Pay Your BillYour Skin in Pregnancy
By George Kroumpouzos, MD, PhD, FAAD
Dermatologist, South Shore Medical Center
Pregnancy can bring about dramatic changes to the skin. During regular checkups, your physician(s) may review and advise you on these skin changes. However, when there are specific rashes, or bothersome spots requiring removal, you should visit your dermatologist.
Below you will find some frequently asked questions and answers which address common skin changes, diseases that may worsen in pregnancy, rashes specific to pregnancy, and the management of itching.
What are the pigmentary changes of pregnancy?
The most common pigmentary changes of pregnancy are hyperpigmentation and melasma. Hyperpigmentation is most noticeable on the areolae, nipples, genital skin, armpits and inner thighs. Melasma (mask of pregnancy) affects the face in 70% of pregnant women and one third of nonpregnant women taking oral contraceptives. Although the cheeks alone can be affected, the entire central face is involved in most patients and, less often, the jaws. Melasma is expected to improve or resolve postpartum, and treatment during pregnancy is not recommended. Your dermatologist will review treatment options if it persists after delivery.
What changes are expected in moles?
Moles may develop for the first time, and existing ones may become darker and/or larger in pregnancy. These changes, however, are thought to be mild and do not place you at higher risk for skin cancer. Many studies performed by dermatologists using dermoscopy show that mole changes in pregnancy reverse postpartum. Nevertheless, if a mole shows dramatic change it needs to be biopsied. Skin biopsy is a safe procedure in pregnancy.
What happens to the new red spots and broken vessels that develop in pregnancy?
Red spots (spider angiomas) and broken vessels (telangiectasias) develop in approximately two thirds of Caucasian women and 10% of African American women between the second and fifth months of pregnancy, and typically resolve within 3 months postpartum. Approximately 10% of women have persistent spider angiomas.
What are the hair and nail changes in pregnancy?
Most pregnant women develop new hair (hirsutism) on their face, trunk and extremities that typically regresses within 6 months of delivery. Additionally, postpartum hair shedding (telogen effluvium) may be noted and can cause distress. The severity of telogen effluvium varies considerably but recovery is typically spontaneous. This type of hair thinning usually resolves within 5 months of delivery, but complete resolution may occasionally take up to 15 months. Nail changes can be noticed as early as the first trimester of gestation, and include brittleness, uplifting, deposition of keratinous material under the nail, and transverse grooving. Nail changes are expected to resolve after delivery.
Will the newly developed growths resolve after delivery?
A large number of skin tags may develop in pregnancy and often persist after delivery. They do not require treatment during gestation but, if they are bothersome, can be treated safely. Other innocent growths, such as seborrheic keratoses, dermatofibromas and neurofibromas, may also develop and often persist after delivery.
Can stretch marks be prevented?
Stretch marks (striae) develop in up to 90% of Caucasians between the sixth and seventh months of gestation and less commonly in other races/ethnic groups. Risk factors include younger maternal age, genetic susceptibility, excessive weight gain, occurrence in previous pregnancy, and concurrent use of corticosteroids. Stretch marks are most prominent on the abdomen, breasts, buttocks, groin and armpits, and may become itchy. Prevention of stretch marks may be achieved with avoidance of excessive or rapid weight gain, following a nutritious diet, keeping skin well hydrated and using an effective moisturizer daily on the areas that are prone to develop stretch marks. The efficacy of commercially advertised creams, such as cocoa butter, in the prevention of stretch marks, has been modest.
Can varicosities and spider veins be prevented?
Varicosities of the distal leg veins and hemorrhoidal veins develop in more than 40% of women, but clotting (thrombosis) within these varicosities is infrequent (<10%). Avoidance of prolonged standing, using leg elevation while resting, and compression (i.e. wearing support /compression hosiery) may help to prevent varicosities. Varicosities may regress postpartum but usually not completely.
Are pregnant women prone to infections?
