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Journal of Pakistan Association of Dermatologists 2013;23 (3):256-261.
Original Article
Frequency of specific dermatoses of pregnancy
in a tertiary care hospital
Furqana Niaz*, Zarnaz Wahid**, Ijaz Ahmed***, Sarwat Nasreen***
*Department of Dermatology, Sir Syed Medical College for Women, Karachi
**Department of Dermatology, Dow University of Health Sciences, Karachi
***Department of Dermatology, Ziauddin University, Karachi
Abstract
Objective To assess the frequency of specific dermatoses of pregnancy in a tertiary care hospital.
Patients and methods This cross sectional study was conducted on patients attending outpatient
department of Dermatology, civil hospital, Karachi referred from the outpatient department of
gynecology and obstetrics spanning, 1st May 2006 till 31st August 2006. Pregnant females of
different age groups, both primigravida and multigravida fulfilling the selection criteria were
enrolled. After an informed consent, selected patients were subjected to a detailed history and
clinical examination. Diagnosis of the diseases was made clinically and relevant investigations were
carried out where required.
Results 100 patients, comprising 32 primigravida (32%) and 68 multigravida (68%), diagnosed as
suffering from specific dermatoses of pregnancy completed the study. Minimum age of presentation
was 20 years and maximum 44 years the mean age being 32±6.8 years. Prurigo of pregnancy (96%)
was the most common dermatoses seen followed by pruritic folliculitis of pregnancy (2%), herpes
gestationis (1%) and polymorphic eruption of pregnancy (1%). Amongst 96 patients (96%)
suffering from prurigo of pregnancy, there were 28 primigravida (29%) and 68 multigravida (71%).
Both the primigravida with pruritic folliculitis of pregnancy presented one each in the 2 nd and 3rd
trimester. Patients suffering from herpes gestationis and polymorphic eruption of pregnancy (PUPP)
were primigravida presenting in 2nd trimester.
Conclusion Specific dermatoses of pregnancy can present in any trimester. Prurigo of pregnancy
remains the most common disorder followed by pruritic folliculitis of pregnancy.
Key words
Specific dermatoses of pregnancy, prurigo of pregnancy, pruritic folliculitis of pregnancy, herpes
gestationis, polymorphic eruption of pregnancy.
Introduction
Pregnancy is a physiological state leading to
changes of skin and appendages which may
become pathological when severe.1,2 These
physiological skin changes occur due to
temporary shift in hormonal, metabolic and
immunological factors.3 These conditions are
Address for correspondence
Prof. Ijaz Ahmed
Department of Dermatology,
Ziauddin University, Karachi
Email: [email protected]
generally benign, but they cause substantial
anxiety in pregnant women.4 The dermatoses of
pregnancy can be classified into 3 groups i.e.
physiological skin changes in pregnancy,
dermatoses and cutaneous tumors affected by
pregnancy and specific dermatoses of
pregnancy.4 Specific dermatoses of pregnancy
describe those conditions which result from the
state of gestation or the products of conception.
The group includes: herpes gestationis, pruritic
urticarial papules and plaques of pregnancy,
prurigo of pregnancy and pruritic folliculitis of
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Journal of Pakistan Association of Dermatologists 2013;23 (3):256-261.
pregnancy.4 These pregnancy associated specific
dermatoses are rare, but may cause significant
distress and harm to both mother and the fetus.5
Therefore, early diagnosis, prompt treatment,
and close obstetric surveillance are mandatory in
these cases.4 Specific dermatoses of pregnancy
usually, but not always, resolve after delivery.4
Herpes gestationis has an incidence of
approximately 1 in 10,000 pregnancies having
onset usually about 21st week of gestation but in
20% cases, the eruption appears immediately
postpartum.6,7 The disease usually begins with
urticarial papules and plaques around umbilicus
and extremities. Lesions tend to spare face,
palms, and soles. In about 75% of cases, herpes
gestationis flares around the time of delivery,
regressing spontaneously after the baby is born.8
Pruritic urticarial papules and plaques of
pregnancy now called as polymorphic eruption
of pregnancy is a pruritic, inflammatory skin
disorder seen in anywhere from 1 in 120 to 1 in
240 pregnancies.9 It starts in 2nd or 3rd trimester
(mean onset, 35 weeks) in 1st pregnancy.10 The
eruption is polymorphic comprising intensely
itchy urticarial, vesicular, purpuric, polycyclic or
targetoid lesions.10 The risk for fetal mortality
and morbidity is not high.11 Pruritic folliculitis of
pregnancy has a variable frequency as some
sources report less than 30 cases in all the
literature, while others indicate that the
prevalence is 1 in 10,000 pregnancy.7 Pruritic
folliculitis
of
pregnancy
presents
as
perifollicullar papules and pustules starting on
abdomen and spreading to the extremities.12 The
condition is often, but not always, pruritic and
patients are more concerned rather than being
distressed by the symptoms. Pruritic folliculitis
of pregnancy has a frequency of 1 in 450
pregnancies.13 Prurigo of pregnancy has been
reported to be the most common specific
dermatoses of pregnancy in literature.4
Kroumpouzos and Cohen12 have also described
atopy as an etiological factor for prurigo of
pregnancy.
