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Research Article | Volume 11 Issue :1 (, 2021) | Pages 61 - 67
An Observational Study of Dermatoses in Pregnancy in A Tertiary Care Hospital
1
Assistant Professor, Department of Dermatology Venereology and Leprosy, Guntur Medical College, Guntur, Andhra Pradesh. India
Under a Creative Commons license
Open Access
DOI : 10.5083/ejcm
Received
March 2, 2021
Revised
March 13, 2021
Accepted
March 21, 2021
Published
March 30, 2021
Abstract

Background: For numerous women, pregnancy can bring about radiant skin, rosy cheeks, and lustrous hair. Conversely, some may deal with less appealing skin issues, such as acne, dark patches, and stretch marks. The journey to becoming a mother is filled with significant changes and adaptations for all mothers, and welcoming a new baby brings both happiness and challenges.  

Objectives:

  1. To study the various physiological skin changes occurring during pregnancy.
  2. To study the frequency and clinical features of specific dermatoses of pregnancy.

Material & Methods: Study Design: Hospital-based observational descriptive study. Study area: Department of Dermatology Venereology and Leprosy, Guntur Medical College, Guntur. Study Period: September 2020 – February 2021 (6 months).  Study population:  The study included 500 pregnant women attending the outpatient departments of Obstetrics and Gynaecology, and the department of D.V.L.   Sample size: The study consisted of a total of 500 subjects.  Sampling method: Simple random method. Results: Amongst 500 cases, 36 (7.2%) presented with prurigo of pregnancy, and 25 (5%) presented with pruritus gravidarum. PUPPP constituted 4.6% of the cases, and 5 (1%) presented with pruritic folliculitis of pregnancy.  Conclusion: In this research involving 500 pregnant individuals with skin issues, it is clear that pregnant women are susceptible to a variety of dermatological conditions beyond just the specific skin disorders associated with pregnancy.

Keywords
INTRODUCTION

For numerous women, pregnancy can bring about radiant skin, rosy cheeks, and lustrous hair. Conversely, some may deal with less appealing skin issues, such as acne, dark patches, and stretch marks. The journey to becoming a mother is filled with significant changes and adaptations for all mothers, and welcoming a new baby brings both happiness and challenges. Skin changes linked to pregnancy thought to be caused by hormonal fluctuations, are referred to as physiological skin changes; these can become pathological when they are severe and not solely due to hormones.1 While dermatoses that are specific to pregnancy are uncommon, it is crucial to identify them as they can be extremely itchy or painful for the mother and pose substantial risks to both her and her unborn child. Conditions such as intrahepatic cholestasis of pregnancy, impetigo herpetiformis, and pemphigoid gestationalis are associated with heightened risks of premature birth, intrapartum fetal distress (22%-33%), early delivery (19%-60%), and stillbirths (1%-2%).2-5

Expectant mothers may experience four primary skin conditions:6 

  1. Atopic Eruption of Pregnancy (AEP) or Prurigo of Pregnancy (PP)
  2. Polymorphic Eruption of Pregnancy or Pruritic Urticarial Papules and Plaques of Pregnancy (PUPP)
  3. Gestational Pemphigoid
  4. Intrahepatic Cholestasis during Pregnancy

 

Prurigo of pregnancy (PP) is the most prevalent skin condition encountered during pregnancy, affecting 50% of patients, and often begins early, with 75% of cases emerging before the third trimester; due to its atopic nature, it frequently recurs in subsequent pregnancies. [6] 

 

PP is a harmless itchy skin disorder that occurs during pregnancy, characterised by eczematous or papular lesions in individuals with a personal or family history of atopy or elevated IgE levels, after ruling out other skin conditions.

Eighty per cent of individuals will either encounter atopic skin alterations for the first time or after a lengthy period of remission (such as since childhood). Two-thirds of patients exhibit extensive eczematous changes (E-type AEP)6, frequently impacting typical atopic areas like the face, neck, upper chest, and the creases of the limbs, while one-third display papular lesions (P-type AEP) scattered across the trunk and limbs, along with common prurigo nodules primarily found on the shins and arms. Regarding prognosis and fetal outcome, maternal prognosis remains favourable even in serious cases, as skin lesions typically respond quickly to treatment; however, recurrences during subsequent pregnancies are frequent. The prognosis for the fetus is not affected.