Yes. High estrogen levels make immune system weaker in gestation, and therefore, the risk for infections increases. The most common infection is candida vaginitis, a yeast infection of the vagina, which can affect 17% to 50% of pregnant women; of those, 10% to 40% have no symptoms. Yeast infections, such as pityrosporum folliculitis and tinea versicolor, may also develop; the latter develops on the chest, back and shoulders, typically in the warm months of the summer. Trichomoniasis is another vaginal infection that develops in 12% to 27% of pregnant women. Common and genital warts may grow during pregnancy, and the genital warts may increase in size so that they can block the birth canal, thus interfering with delivery. Herpes virus infections (similar to cold sores on the lips) of the vagina should be diagnosed promptly, as there is a risk of transmission of the virus to the fetus, which can cause serious fetal complications.
What is cholestasis of pregnancy and how does it affect the skin?
Cholestasis is a temporary liver dysfunction that can occur in pregnancy, etiologically related to high estrogen and progesterone levels. Laboratory abnormalities of the disease include liver enzyme and bile acid elevations in the blood, and can cause significant itching that cannot be easily controlled with topical antipruritic medications and antihistamines. Cholestasis needs to be diagnosed promptly by your physician as it has been linked to serious fetal risks, such as fetal distress/compromise, intrauterine death, stillbirth, preterm delivery associated with an increased prevalence of cesarean section, and meconium staining. Prompt treatment of cholestasis is critical in order to minimize fetal risks.
How can gestational itching (pruritus)be controlled?
If the itching is mild, cooling baths, topical antipruritic medications, such as Sarna lotion, emollients and certain oral antihistamines are usually helpful. When the itching is moderate to severe, a more thorough laboratory examination is required to rule out cholestasis (see above).
Is eczema expected to worsen in pregnancy?
Eczema (atopic dermatitis) is more likely to worsen than improve in pregnancy. It is the most common pregnancy dermatosis, accounting for 36 to 49.7% of all pregnancy dermatoses. A recent study indicates that 46% of females with eczema experience deterioration of the disease in pregnancy or in relation to their menstrual cycle. Two other studies showed that “new eczema” (eczema developing for the first time in gestation) accounts for up to 79% of eczema cases in pregnancy. Eczema deterioration can be prevented with dry skin care, including faithful daily use of an effective moisturizer, and judicious use of mild or mid-potency steroid creams or ointments on small skin areas.
Is acne expected to worsen in pregnancy?
The course of acne in pregnancy is unpredictable. A study indicates that 41% of women reported improvement and 29% worsening during pregnancy. Some patients may develop acne for the first time in pregnancy or in the postpartum period. Treatment for acne is tailored to the patient’s needs and should be determined by a dermatologist.
Is psoriasis expected to worsen in pregnancy?
Psoriasis is one of the skin diseases that may improve in pregnancy. Nevertheless, the pustular form of the disease can be triggered by pregnancy and is then called impetigo herpetiformis. Pustular psoriasis needs to be treated promptly as it has been associated with significant fetal risks, such as stillbirth, neonatal death and fetal abnormalities secondary to placental insufficiency.
Which rashes are specific to pregnancy?
Rashes specific to pregnancy are the following: a blistering rash called herpes (pemhigoid) gestationis, a hives-like rash called pruritic urticarial papules and plaques of pregnancy (PUPPP), an itchy rash on the extremities called prurigo of pregnancy, and an acne-like rash that is called pruritic folliculitis of pregnancy. These rashes usually resolve with delivery or soon afterwards.
Herpes (pemphigoid) gestationis: this rare blistering rash may become generalized and affect large areas of
the skin. It has been associated with fetal risks, such as preterm delivery.
Pruritic urticarial papules and plaques of pregnancy (PUPPP): a hive-like itchy rash that typically starts on the abdominal stretch marks, and can spread to other areas. No fetal risks are seen in PUPPP.
Prurigo of pregnancy: a rash that presents with itchy bumps on the extremities and is not associated with any fetal risks.
Pruritic folliculitis of pregnancy: an acne-like itchy rash on chest, back and abdomen not related to fetal risks.
Evaluation of these rashes should be performed by a dermatologist, as specific tests may be required. Your dermatologist will formulate an appropriate treatment plan, and will cooperate with your obstetrician in order to minimize any fetal risks.
