy, including corticosteroids, dithranol and tars, see Topical therapy in management of psoriasis, and ultraviolet B therapy, see Phototherapy in management of psoriasis, may be used in pregnancy. Oral therapy is contraindicated.

Acne and rosacea – rarely, both conditions may be present in a very severe form in pregnancy. Treatment is limited to oral or topical erythromycin, the effect of which is often disappointing. Recovery after the birth of the baby may be delayed for weeks or months.

Herpes simplex – if present in a severe degree in pregnancy, aciclovir (category B3) may be used. Consultation with an infectious disease specialist is recommended.

Pityrosporum folliculitis and vulvovaginal candidiasis – topical nystatin and imidazole antifungals may be used in pregnancy. Oral therapy is contraindicated.

Lupus erythematosus and other autoimmune conditions – may flare in pregnancy, and may require treatment with oral prednisolone and azathioprine. Specialist consultation is recommended.

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