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1、Pregnancy dermatoses2009.08.111Physiologic skin changes in pregnancyDermatoses exacerbated by pregnancyDermatoses only occurring in pregnancySpecific dermatoses of pregnancy2Physiologic skin changes in pregnancy妊娠期皮肤的生理变化34Hyperpigmentation 色素沉着Occurs in 90% of pregnant womenIncreased melanocyte-sti
2、mulating hormoneAccentuation on areolae, genital skin, and linea albaUsually regresses postpartum5Melasma 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 exposur
3、e6Hirsutism 多毛症Face, limbs, and backRegresses within 6 months postpartumSlowed conversion from anagen to telogen hairs7Nail changes 甲改变 Transverse grooving Brittleness Distal onycholysis8Increased eccrine gland activity 内分泌腺活性增加MiliariaDyshidrotic eczemaHyperhidrosis9Decreased apocrine gland activit
4、y大汗腺活动性减少Hidradenitis suppurativa alleviated10Increased sebaceous gland activity 皮脂腺活动性增加Exacerbation of acne vulgarisMontgomerys tubercles enlarge11Striae distensae妊娠纹Occur in 90% of pregnant womenPink or purple atrophic longitudinal bandsCaused by increased adrenocortical activityFade postpartum t
5、o persistent pale atrophic bands12Vascular changes血管变化Spider neviPalmar erythemaNonpitting facial edemaVenous varicosities: LegsVasomotor instabilityDermographismEdema and hyperemia of gingivae13Dermatoses exacerbated by pregnancy妊娠期加重的皮肤病1415Atopic eczema 特应性皮炎May deteriorate or remit during pregna
6、ncylimbs 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, UVB16Psoriasis 银屑病Most common type : chronic plaque psoriasisDifferential diagnosis of pustular v
7、ariant 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 an
8、d breast-feeding.17Acne vulgaris寻常痤疮Urticaria荨麻疹Lichen planus扁平苔藓18Infections 感染性皮肤病Viral (herpes simplex, varicella zoster)Bacterial (impetigo, trichomoniasis, leprosy)Fungal (candidal, Pityrosporum folliculitis)AIDS19Lupus erythematosus (LE)Debate continues ：whether lupus flares are more common in
9、 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
10、 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.20Systemic sclerosisPolymyositis/DermatomyositisPemphigus21Cutaneous
11、 tumors affected by pregnancyPyogenic granulomaHemangiomaHemangioendotheliomaGlomus tumorDermatofibromaLeiomyomaKeloidNeurofibromaNeviMelanoma22Dermatoses only occurring in pregnancy仅发生在妊娠期的皮肤病23Impetigo herpetiformis疱疹样脓疱病Reminiscent of pustular psoriasis, no prior history of psoriasisAssociated wi
12、th 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 featu
13、res 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 pla
14、cental insufficiency still frequently seen even when disease is apparently controlled. Remission postpartum but recurrence in successive pregnancies occurs frequently.24Intrahepatic cholestasis of pregnancy妊娠期肝脏内胆汁郁积Increased incidence Presents in third trimester with severe intractable pruritus Cli
15、nical : 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
16、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
17、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, a
18、nd preterm delivery. 25Specific dermatoses of pregnancy妊娠特异性皮肤病26Pruritic 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 sub
19、sequent 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 fa
20、ceSerologic 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, alt
21、hough several theories including the role of sex hormones and abdominal wall distension caused by pregnancy272829Prurigo 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 describe
22、d 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 resul
23、t of physiologic pruritus in women with an atopic backgroundTreatment: Moderately potent topical corticosteroids, antihistaminesPrognosis: No adverse effects to mother or infant; resolution postpartum30Herpes gestationis 妊娠疱疹Autoimmune bullous disorder, closely related to bullous pemphigoid (BP)Rare
24、 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 preg
25、nancy)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 insuffi
26、ciencyHistopathologic 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
27、 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 of hemidesmosomes; anti-HLA antibodies found in serum of patients with PGTreatment: Mild cases will respond to po
28、tent topical steroids; most cases require systemic corticosteroids with gradual dose reduction as disease remits; postpartum flare often occurs; oral contraceptive therapy also leads to disease flare; Goserelin (LHRH analogue)(chemical oophorectomy) used in severe cases in postpartum phase313233Prur
29、itic folliculitis of pregnancy妊娠瘙痒性毛囊炎Pruritic erythematous follicular papules and urticarial lesions on limbs and abdomen in most casesOnset in second and third trimester with resolution within 2 to 3 weeks postpartumHistopathologic features: Acute folliculitis with mixed inflammatory cells, upper dermal edema and spongiosis; negative Grams stainPathophysiology: Unknown; maternal androgens not implicated as previously suggestedPrognosis: Maternal and fetal outcome normal3435
