Pregnancy dermatosis, atopic L30.8

Besnier 1904

Second most common dermatosis in pregnancy associated with severe pruritus (about 50% of pruritic dermatoses in pregnancy are due to this diagnosis) in patients with atopic self history or atopic family history.

50% of all pruritic dermatoses in pregnant women: incidence: 1: 300 to 1: 450

Exacerbation of the pre-existing atopic eczema in 20% of cases. In all other patients either first manifestation or re-manifestation of a previously existing atopic eczema (e.g. flexural eczema in adolescence).

Exacerbation can be explained by the dominance of a Th2 immunity, which ensures the "survival of the fetal allograft", typical of pregnancy.

The reduced cellular immune response is contrasted by a dominant humoral immune response with increased secretion of Th2 cytokines (IL-4, IL-10) (see also eczema, atopic).

Frequently (75% of cases) occurring in the 2nd trimester, possibly as early as the 1st trimester.

Face, neck, décolleté, flexion of the extremities with armpits and groin .

In the majority of cases (70%) the disease manifests itself for the first time or after years of latency with severe itching. Typically, different stages of eczema can occur: from multiple weeping and scaling papules to multiple, chronically active, flexor-side-emphasized, partly symmetrical, disseminated, dry, possibly scaly, scaly, extensive skin lesions.

In about 30% of the cases, disseminated prurigo-like, itchy papules or nodes on the trunk and extremities are found.

Patients report a very pronounced xerosis cutis.

IgE increased in 30-70% of cases!

Pemphigoid gestationis: vesiculo-bullous HV; onset in 3rd trimester, postpartum; severe pruritus; DIF: linear C3 deposits; histology: subepidermal blister.

Pruritus gravidarum (ICP; see also pregnancy, skin lesions): No primary HV; only scratch excoriations; DIF: nonspecific; laboratory: bile acids elevated.

PUPPP: Papulo-urticarial HV; onset in striae distensae; umbilical region remains exposed; DIF: nonspecific; Laboratory: o.b.; Late onset of HV (3rd trimester or postpartum).

Impetigo herpetiformis: Acute onset with severe impairment of general condition, with marked feeling of illness, fever, chills, possibly diarrhea. Flexural exanthema with bright red, extensive erythema and plaques and pustules. Laboratory: Dysproteinemia; leukocytosis; neutrophilia; iron deficiency with anemia; decreased serum calcium; markedly accelerated ESR; CRP is elevated.

• Refatting local therapy with urea-containing preparations (unproblematic during pregnancy)
• First, experiment with bland-free Lotio alba, ethanolic zinc oxide shaking mixture.
• Cool showers, "cool packs" or moist compresses, e.g. with 0.9% NaCL solution, also have a soothing effect.
• Polidocanol-containing lotions or creams (e.g. Optiderm®), shaking mixtures or gels provide relief. Especially the gel base has a pleasant, cooling and itch-relieving accompanying effect.
• Light therapy (UVB) can be helpful in addition.

• For severe and intolerable itching with considerable sleep disturbances glucocorticoids such as prednisone (e.g. Decortin) as short-term therapy (4 weeks). Initial: 0.5-2.0 mg/kg bw/day; continuing: 0.1-0.5 mg/kg bw/day; gradual dose reduction according to clinical findings.
• The administration of antihistamines during pregnancy is assessed differently in the literature. However, at the most, 1st generation preparations such as clemastine (e.g. Tavegil 2 times/day 1 tbl. p.o. or 2 times/day 1 amp. i.v.); Dimetinden (e.g. Fenistil) or Hydroxyzin (e.g. Atarax 1-3 tbl./day) come into question.

Good prognosis with rapid response to local therapy. Significant improvement even during pregnancy. Recurrences are frequent in subsequent pregnancies.

No impairment of the fetus known.

In case of bacterial superinfection, beta-lactam antibiotics and macrolides as well as acyclovir can be used systemically during the entire pregnancy.

1. Ambros-Rudolph CM (2006) Dermatoses of pregnancy. J Dtsch Dermatol Ges 4: 748-759
2. Ambros-Rudolph CM (2010) Specific pregnancy dermatoses. Dermatologist 61: 1014-1020
3. Roth MM et al (2016) Prurigo, pruritic folliculitis, and atopic eruption of pregnancy: Facts andcontroversies
   .Clin Dermatol 34:392-400.