 

PUPPP is a non-threatening, self-resolving itchy inflammatory condition that typically occurs in first-time mothers during the later stages of pregnancy or just after giving birth (15%)7 and is linked to significant maternal weight gain and multiple gestations.8,9

 

Intrahepatic cholestasis of pregnancy (IHC) is a reversible type of cholestasis that is often triggered and usually arises in individuals with a genetic predisposition during the later stages of pregnancy. It is known to have familial tendencies and frequently reappears in future pregnancies, with recurrence rates ranging from 45% to 70%.10,11

 

Pemphigoid gestational (PG): This is an uncommon autoimmune blistering condition that primarily manifests during late pregnancy or shortly after childbirth, and there is an association with the HLA-DR3 and DR4 haplotypes.12

The patient's concerns can vary from the aesthetic outcome to the possibility of recurrence of specific issues in future pregnancies, as well as the potential impact on the fetus regarding health complications and mortality. Therefore, it was deemed valuable to investigate the frequency of different physiological changes, skin conditions, and tumours that are altered by pregnancy, particular skin disorders related to pregnancy, and coincidental skin diseases, as well as to examine how pregnancy affects the progression of various skin disorders.

 

Objectives:

  1. To study the various physiological skin changes occurring during pregnancy.
  2. To study the frequency and clinical features of specific dermatoses of pregnancy.
MATERIALS AND METHODS

Study Design: Hospital-based observational descriptive study.

 

Study area: Department of Dermatology Venereology and Leprosy, Guntur Medical College, Guntur.

 

Study Period: September 2020 – February 2021 (6 months).

 

Study population:  The study included 500 pregnant women attending the outpatient departments of Obstetrics and Gynaecology, and the department of D.V.L 

 

Sample size: The study consisted of a total of 500 subjects. 

Sampling method: Simple random method.

 

Ethical consideration: Institutional Ethical committee permission was taken before the commencement of the study.

 

Study tools and Data collection procedure:

After taking informed consent, all the cases were screened for skin lesions. Detailed case history was taken in all the patients regarding the onset, duration and progression of the problem, the presence of similar problems during previous pregnancies, positive family history, treatment taken and other associated diseases.

 

In all the patients irrespective of the problem presented, physiological changes in pregnancy were noted. A thorough cutaneous examination was carried out to diagnose specific dermatoses of pregnancy and dermatoses coexisting with pregnancy.

 

A complete blood picture and urine examination were done on all the patients. Screening for HIV was done as a part of a routine procedure at the obstetrics and gynaecology department. In relevant cases, investigations like liver function tests, KOH mount for fungal elements, Tzank smear, and histopathological examination were done.

RESULT

A total of 500 pregnant women were examined throughout the study period. The findings related to physiological changes, specific pregnancy-related skin disorders, and existing skin conditions are evaluated and presented in tables.

 

Table No – 1 Age Distribution:

Age group

Number

Percentage

15 – 20

180

36%

21-30

292

58.4%

31-40

28

5.6%

Total

500

100

 

Amongst 500 enrolled cases, the majority of the patients were in the age group of 21-30 years 292(58.4%) followed by 15-20 years 180(36%), 31- 40 years 28(5.6%).

 

Table No: 2 Gravida Distribution

Gravida

Number

Percentage

Primi gravida

254

50.8

Multi gravida

246

49.2

Total:

500

100

 

Amongst 500 Enrolled cases, 254 (50.8) were primigravida, and 246(49.2%) were multigravida. 

 

Table No: 3 Stage of pregnancy

Trimester

Number

Percentage

I.Trimester (1 to 3 months)

63

12.6

II. Trimester (4 to 6 months)

203

40.6

III. Trimester (7 to 9 months)

234

46.8

Total

500

100

 

Amongst 500 enrolled cases 63(12.6%) were in 1st trimester, 203 (40.6%) were in 2nd trimester, 234(46.8%) were in 3rd trimester.

 

Table No: 4: Physiological changes

Conditions

No.

Percentage

Striae gravidarum

425

85%

Pigmentation

410

82%

Pruritus

320

64%

Telogen efluvium

100

20%

Melasma

53

10.6%

 

Physiological changes were seen in all cases. Amongst 500 enrolled cases the most common Physiological Change observed is striae gravidarum 425, (85%) followed by pigmentation in 410 cases (82%).

