IJD FOCUS: DERMATOLOGY IN INDIA
|Year : 2015 | Volume
| Issue : 1 | Page : 28-32
|A clinical study of the skin changes in pregnancy in Kashmir valley of north India: A hospital based study
Iffat Hassan, Safia Bashir, Shahnaaz Taing
Department of Dermatology, STD, Leprosy, Gynaecology and Obstetrics, Government Medical College, Srinagar (University of Kashmir), Jammu and Kashmir, India
|Date of Web Publication||26-Dec-2014|
Department of Dermatology, STD and Leprosy, Government Medical College, Srinagar (University of Kashmir), Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Pregnancy is associated with multiple skin changes, most of which are physiological in nature, being the direct result of expected modifications of the hormonal, vascular, metabolic or immunologic status in pregnant females. Pregnancy however is also associated with certain pruritic eruptions, which not only cause distress to the pregnant female, but may influence the fetal outcome as well. Objective: The objective of this study was to determine the pattern of skin changes associated with pregnancy and to identify the various clinical types of pregnancy specific dermatoses (PSDs). Materials and Methods: The study was a cross sectional study carried out at the out-patient Department of Gynecology and obstetrics of our hospital. A total of 650 pregnant females, irrespective of their parity and gestational age were screened for the presence of any dermatological complaint. Results: The age of the study population ranged from 17 to 39 years (mean age: 24 years). The study population included 272 (42%) primigravidae and 378 (58%) multigravidae. Physiological skin changes of pregnancy were seen in all patients, out of which linea nigra was the most common change, seen in 520 (80%) cases. Specific dermatoses of pregnancy were seen in 32 (4.9%) cases, which included (in the decreasing order of frequency) prurigo of pregnancy (50% cases), intrahepatic cholestasis of pregnancy (25% cases), polymorphic eruption of pregnancy (22% cases) and pemphigus gestationis (3% cases). Conclusion: Skin changes were seen in 100% of pregnant females in this study, the major proportion being formed by physiological skin changes of pregnancy though PSDs were also seen in a significant number.
Keywords: Physiological changes, pregnancy specific dermatoses, skin
|How to cite this article:|
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;60:28-32
|How to cite this URL:|
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 [serial online] 2015 [cited 2020 Sep 23];60:28-32. Available from: http://www.e-ijd.org/text.asp?2015/60/1/28/147782
What was known?
Skin changes are quite common in pregnancy.
| Introduction|| |
Pregnancy is a physiological state characterized by profound immunologic, metabolic, endocrine and vascular changes, which make the pregnant woman susceptible to changes of the skin and its appendages. These alterations may range from normal cutaneous changes that occur with almost all pregnancies, to common diseases that are not associated with pregnancy, to eruptions that appear to be specifically associated with pregnancy.  Physiological skin changes in pregnancy include changes in pigmentation, alterations of the connective tissue and vascular system as well as changes in hair and nails.  Many of these alterations regress significantly within the 1 st 6 months postpartum. Several skin eruptions seem to be specifically related to pregnancy and are best known as pregnancy specific dermatoses (PSDs). These are most commonly seen during the third trimester of pregnancy, with pruritus being the leading symptom. , Over decades, attempts have been made to establish a reasonable classification of these dermatoses, , but their rarity, variable clinical morphology and lack of unequivocal diagnostic tests has led to confusing terminologies. The most recent rationalized classification of PSDs has been proposed by Ambros-Rudolph et al.  in 2006, which includes pemphigoid gestationis (PG), polymorphic eruption of pregnancy (PEP), intrahepatic cholestasis of pregnancy (ICP) and the atopic eruption of pregnancy.
| Materials and Methods|| |
The study was conducted on pregnant females attending the outpatient Department of Gynecology and obstetrics of our hospital, over a period of 1 year. A written informed consent was taken from all the patients before the study. A total of 650 pregnant females attending the out-patient department of the above mentioned hospital for routine obstetric checkup were enrolled in the study and screened for the presence of any dermatological complaint/s. A detailed history including demographic data, parity, chief dermatological complaints, onset in relation to the duration of pregnancy, presence of itching, history of atopy, jaundice, similar complaints in previous pregnancies, family history, exacerbating factors, associated medical or skin disorders, was elicited. General physical, systemic and complete cutaneous examination was carried out in all patients. The physiological changes of skin and its appendages were noted. In patients presenting with specific dermatoses of pregnancy, the morphology and distribution of lesions was recorded. The presence of any coincident dermatoses developing during pregnancy was studied. Routine investigations including complete blood count, liver function tests, kidney function tests and urine examination were carried out in all patients. Screening for syphilis, enzyme-linked immunosorbent assay for human immunodeficiency virus and hepatitis serology was also done in all cases. Relevant bedside laboratory procedures such as Tzanck smear, potassium hydroxide mount, etc., were carried out. Skin biopsy and direct immunofluorescence were carried out in a few patients to confirm the diagnosis. Total serum immunoglobulin E (IgE) levels and total serum bile acid levels were measured wherever deemed necessary.
