Dermatological Problems in Pregnancy

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Dermatological Problems in Pregnancy — Safe Treatment

Skin problems in pregnancy range from harmless physiological changes to conditions that endanger the baby, such as cholestasis, pemphigoid gestationis, and pustular psoriasis. This guide covers normal changes, pregnancy-specific dermatoses, common skin diseases, and safe treatment, using the ITCHING approach.

🎯 AT A GLANCE — SKIN AND PREGNANCY

Skin changes occur in nearly every pregnancy; most are harmless physiological changes (pigmentation, stretch marks, vascular spiders, hair and nail changes)

Four pregnancy-specific dermatoses: atopic eruption of pregnancy (AEP), polymorphic eruption of pregnancy (PEP), pemphigoid gestationis (PG), and intrahepatic cholestasis of pregnancy (ICP) — plus pustular psoriasis of pregnancy

Itch is the commonest symptom: itch without a rash (especially palms and soles at night) is ICP until proved otherwise — it is the one that can kill the baby

Two things decide management: is there a primary rash (papules, plaques, blisters)? and is the fetus at risk? (ICP, PG, and pustular psoriasis are; AEP and PEP are not)

Never attribute generalised itch in late pregnancy to 'dry skin' before checking liver function tests and fasting or random bile acids

🚨 ACT AT ONCE

Itch on palms and soles, worse at night, no rash — obstetric cholestasis: bile acids and liver tests the same day; risk of stillbirth

Blisters beginning around the navel — pemphigoid gestationis: skin biopsy with direct immunofluorescence; fetal growth scans

Widespread pustules with fever — pustular psoriasis of pregnancy: admit, check calcium and albumin, fetal surveillance

Rash with fever or palm and sole lesions: exclude syphilis, varicella, measles, rubella, drug eruption

🗺️ THE PATHWAY AT A GLANCE

1 · LookIs there a primary rash? Where did it start? (navel, striae, flexures, palms)

2 · TimeGestation at onset, first or later pregnancy, previous skin disease

3 · TestBile acids and liver tests; biopsy with immunofluorescence for blisters; exclude infection

4 · TreatEmollients, topical steroids, antihistamines; specific drugs by diagnosis

5 · WatchFetal growth and wellbeing in ICP, PG, and pustular psoriasis

6 · PlanTiming of delivery, postpartum flares, and recurrence advice

STEP 1 · PHYSIOLOGICAL SKIN CHANGES — common, harmless, reassure

🌸 NORMAL SKIN CHANGES OF PREGNANCY

Change	Details
Pigmentation	Darkening of nipples, areola, genitalia, linea nigra; melasma (chloasma) in about 50–70% (face, worse in sun); fades after delivery but may persist — sunscreen with broad-spectrum protection and a hat
Striae gravidarum	Stretch marks in about 80–90% (abdomen, breasts, thighs); risk higher in young women, family history, large weight gain, big babies; no cream is proven to prevent them; fade to silvery lines
Vascular	Spider naevi, palmar erythema, varicose veins, haemorrhoids, oedema; gingival swelling and bleeding; pyogenic granuloma (epulis)
Hair	Hair thicker in pregnancy (longer growth phase); telogen effluvium (diffuse shedding) 1–5 months after delivery, recovers in 6–12 months
Nails and glands	Brittle nails, ridging, separation from the nail bed; acne may flare; increased sweating, and reduced apocrine gland activity

Counsel: these are normal; sun protection limits melasma; avoid hydroquinone and tretinoin in pregnancy; treat melasma after delivery if it persists