 

Table No: 5 Specific dermatoses of pregnancy were observed in 17.8% of the total study population

Diseases specific to pregnancy

Disease

Number

Percentage

Prurigo of pregnancy

36

7.2%

Pruritus gravidarum

25

5%

Polymorphic                    eruption                  of

 

pregnancy/PUPPP

23

4.6%

Pruritic folliculitis

5

1%

Total

89

17.8%

 

Amongst 500 cases, 36 (7.2%) presented with prurigo of pregnancy, and 25 (5%) presented with pruritus gravidarum. PUPPP constituted 4.6% of the cases, and 5 (1%) presented with pruritic folliculitis of pregnancy.

 

Table No: 6: The various dermatological diseases observed in the study population have been tabulated below.

Distribution of Dermatological diseases

Disease

Number

Percentage

Scabies

56

11.2%

Pityriasis versicolor

51

10.2%

Acnevulgaris

50

10%

Candidiasis

33

6.6%

Tinea Cruris

26

5.2%

Tinea corporis

30

6%

Achrochordon

17

3.4%

Polymorphic light eruption

17

3.4%

Miliaria rubra

27

5.4%

Allergic contact dermatitis

15

3%

Irritant contact dermatitis

11

2.2%

Varicosities

11

2.2%

Discoid eczema

9

1.8%

Keloids

8

1.6%

Chicken pox

8

1.6%

Tinea fecei

5

1%

Urticaria

7

1.4%

Herpes simplex

6

1.2%

Onychomycosis

8

1.6%

Verruca vulgaris

8

1.6%

Erythrasma

6

1.2%

Intertrigo

7

1.4%

Systemic lupus erythematosus

1

0.2%

Leprosy

3

0.6%

Neurofibromatosus

4

0.8%

Condyloma acuminate

6

1.2%

Molluscum contagiosum

7

1.4%

Vitiligo

8

1.6%

Pityriasis rosea

10

2%

Furuncle

5

1%

Milia

5

1%

Acanthosis Nigricans

8

1.6%

Herpes simplex

8

1.6%

Prurigo nodularis

1

0.2%

Papular urticaria

5

1%

Scabies, fungal, infections (pityriasis versicolor, T.corporis, T cruris, candidiasis) and acne vulgaris were the commonly observed skin diseases associated with pregnancy.

 

Fig: 1 INTERTRIGO ON WAIST REGION

 

 

Fig: 2 TINEA INCOGNITO AROUND UMBELICUS

 

Fig: 3 PITYRIASIS VERSICOLOR ON FACE

 

Fig: 4 PEP/P.U.P.P.P

DISCUSSION

Pregnancy leads to various changes in the skin, with some linked directly to pregnancy and others referred to as physiological changes, resulting from hormonal fluctuations during this period. Typically, these physiological skin changes do not negatively affect the health of either the mother or the fetus. However, some of these alterations can be cosmetically important and relevant for dermatologists. The physiological changes may become pathological if they are severe. Moreover, it's essential to note that certain skin changes might not originate primarily from hormonal influences. Additionally, metabolic, endocrine, vascular, and immunological adjustments make pregnant women more prone to exacerbation of particular skin conditions.

In the present study, the maximum number of patients were observed in the 15 to 20-year age group [36%], followed by the 21 to 30-year age group [58.4%]. The number of patients in 31 to 40 years constituted 5.6% of total patients. The youngest patient was 18 years old and the oldest patient was 40 years old.

 

In this study, the incidence of primigravidas was 50.8%, whereas multigravidas accounted for 49.2% of cases. This observation may be because multigravidas are more prone to profound physiological changes. The maximum number of patients examined was in the third trimester 46.8%, while those in the second and first trimesters accounted for 40.6% and 12.6% of cases respectively.

 

The most common physiological changes are pigmentary alterations, stretch marks, vascular spider and telogen effluvium. In an Indian study13, 91.4% of cases had hyperpigmentation, the most common being linea nigra seen in 91.4% of cases. Secondary areola developed in 78.4% of cases. Generalised darkening of skin was reported in 4(0,66%) cases. The findings are comparable to our study.