Data regarding specific dermatoses of pregnancy
in our community are insufficient. Current study
was designed to assess the frequency of specific
dermatoses of pregnancy in a tertiary care
hospital so that any devastating complication
can be prevented in affected mothers and the
baby
Patients and methods
The cross-sectional study was conducted on
patients attending outpatient department of
Dermatology, Civil Hospital, Karachi referred
from the outpatient department of gynecology
and obstetrics. The study was completed over a
period of 4 months spanning from 1st May 2006
till 31st August 2006. Pregnant females of
different age groups, both primigravida and
multigravida, were enrolled for the study.
Patients having physiological dermatoses or
dermatoses which flare up during pregnancy
were excluded. Patients suffering from any other
dermatological or systemic diseases were also
ruled out. Patients taking any medication for any
other underlying illness during pregnancy or on
hormonal therapy were also excluded.
After an informed consent, selected patients
were subjected to a detailed history including
parity, gestational age and any cutaneous
eruption in the current pregnancy, as well as, its
duration. Past history of similar eruption and any
relevant family history of similar eruption were
also explored. A detailed clinical examination
was done. Diagnosis of the diseases was made
clinically and biopsy was performed in doubtful
cases. Any relevant investigations were carried
out e.g. lipid profile and liver function tests
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Journal of Pakistan Association of Dermatologists 2013;23 (3):256-261.
Table 1 Age distribution (n=100).
Age
20-30 years
31-40 years
41-44 years
N (%)
30 (30)
41 (41)
29 (29)
Table 2 Frequency of specific dermatoses (n=100).
Dermatosis
N (%)
Prurigo of pregnancy
96 (96)
Pruritic folliculitis of pregnancy
02 (2)
Pemphigoid gestationis
01 (1)
Polymorphic eruption of pregnancy
01 (1)
where required to rule out other causes of
pruritus.
The findings were recorded on a predesigned pro
forma. All the findings were compiled, tabulated
and analyzed using the software SPSS using the
percentages of variables like age, parity and
gestational age. No statistical test of significance
was applicable for this descriptive study.
Results
A total of 100 patients, comprising 32
primigravida (32%) and 68 multigravida (68%),
diagnosed as suffering from specific dermatoses
of pregnancy completed the study. Minimum
age of presentation was 20 years and maximum
44 years, the mean age being 32±6.8 years.
Table 1 reveals the different age groups. Parity
of patients ranged between 0-6.
Table 2 shows the frequency of specific
dermatoses of pregnancy. Prurigo of pregnancy
(96%) was the most common dermatosis seen
followed by pruritic folliculitis of pregnancy
(2%) while herpes gestationis and polymorphic
eruption of pregnancy (PUPP) were respectively
seen in 1 patient each. Amongst 96 patients
(96%) suffering from prurigo of pregnancy there
were 28 primigravida (29%) and 68
multigravida (71%). Predominant lesions
included excoriations followed by nodules and
papules. All the patients with prurigo of
pregnancy had positive personal or family
history of atopy, while (85%) had elevated
serum IgE level.
Both the primigravida with pruritic folliculitis of
pregnancy presented one each in the 2nd and 3rd
trimester. The patient suffering from herpes
gestationis was a primigravida and presented in
2nd trimester. The only lady with polymorphic
eruption of pregnancy (PUPP) was also a
primigravida presenting in 2nd trimester.
Discussion
Our study targeted to determine the frequency of
specific dermatoses of pregnancy irrespective of
the three trimesters. The study also highlights
the frequency in association with variables like
age, gestational age, parity, history of similar
eruption in their previous pregnancies and
family history. The results of our study cover
percentages only among the patients with
specific dermatoses.
Prurigo of pregnancy (96%) was the most
common dermatoses seen followed by pruritic
folliculitis of pregnancy (2%) while herpes
gestationis and polymorphic eruption of
pregnancy (PUPP) were seen in 1 patient each.
Prurigo of pregnancy is the most common
specific
dermatosis
of
pregnancy
in
11,15-17
literature.
A frequency of 96% for prurigo
of pregnancy in our study is markedly higher
than that reported (2.5%) by Masood et al.4 who
have also noted prurigo of pregnancy to be the
most common specific dermatoses of pregnancy.