| Results|| |
A total of 650 pregnant females with a mean age of 24 years (range: 17-39 years) were included in the study, out of which 272 (42%) were primigravidae and 378 (58%) were multigravidae. Skin changes were observed in all cases. All 650 cases presented with physiological skin changes of pregnancy, 32 (4.9%) had specific dermatoses of pregnancy, whereas 48 (7%) presented with miscellaneous skin disorders coinciding with pregnancy. Of the physiological changes, melasma was seen in 420 (64%) cases. Centrofacial pattern of melasma was seen in 282 (67%) cases, malar in 130 (31%) cases and mandibular pattern in 8 (2%) cases. Linea nigra occurred in 520 (80%) cases [Figure 1], whereas secondary areola was seen in 487 (75%) cases [Figure 2]. Localized pigmentation at other sites including abdomen, breasts and buttocks was seen in 23 (3.5%) cases. Striae distensae were present in 252 (38.7%) cases [Figure 3] of which 103 (41%) were primigravidae and 149 (59%) were multigravidae. The most common site for occurrence of striae was the abdomen (seen in all cases with striae) though other sites like thighs, abdomen and breasts were also involved in a few patients. Palmar erythema was seen in 41 (6.3%) cases, 24 (3.7%) had spider nevi [Figure 4], increased hair loss occurred in 12 (1.8%) cases and pyogenic granuloma was seen in 2 (0.3%) cases. Pyogenic granuloma occurred over the hand in one case whereas the lower lip was affected in the other [Table 1].
Among the specific dermatoses of pregnancy, prurigo of pregnancy was seen in 16 (50%) cases [Figure 5]. Of the 16 cases, 11 (69%) were multigravidae whereas 5 (31%) were primigravidae. History of atopy could be elicited in 12 (75%) cases. 3 out of the 11 (27%) multigravidae gave a history of similar lesions in previous pregnancy. In all cases, the lesions predominantly involved the limbs. In 3 (19%) cases, the eruption started during the first trimester, in 5 (31%) cases during the 2 nd trimester and in 8 (50%) cases, it started during the third trimester. Serum IgE levels were raised in 3 (19%) cases.
ICP occurred in 8 (25%) cases. Of these, 3 (37.5%) were primigravidae and 5 (62.5%) were multigravidae. All patients presented with pruritis as the only complaint. No primary lesion could be appreciated in any of the cases. Pruritis started during the 2 nd trimester in 2 (25%) cases and during the third trimester in 6 (75%) cases. 4 out of 5 (80%) multigravidae reported identical symptoms in the previous pregnancies. A family history of similar complaints during pregnancy could be elicited in 2 (25%) cases. Jaundice was seen in 1 (12.5%) case and alkaline phosphatase was raised in 3 (37.5%) cases. Hepatitis serology was negative in all cases.
PEP was observed in 7 (22%) cases, all being primigravidae [Figure 6]. All were single gestation pregnancies. The eruption started in the third trimester in all cases. 6 out of 7 (86%) patients developed the eruption first over the lower abdomen, which was followed by the appearance of similar lesions over the rest of the body. One (14%) patient however developed the eruption first over upper thighs and flanks.
|Figure 6: Typical urticarial lesions along the striae in polymorphic eruption of pregnancy|
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One (3%) case of PG was seen in this study [Figure 7]. Patient was a multigravida with no such history in the previous pregnancy. Patient started with itchy, urticarial lesions over the abdomen during the third trimester, which was followed by a generalized bullous eruption. Palms, soles and mucosae were spared [Table 2].
|Figure 7: Bullous lesions over a background of urticarial lesions in pemphigoid gestationis|
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Other coincident dermatological disorders developing during pregnancy that were observed in this study included scabies (14 cases, 2%), acute urticaria (9 cases, 1.3%), acne vulgaris (6 cases, 0.1%), polymorphic light eruption (4 cases, 0.6%), discoid eczema (4 cases, 0.6%), psoriasis (3 cases, 0.5%), contact dermatitis (2 cases, 0.3%), pityriasis versicolor (2 cases, 0.3%), molluscum contagiosum (2 cases, 0.3%), herpes simplex (1 case, 0.1%) and dermatitis artefacta (1 case, 0.1%) [Table 3]. None of the patients reported any change in these conditions over the course of pregnancy.
| Discussion|| |
Pregnancy is associated with significant cutaneous changes which may range from physiological skin changes, to common skin diseases occurring coincidently with pregnancy, to eruptions seen exclusively during pregnancy or postpartum period. Physiological cutaneous changes may be seen in up to 100% of pregnant females. The commonly encountered physiological skin changes include pigmentary changes (in the form of melasma, linea nigra, secondary areola, localized or generalized hyperpigmentation), vascular alterations (such as palmar erythema, spider angiomas, varicosities), striae distensae, hair and nail changes. Pigmentary skin changes constitute the most common cutaneous alteration seen in up to 90% of pregnant women.  In our study, pigmentary changes were seen in 89% of cases, of which linea nigra was the most common, seen in 80% of cases followed by secondary areola seen in 75% of cases. Kumari et al.  reported linea nigra in 91.4% of their cases and secondary areola in 78.4%, which is comparable to our study. Melasma was seen in 64% of cases in our study, with centrofacial pattern being the most common, seen in 67% of those affected. Most of the studies from the Indian subcontinent, ,,, have reported a much lower incidence of melasma in pregnant females. Muzaffar et al.  found melasma to be present in 46% of their cases.