 

In the present study, 82% of pregnant women had pigmentation of skin mostly over the areolae, external genitalia, neck, face, axillae, abdomen & buttocks, while linea nigra was observed in 91%. This is because most of the patients entered in this study were multigravidas and the pigmentary changes are more marked in them, and also because most of the primigravidas in this study belonged to the last trimester, the period by which pigmentary changes tend to be more noticeable. In an Indian study13, 91.4% of cases had hyperpigmentation, the most common being linea nigra seen in 91.4% of cases, and secondary areolae developed in 78.4% of cases. Generalised darkening of skin was reported in 4(0.66%) cases. These findings are comparable to our study.

 

Melasma was observed in 10.6% of patients in this study. Melasma was noted in 8.8% of patients in an Indian study. In Western literature, an incidence of 50 to 70% of melasma was reported to occur in white skin. The difference may be because in Indians, being dark skinned it is difficult to detect very minimal change.  In addition, most of the women attending the hospital, being agricultural workers, are occupationally exposed to sunlight and are pigmented.  40% had strain over the thighs, 5% had striae over the breast and 2% had striae over the hips which correlated with increased maternal weight gain. In a study by Sujata Raj et al14, striae distensae were found in 75%, thus confirming our earlier findings. Abdominal striae were commoner in muligravidas, but the prevalence of striae at other sites was approximately equal in multi and primigravida.

 

The commonest symptom complained by patients was pruritus (64%). In an Indian study13, an incidence of 73.6% was found. In the present study, pruritus was due to specific diseases of pregnancy like prurigo pregnancy, pruritus gravidarum, polymorphic eruption of pregnancy and co-existing diseases like scabies, dermatophytoses, polymorphic light eruption, papular urticaria, allergic contact dermatitis, miliariarubra, urticaria. In this study pruritus without skin lesions was seen in 5% of cases. In this study pruritus without skin lesions was seen in 5% of cases. This finding emphasizes the need for thorough screening of pregnant women presenting with itching rather than dismissing the patients as cases related to pregnancy. Telogen effluvium is observed in 20% of cases.

 

SPECIFIC DERMATOSES OF PREGNANCY

 Specific dermatoses of pregnancy are almost associated with pruritus and an eruption of variable severity. The incidence of these specific disorders of pregnancy is 0.5%-3 %. In our study, specific dermatoses of pregnancy are seen in 17.8% of the cases. In a study by Rashmi et al15 out of 607 pregnant women, 22(3.6%) specific dermatoses of pregnancy were seen. Of these, the most common was PUPPP with a total of 63.6% (14/22) cases followed by 5 (22.7%) cases of pruritus gravidarum.

 

PRURIGO OF PREGNANCY

 Prurigo of pregnancy was the commonest specific disorder of pregnancy. Accounting for 9.14%. In this study prurigo of pregnancy was the commonest specific disease found accounting for 7.2% of cases. The cases ranged from 5th month to 9th month of gestation. Most of the patients presented with lesions on the extensor aspects of extremities.  Lesions over the abdomen also were present in a few patients. Two multigravidas gave a history of similar conditions in their previous pregnancies. In both of them, the condition resolved postpartum only to recur in the present pregnancy. In the present study, none of the affected patients had a history of atopy. Western studies15 report an incidence of 0.5% to 2% of prurigo of gestations. An incidence of 1.2% was found in an Indian study13. In their study prurigo of pregnancy was the commonest specific disorder. The difference in incidence may be because the above-quoted studies were done about women attending antenatal clinics and the incidences quoted are to the total number of pregnant women screened, but the present study is concentrated on the incidence of pregnant women attending the department with skin problems.

 

PRURITUS GRAVIDARUM

The incidence of pruritus graviduram is reported to be 0.02% - 2.4%. Worldwide. In an Indian study13, an incidence of 3.52% was noted. All patients were in the last trimester. Liver function tests revealed a slight increase in alkaline phosphatase, thus confirming previous reports.

 

POLYMORPHIC ERUPTION OF PREGNANCY

 An incidence of 4.6% polymorphic eruption of pregnancy was obtained in this study. In Western literature, it was described as the most common of gestational dermatoses with an approximate incidence of 1 in 160 pregnancies.17 An Indian study13 found an incidence of 0.2% of polymorphic eruption of pregnancy. In the present study, the affected patients were primi gravidas in the third trimester. They presented with wheals, papules and target lesions over the abdomen. Sparing of the umbilical area was noted. 