STEP 2 · PREGNANCY-SPECIFIC DERMATOSES — know the four, and the fifth

🔴 ATOPIC ERUPTION OF PREGNANCY AND POLYMORPHIC ERUPTION

Condition	Features and management
Atopic eruption of pregnancy (AEP)	Commonest (about half of pregnancy dermatoses); early or mid pregnancy; eczema on flexures (E-type) or itchy papules and nodules (P-type); often a history of atopy; no fetal risk
Treatment of AEP	Emollients, mild to moderate topical steroids, antihistamines (chlorphenamine at night; loratadine or cetirizine by day); narrowband ultraviolet B or short oral prednisolone if severe; treat infection (staphylococcus)
Polymorphic eruption of pregnancy (PEP, PUPPP)	First pregnancy, third trimester, twins; itchy urticarial papules and plaques that start in the stretch marks of the abdomen and spare the navel; spreads to thighs and limbs; no fetal risk
Treatment of PEP	Emollients, moderate to potent topical steroid, antihistamines; oral prednisolone if severe; resolves within days to weeks after delivery; seldom recurs

🫧 PEMPHIGOID GESTATIONIS (PG)

Topic	Details
What it is	Rare autoimmune blistering disease (about 1 in 50,000) with antibodies against BP180, a skin basement membrane protein; linked to HLA-DR3 and DR4, Graves disease, and molar pregnancy
Features	Intense itch, then urticarial papules and plaques around the navel that spread to limbs and trunk and develop tense blisters; second or third trimester; may flare around delivery
Diagnosis	Skin biopsy with direct immunofluorescence (linear C3 along the basement membrane), serum anti-BP180; exclude PEP (which spares the navel and has no antibodies)
Fetal risk	Preterm birth, small-for-gestational-age babies, and stillbirth; 10% of newborns have transient blisters
Treatment	Potent topical steroids and antihistamines; oral prednisolone 0.5 mg/kg daily for blisters, reduce slowly after control
Monitoring	Growth scans and fetal surveillance; delivery at 37–38 weeks if no complications, earlier for fetal concern
Afterwards	Flare after delivery in about 75%, resolves in weeks to months; recurs in later pregnancies, usually earlier and more severe

🟡 INTRAHEPATIC CHOLESTASIS OF PREGNANCY (OBSTETRIC CHOLESTASIS)

Topic	Details
Features	Itch without a primary rash, worse at night and on palms and soles; usually after 28 weeks (can be earlier); excoriations only; dark urine, pale stools, jaundice in a few
Who	About 0.7% in the UK, higher in South Asian women; multiple pregnancy, previous ICP, family history, hepatitis C, gallstones
Tests	Fasting serum bile acids (10 µmol/L or more is abnormal; a non-fasting sample is acceptable) and liver tests (ALT, AST); if normal and the itch persists, repeat weekly; exclude hepatitis, gallstones, pre-eclampsia, HELLP
Fetal risk	Stillbirth, preterm birth, meconium, fetal distress; risk rises with bile acids, with the highest risk at 100 µmol/L or more
Treatment	Ursodeoxycholic acid 10–15 mg/kg daily in divided doses (relieves itch for many; does not clearly prevent stillbirth); emollients, cooling; vitamin K 10 mg daily if prothrombin time is prolonged
Monitoring	Bile acids and liver tests weekly; fetal growth scans; cardiotocography does not predict stillbirth
Delivery	Bile acids 100 or more: consider delivery at 35–36 weeks; 40–99: 36–37 weeks; under 40: by 38–39 weeks (local protocol; earlier for fetal compromise or deranged liver function)
Afterwards	Itch and liver tests settle within 1–2 weeks; repeat liver tests at 6–8 weeks; recurrence about 60–90%; avoid oestrogen-containing contraception until normal

🟠 PUSTULAR PSORIASIS OF PREGNANCY (IMPETIGO HERPETIFORMIS)

Rare, third trimester: sheets of sterile pustules in flexures and trunk, with fever, malaise, vomiting; low calcium and albumin cause tetany, seizures

Risks: maternal sepsis and collapse, placental insufficiency, stillbirth, and neonatal death

Treat: admit, correct calcium and fluids, oral prednisolone 30–60 mg daily, ciclosporin if needed, antibiotics for infection; deliver if refractory or fetal compromise

Differential: pustular drug eruption, bacterial infection, and generalised pustular psoriasis from steroid withdrawal