Striae distensae develop in up to 90% of women during the 6 th and 7 th month of pregnancy.  In our study, striae were seen in 38.7% of cases and were more common in multigravidae (59%) than in primigravidae (41%). Lower abdomen was the most commonly involved site.
Vascular changes result from distension, instability and proliferation of vessels during pregnancy and are more discernible in fair skinned individuals. Palmar erythema was observed in 6.3% of our cases, whereas spider nevi occurred in 3.7%. Muzaffar et al.  reported palmar erythema in 12% of their cases.
Pregnancy may be associated with a change in physical characteristics of pre-existing naevi as suggested by some authors. , However, no such changes were observed in any of our cases.
Nail changes such as brittleness, subungual hyperkeratosis, onycholysis and leuconychia have been reported during pregnancy. However, no significant nail changes in pregnant females were observed in our study.
Pregnancy specific skin dermatoses include an ill-defined, heterogenous group of pruritic skin eruptions, which are seen only in pregnancy. Specific dermatoses of pregnancy include PEP, ICP, PG and atopic eruption of pregnancy (which is a combination of eczema of pregnancy, prurigo of pregnancy and pruritic folliculitis of pregnancy). The incidence of these specific dermatoses of pregnancy ranges from 0.5% to 3%.  In our study comprising of 650 cases, PSDs were seen in 32 (4.9%) cases, which is comparable to that seen in a study by Chander et al. 
Prurigo of pregnancy was the most common PSDs seen in our study. It was observed in 16/32 (50%) cases. The results are similar to those encountered by Masood et al.  However, a much lower incidence of 4.5% and 19% has been reported by Kumari et al.  and Puri and Puri  respectively. Prurigo of pregnancy, previously described as Besnier's prurigo gestationis is seen in about 1 in 300 pregnancies and is reported in all trimesters of pregnancy.  It presents as intensely pruritic papules, chiefly over the extensor aspects of limbs, though abdomen may also be involved in some cases. Recurrence during subsequent pregnancies is variable. History of similar lesions in the previous pregnancy was present in 27% of multigravidae in our study. History of atopy could be elicited in 2/3 rd of patients. In most of the patients, the eruption developed during the second half of pregnancy.
The second most common PSDs observed in our study was ICP, seen in 8/32 (25%) cases. ICP occurs due to a mild form of intrahepatic bile secretory dysfunction. Incidence of ICP is reported at 1 in 100 pregnancies.  It is seen in the third trimester of pregnancy in about 70% of cases.  Recurrence in subsequent pregnancies occurs in many patients.  The important feature of cholestasis is the absence of primary lesions such that excoriations are the only cutaneous finding.  Elevation of serum bile acids is the most sensitive marker of ICP.  In our study, 2/3 rd of cases developed the symptoms first during the third trimester of pregnancy. 80% of multigravidae reported history of similar eruption in previous pregnancy/ies and a family history of ICP was present in 25% of cases.
PEP was seen in 7/32 (22%) cases of PSDs in our study. Two recent studies from India , reported a higher prevalence, with PEP being the most common PSDs in their respective studies. PEP occurs in 1 of 160-240 pregnancies and is more common in white women.  It occurs classically in primigravidae during the third trimester of pregnancy or occasionally postpartum and does not usually recur in subsequent pregnancies. Incidence of PEP is higher in multiple gestations. All the affected patients in our study were primigravidae and all carried single gestation pregnancies.
There was a single case (3%) of PG in our study. PG is a rare autoimmune bullous disease of pregnancy with incidence of 1 in 10,000-1 in 50,000 pregnancies.  The disease is probably triggered by a placental antigen that cross-reacts with skin antigens.  It often recurs in subsequent pregnancies appearing earlier in gestation and in more severe forms.  The condition is characterized by sudden onset of intensely pruritic urticarial lesions usually over the abdomen, followed by development of a generalized bullous eruption with relative sparing of face, mucous membranes, palms and soles.  Our patient was a multigravida, but there was no history of similar complaints in the previous pregnancy.
| Conclusion|| |
Skin changes are quite common in pregnancy though most of them are physiological in nature and need no further management. However, the pruritic eruptions of pregnancy, which are not a rare entity, can be a source of significant distress to the pregnant female and need timely therapeutic intervention.
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What is new?
Prurigo of pregnancy is also a common pregnancy specific dermatosis.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2], [Table 3]
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