 

OTHER DERMATOLOGICAL CONDITIONS

In the present study 500 pregnant women were examined and a total number of 36 different diseases were diagnosed apart from the specific dermatoses of pregnancy. Scabies were noted in 11.2% of the cases and were the most common dermatological condition recorded. Positive family history, poor hygiene and ignorance of these people might have contributed to the high incidence of scabies. Pityriasis versicolor was noted in 10.2% of the pregnant women. Though P.Versicolor is known to be exacerbated by pregnancy, except for a few patients, who exhibited an extensive distribution, no particular difference from the general population was noted.

 

Allergic contact dermatitis and irritant contact dermatitis accounted for 3% and 2.2% of cases respectively, and were found to be occupational. Discoid eczema was noted in 1.8% of cases. All the patients had eczema before the onset of pregnancy. Varicosities in different sites are common during pregnancy and may occur in up to 40% of cases. In this study leg varicosities were noted in 2.2% of cases. Keloids were noted in 1.6% of cases. One patient presented with keloids in striae, and one patient noted an increase in the size of the keloid. This may be due to the tendency of the keloids to grow rapidly during pregnancy.

 

Multiple giant molluscum contagiosum, and extensive condylomata acuminate were noted in 1.4%1.2% respectively. One patient with condyloma acuminate was primigravida and was found to be seropositive for HIV by tricot method. HIV infection is frequently associated with dermatological, manifestations like condylomata accuminata, molluscum contagiosum and scabies. Knowledge of pregnant women’s HIV status allows them to get the interventions to minimize mother-to-child transmission. Condylomata accuminata are known to grow rapidly during pregnancy irrespective of the H.I.V. status.

Miliaria rubra was noted in 5.4% of cases and intertrigo was noted in 1.4% of cases. Eccrine sweating increases during pregnancy, which might predispose to an increased incidence of miliaria and intertrigo in a pregnant woman. Pityriasis rosea was diagnosed in 2% of cases. P.R. was reported in 14 pregnant women in a study. However, the incidence of P.R. in pregnancy is unknown. In this study patients presented with herald patch and typical P.R. rash. Other conditions recorded in this study include onychomycosis (1.6%), milia (0.5%), and erythrasma (1.2%). These diseases were uninfluenced by pregnancy. Acanthosis nigricans is observed in 1.6%, and prurigo nodularis in 0.2%.

CONCLUSION

In this research involving 500 pregnant individuals with skin issues, it is clear that pregnant women are susceptible to a variety of dermatological conditions beyond just the specific skin disorders associated with pregnancy. This research highlights the importance of thorough and careful examination for skin diseases rather than simply conducting a quick assessment and attributing symptoms to the normal phases of pregnancy. Collaboration between dermatologists and obstetricians should enable the identification and treatment of skin conditions in this unique population.

REFERENCES
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  2. Sachdeva S. The dermatoses of pregnancy. Indian J Dermatol 2008;53(3):103–5.
  3. Khan Y, Gills S. Herpes gestationis in a primigravida resulting in foetal death. J Pak AssocDermatol. 2002;12:54-7.
  4. Samdani A J. Pregnancy dermatoses: A three-year study. Pak J Med Sci. 2004;20:92-5.
  5. Ropponen A, Sund R, Riikionen S, Yikorkala O, Aittomaki K. Intrahepatic cholestasis of pregnancy as an indicator of liver and biliary diseases: a population-based study. Hepatology. 2006; 43(4):723-8
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  9. Black MM. Polymorphic eruption of pregnancy. In: Black MM, et al., editors. Obstetric and Gynecologic Dermatology. 2nd ed. London: Mosby, 2002, 39–44p.
  10. Lammert F, Marschall HU, GlantzA et al. Intrahepatic cholestasis of pregnancy: molecular pathogenesis, diagnosis and management. J Hepatol. 2000;33:1012–21.
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  12. Black MM. Pemphigoidgestationis. In: Black MM, et al., editors. Obstetric and Gynecologic Dermatology.2nd ed. London: Mosby, 2002, 32–8p.
  13. Hassan I, Bashir S, Taing S. A clinical study of the skin changes in pregnancy in Kashmir valley of north India: a hospital-based study. Indian J Dermatol. 2015;60(1):28-32.
  14. Raj S, Khopkar U, Kapasi A, Wadhwa SL. Skin in pregnancy. Indian J Dermatol Venereol Leprol. 1992;58:84-8.
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