Ahmedi and Powell18 on the contrary, have
reported polymorphic eruption of pregnancy to
be the most common. Likewise, Rashmi19 has
also claimed polymorphic eruption of pregnancy
as the most common specific dermatoses
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Journal of Pakistan Association of Dermatologists 2013;23 (3):256-261.
associated with pregnancy. However, the results
can vary from one study to another depending
upon the setting and design. Masood et al.4
reported prurigo of pregnancy to be more
common in multigravida, a finding consistent
with our study. Other studies have also
suggested prurigo of pregnancy to be the most
common specific dermatoses seen in
pregnancy.20,21 In the study mentioned, all the
enrolled patients were in 3rd trimester. Our
patients presented in 2nd as well as 3rd trimesters,
although, prurigo of pregnancy has been
reported in all the trimesters.19 All the enrolled
patients with prurigo of pregnancy had a
personal or family history of atopy, while (85%)
had elevated serum IgE level. Masood et al.4
have reported only one of their patients to be
suffering from an atopic disorder i.e. asthma.
Workers have reported increased serum level of
IgE in majority of their patients with prurigo of
pregnancy.22 Therefore, the finding in our study
is quite consistent with the previous reports in
literature.4,22 Kroumpouzos and Cohen10,23 have
also described atopy as an etiological factor for
prurigo of pregnancy.
Pruritic folliculitis of pregnancy (2%) was next
in frequency to prurigo of pregnancy in our
study. Patients with pruritic folliculitis presented
with generalized red follicular itchy papules
distributed on the abdomen and the limbs.3,18
Roger et al.24 have also reported it as a rare
specific dermatoses associated with pregnancy.
Masood et al.4 reported a slightly lower
frequency and all the patients were multigravida
presenting in the 3rd trimester. Similarly,
Ambros-Rudolph et al.13 reported a further lower
frequency of the disease in a comparable study.
However, both our patients were primigravida
but one was in 2nd and the other in 3rd trimester.
Roger et al.24 have also reported their similar set
of patients (all primigravida) to present in 2nd
and 3rd trimester. Therefore, our findings are at
par with the reports in literature.24 On the other
hand, Masood et al.4 had all their enrolled
patients in 3rd trimester.
The only patient suffering from herpes
gestationis in our study was a primigravida and
presented in the 2nd trimester. Masood et al.4
found no patient with herpes gestationis in their
study. Our study targeted patients with specific
dermatoses of pregnancy in all the three
trimesters of pregnancy in contrast to Masood et
al.4 where study included patients only in the 3rd
trimester. Ambrose-Rudolph et al.13 reported a
higher frequency i.e. 4.3% in a similar series of
patients. On the contrary, Muzaffar et al.21
reported a frequency much higher then that in
our study i.e. 20%. Roger et al.24 reported a
frequency of 12.3%, which is less then that
reported by Muzaffar et al.21 However, the
results of different studies, can vary depending
upon the study design and setting. Herpes
gestationis although rare, has been reported in
national and international literature from time to
time.25,26 Herpes gestationis is a rare autoimmune
disorder, begins in the second or third trimester
and requires antenatal surveillance for its lethal
complications in the fetus and a tendency to
relapse in subsequent pregnancies.
The only lady with polymorphic eruption of
pregnancy (PUPP) was a primigravida
presenting in the 2nd trimester. Masood et al.4
have reported a slightly high frequency in a
similar set of patients i.e. 2.5% and all the
patients were primigravida. However, their study
aimed to determine the frequency only in 3rd
trimester. Samdani20 and Roger et al.24 reported
polymorphic eruption of pregnancy to be the
most common pregnancy associated dermatoses
with a frequency as high as 38% and 44%
respectively. On the other hand, AmbroseRudolph et al.13 have also reported a frequency
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Journal of Pakistan Association of Dermatologists 2013;23 (3):256-261.
of 22% as far as polymorphic eruption of
pregnancy is concerned. Ahmedi and Powell18
and Rashmi19 also claimed polymorphic eruption
of pregnancy to be the most common specific
dermatoses of pregnancy. However, study
design and setting can influence the results of
different studies. Therefore, polymorphic
eruption of pregnancy remains an important
member of the group of disorders.27,28
3.
4.
5.
6.
The short duration of our study limits its
significance because most of the other studies
were of long durations. Large scale studies are
recommended to substantiate the findings of
these types of studies. Moreover, fetal outcome
should be assessed in every patient with specific
pregnancy associated dermatoses during a
particular pregnancy to see its potential effects
subsequently.
7.
8.
9.
Conclusion
Prurigo of pregnancy remains the most common
disorder followed by pruritic folliculitis of
pregnancy. Herpes gestationis and polymorphic
eruption of pregnancy are seen less frequently.
Awareness of pregnancy related skin changes
can facilitate improved care of pregnant women
by identifying those skin changes that require
further evaluation. We recommend that these
patients should be followed up during pregnancy
as well as after delivery to see resolution of
symptoms and any foetal complications.
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