妊娠期皮肤病

Pregnancy dermatoses,2009.08.11,Physiologic skin changes in pregnancyDermatoses exacerbated by pregnancyDermatoses only occurring in pregnancySpecific dermatoses of pregnancy,Physiologic skin changes in pregnancy妊娠期皮肤的生理变化,Hyperpigmentation 色素沉着,Occurs in 90% of pregnant womenIncreased melanocyte-stimulating hormoneAccentuation on areolae, genital skin, and linea albaUsually regresses postpartum,Melasma 黄褐斑,Occurs in 70% of pregnant womenAlso seen with oral contraceptivetherapyCentrofacial, malar, and mandibular patternsExcessive melanin in epidermis or dermal macrophagesWorsens with UVB exposure,Hirsutism 多毛症,Face, limbs, and backRegresses within 6 months postpartumSlowed conversion from anagen to telogen hairs,Nail changes 甲改变,Transverse grooving Brittleness Distal onycholysis,Increased eccrine gland activity 内分泌腺活性增加,MiliariaDyshidrotic eczemaHyperhidrosis,Decreased apocrine gland activity大汗腺活动性减少,Hidradenitis suppurativa alleviated,Increased sebaceous gland activity 皮脂腺活动性增加,Exacerbation of acne vulgarisMontgomerys tubercles enlarge,Striae distensae妊娠纹,Occur in 90% of pregnant womenPink or purple atrophic longitudinal bandsCaused by increased adrenocortical activityFade postpartum to persistent pale atrophic bands,Vascular changes血管变化,Spider neviPalmar erythemaNonpitting facial edemaVenous varicosities: LegsVasomotor instabilityDermographismEdema and hyperemia of gingivae,Dermatoses exacerbated by pregnancy妊娠期加重的皮肤病,Atopic eczema 特应性皮炎,May deteriorate or remit during pregnancylimbs and/or trunk and faceMay present for the first time in pregnancy in predisposed personIrritant hand dermatitis and nipple eczema common postpartumTreatment: topical corticosteroids, emollients, UVB,Psoriasis 银屑病,Most common type : chronic plaque psoriasisDifferential diagnosis of pustular variant from impetigo herpetiformis may be difficultTopical treatment: Dithranol, calcipotriol, tar, and corticosteroids are all safe in pregnancySystemic drugs: retinoids, methotrexate, and hydroxyurea are all contraindicated in pregnancy. Cyclosporine should be used with caution during pregnancy and breast-feeding.,Acne vulgaris寻常痤疮Urticaria荨麻疹Lichen planus扁平苔藓,Infections 感染性皮肤病,Viral (herpes simplex, varicella zoster)Bacterial (impetigo, trichomoniasis, leprosy)Fungal (candidal, Pityrosporum folliculitis)AIDS,Lupus erythematosus (LE),Debate continues ：whether lupus flares are more common in pregnancy.Cutaneous flares are the most common, followed by arthritis.Painful vasculitic lesions on the peripheries are the most common skin lesions.Neonatal LE is seen in babies of mothers with circulating anti-Ro(SSA) antibodies and can lead to congenital heart block.The antiphospholipid syndrome presents with thrombosis, recurrent miscarriage, livedo reticularis, migraine, stroke, and/or thrombocytopenia.Treatment with systemic corticosteroids and antimalarials should not be stopped in pregnancy, to prevent an acute flare.,Systemic sclerosisPolymyositis/DermatomyositisPemphigus,Cutaneous tumors affected by pregnancy,Pyogenic granulomaHemangiomaHemangioendotheliomaGlomus tumorDermatofibromaLeiomyomaKeloidNeurofibromaNeviMelanoma,Dermatoses only occurring in pregnancy仅发生在妊娠期的皮肤病,Impetigo herpetiformis疱疹样脓疱病,Reminiscent of pustular psoriasis, no prior history of psoriasisAssociated with hypoparathyroidism and hypocalcemiaSystemic upset with malaise, fever, delirium, diarrhea, vomiting, and tetany secondary to hypocalcemiaErythematous patches with pustular margin in flexural distributionSparing of face, hands, and feetPostinflammatory hyperpigmentation commonHistopathologic features identical to pustular psoriasis with spongiform pustules of Kogoj, large collections of neutrophils within foci of spongiotic epidermisLaboratory findings: Elevated leukocyte count and erythrocyte sedimentation rate, hypocalcemiaTreatment: Prednisolone 30-40 mg dailyPrognosis: Stillbirth and placental insufficiency still frequently seen even when disease is apparently controlled. Remission