STEP 3 · OTHER SKIN PROBLEMS — and safe drug choices

🩹 PRE-EXISTING AND COMMON SKIN DISEASES

Condition	Management in pregnancy
Acne	Topical benzoyl peroxide, azelaic acid, erythromycin or clindamycin; avoid isotretinoin, oral tetracyclines, and topical retinoids
Psoriasis	Emollients, topical steroids, narrowband UVB; ciclosporin or certolizumab for severe disease; avoid methotrexate, acitretin, and PUVA (psoralen with ultraviolet A); may improve in pregnancy, flares after
Atopic eczema	Emollients, topical steroids, sedating antihistamines at night; treat infection
Scabies	Common in India; permethrin 5% cream over the whole body for 8–12 hours, repeat in 7 days; treat contacts; avoid lindane
Fungal infections	Topical clotrimazole or terbinafine; avoid oral griseofulvin and high-dose fluconazole; vaginal candidiasis: clotrimazole pessary for 7 days
Genital warts	Grow faster in pregnancy; trichloroacetic acid or cryotherapy; avoid podophyllin and imiquimod; caesarean only if obstructing
Herpes zoster and varicella	Acyclovir or valacyclovir; see the TORCH sheet for exposure and delivery plans
Urticaria	Non-sedating antihistamines (loratadine, cetirizine); look for a trigger; short oral steroid if severe
Leprosy	Multidrug therapy is considered safe and should continue; reactions and nerve damage may appear in pregnancy and after delivery — refer early
Lupus and syphilis rashes	Lupus: risk of neonatal lupus and heart block; syphilis: palm and sole rash, test and treat (see the dedicated sheet)

💊 SKIN TREATMENTS — SAFE AND TO AVOID

Group	Advice
Generally safe	Emollients, mild to moderate topical steroids, sunscreen, benzoyl peroxide, azelaic acid, permethrin, topical clotrimazole, chlorphenamine, loratadine, cetirizine, oral prednisolone, narrowband UVB
Use with care	Potent or very potent topical steroids (small areas, shortest time; large amounts may lower birth weight), ciclosporin, azathioprine, dapsone (watch for haemolysis), oral fluconazole
Avoid	Isotretinoin, acitretin, topical tretinoin; methotrexate; oral tetracyclines (doxycycline); thalidomide; finasteride and dutasteride; oral minoxidil; lindane; podophyllin; PUVA
Breastfeeding	Emollients, mild steroids, and permethrin are fine; do not apply creams to the nipple before feeds; avoid methotrexate and retinoids

⚠️ COMMON PITFALLS

Treating itch in late pregnancy with antihistamines alone without bile acids and liver tests

Calling a blistering rash 'PUPPP' without checking the navel and doing a biopsy — pemphigoid gestationis carries fetal risk

Normal liver tests on one occasion do not exclude ICP — repeat if the itch persists

Prescribing isotretinoin, tetracyclines, or methotrexate to a woman who may be pregnant

Using potent steroids on large areas for long periods, or calling scabies 'eczema' and missing the household source

Forgetting the postpartum period: PG flares, ICP recurrence advice, and telogen effluvium

Memory Aid

ITCHING

Seven rules for skin disease in pregnancy.

I

Itch without a rash — cholestasis until proved otherwise: bile acids and liver tests

T

Timing and site of onset — navel means pemphigoid; stretch marks mean PEP

C

Care with drugs — emollients, mild steroids, and safe antihistamines first

H

Hospital for pustular psoriasis and severe pemphigoid

I

Insist on fetal surveillance in ICP, pemphigoid, and pustular psoriasis

N

No isotretinoin, acitretin, methotrexate, tetracyclines

G

Give a postpartum plan — delivery timing, flares, and recurrence

Remember: rash or no rash, test the itch, protect the baby, and choose safe drugs.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Clinician-facing summary written from memory of the Royal College of Obstetricians and Gynaecologists (RCOG) obstetric cholestasis guideline, the British Association of Dermatologists (BAD) guidance, and published reviews of pregnancy dermatoses; no Government of India protocol for these conditions was found, so none is incorporated. Check current guidance before use; thresholds, intervals and regimens vary between guidelines — follow local protocol, obtain consent, and involve a senior obstetrician in any high-risk case.