postpartum but recurrence in successive pregnancies occurs frequently.,Intrahepatic cholestasis of pregnancy妊娠期肝脏内胆汁郁积,Increased incidence Presents in third trimester with severe intractable pruritus Clinical : Often only excoriations; clinical jaundice rare; mal-absorption of fat can lead to weight loss and vitamin K deficiency in severe casesUsually nonresponsive to antihistamines and topical emollientsHistopathologic findings: Skin findings nonspecific; liver biopsy specimen will reveal typical changes in severe cases with dilated bile canaliculi, staining of parenchyma with bile pigments and minimal inflammation. These changes are reversible postpartum.Pathophysiology: Associated with HLA subtype B8 and BW16 and positive family history in up to 50% of cases. Physiologic concentrations of estrogens thought to interfere with hepatic bile acid secretionAbnormal serum liver function tests (LFTs) and elevated serum bile acids confirm the diagnosis Treatment: Antipruritic emollients, Ion-exchange resins , UVB, evening primrose oil.Prognosis: Increased rate of fetal distress, stillbirth, and preterm delivery.,Specific dermatoses of pregnancy妊娠特异性皮肤病,Pruritic urticarial papules and plaques of pregnancy (PUPPP)妊娠多形疹,Incidence between 1 in 160 women and 1 in 300Presents in primiparous women in third trimester or postpartumIncreased incidence in multiple pregnancyRare recurrence in subsequent pregnancies Onset with pruritus within striae on abdomen; periumbilical sparing may occurClinically characterized by various lesions including erythematous plaques, papules, vesicles, purpura, and erythema multiformelike lesionsSubsequent spread to breasts, upper thighs, and arms, sparing faceSerologic and immunofluorescence tests negativeSubtype described in which IgM deposition seen either on direct or indirect immunofluorescence Histopathologic characteristics: Spongiosis in epidermis with perivascular or upper dermal chronic inflammatory cell infiltratePathophysiology: Unknown, although several theories including the role of sex hormones and abdominal wall distension caused by pregnancy,Prurigo of pregnancy妊娠痒疹,Described by Besnier in 1904Incidence approximately 1 in 300Similar to nodular prurigo seen in nonpregnant personsLikely to be same eruption that Spangler described as papular dermatitis of pregnancyPruritic papules on extensor aspects of limbs and on abdomenNormal maternal and fetal prognosisHistopathologic features: Chronic inflammatory cell infiltrate in upper dermis with occasional epidermal featuresPathophysiology: Unknown, although thought to be a result of physiologic pruritus in women with an atopic backgroundTreatment: Moderately potent topical corticosteroids, antihistaminesPrognosis: No adverse effects to mother or infant; resolution postpartum,Herpes gestationis 妊娠疱疹,Autoimmune bullous disorder, closely related to bullous pemphigoid (BP)Rare with incidence of approximately 1 in 60,000Onset usually in second and third trimester or postpartum periodRecurrence common in subsequent pregnancy at earlier gestation and with increased severity (apart from skip pregnancies, which occur when a woman with known PG has a subsequent unaffected pregnancy)Pruritic erythematous plaques, which become annular or polycyclic, developing into vesicles or bullaePeriumbilical involvement in 87% of casesTransplacental transfer of antibodies can result in neonatal involvementAssociated with low birth weight and premature birth caused by placental insufficiencyHistopathologic features: Similar to PEP in early phases; subepidermal separation with basal cell necrosis; eosinophilic spongiosisImmunofluorescence diagnostic test: Positive direct immunofluorescence with IgG and complement 3 staining at the basement membrane zone and staining to the roof on indirect immunofluorescence using salt-split skinPathophysiology: HLA-DR3, DR4 subtypes associated; close relationship to BP, sharing same target antigen BP-180 kd (BP-AG2), a component