妊娠期皮肤病

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1、1Pregnancy dermatoses2009.08.112 Physiologic skin changes in pregnancy Dermatoses exacerbated by pregnancy Dermatoses only occurring in pregnancy Specific dermatoses of pregnancy3Physiologic skin changes in pregnancy妊娠期皮肤的生理变化45Hyperpigmentation 色素沉着 Occurs in 90%of pregnant women Increased melanocy

2、te-stimulating hormone Accentuation on areolae,genital skin,and linea alba Usually regresses postpartum6Melasma 黄褐斑 Occurs in 70%of pregnant women Also seen with oral contraceptivetherapy Centrofacial,malar,and mandibular patterns Excessive melanin in epidermis or dermal macrophages Worsens with UVB

3、 exposure7Hirsutism 多毛症 Face,limbs,and back Regresses within 6 months postpartum Slowed conversion from anagen to telogen hairs8Nail changes 甲改变 Transverse grooving Brittleness Distal onycholysis9Increased eccrine gland activity 内分泌腺活性增加 Miliaria Dyshidrotic eczema Hyperhidrosis10Decreased apocrine

4、gland activity大汗腺活动性减少 Hidradenitis suppurativa alleviated11Increased sebaceous gland activity 皮脂腺活动性增加 Exacerbation of acne vulgaris Montgomerys tubercles enlarge12Striae distensae妊娠纹 Occur in 90%of pregnant women Pink or purple atrophic longitudinal bands Caused by increased adrenocortical activit

5、y Fade postpartum to persistent pale atrophic bands13Vascular changes血管变化 Spider nevi Palmar erythema Nonpitting facial edema Venous varicosities:Legs Vasomotor instability Dermographism Edema and hyperemia of gingivae14Dermatoses exacerbated by pregnancy妊娠期加重的皮肤病1516Atopic eczema 特应性皮炎 May deterior

6、ate or remit during pregnancy limbs and/or trunk and face May present for the first time in pregnancy in predisposed person Irritant hand dermatitis and nipple eczema common postpartum Treatment:topical corticosteroids,emollients,UVB17Psoriasis 银屑病 Most common type:chronic plaque psoriasis Different

7、ial diagnosis of pustular variant from impetigo herpetiformis may be difficult Topical treatment:Dithranol,calcipotriol,tar,and corticosteroids are all safe in pregnancy Systemic drugs:retinoids,methotrexate,and hydroxyurea are all contraindicated in pregnancy.Cyclosporine should be used with cautio

8、n during pregnancy and breast-feeding.18Acne vulgaris寻常痤疮Urticaria荨麻疹Lichen planus扁平苔藓19Infections 感染性皮肤病 Viral(herpes simplex,varicella zoster)Bacterial(impetigo,trichomoniasis,leprosy)Fungal(candidal,Pityrosporum folliculitis)AIDS20Lupus erythematosus(LE)Debate continues：whether lupus flares are m

9、ore common in 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 antiphospholip

10、id syndrome 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.21Systemic sclerosisPolymyositis/DermatomyositisPemphigus22Cuta

11、neous tumors affected by pregnancy Pyogenic granuloma Hemangioma Hemangioendothelioma Glomus tumor Dermatofibroma Leiomyoma Keloid Neurofibroma Nevi Melanoma23Dermatoses only occurring in pregnancy仅发生在妊娠期的皮肤病24Impetigo herpetiformis疱疹样脓疱病 Reminiscent of pustular psoriasis,no prior history of psorias

12、is Associated with hypoparathyroidism and hypocalcemia Systemic upset with malaise,fever,delirium,diarrhea,vomiting,and tetany secondary to hypocalcemia Erythematous patches with pustular margin in flexural distribution Sparing of face,hands,and feet Postinflammatory hyperpigmentation common Histopa

13、thologic features identical to pustular psoriasis with spongiform pustules of Kogoj,large collections of neutrophils within foci of spongiotic epidermis Laboratory findings:Elevated leukocyte count and erythrocyte sedimentation rate,hypocalcemia Treatment:Prednisolone 30-40 mg daily Prognosis:Stillb

14、irth and placental insufficiency still frequently seen even when disease is apparently controlled.Remission postpartum but recurrence in successive pregnancies occurs frequently.25Intrahepatic cholestasis of pregnancy妊娠期肝脏内胆汁郁积Increased incidence Presents in third trimester with severe intractable p

15、ruritus Clinical: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 typ

16、ical 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,and preterm

18、 delivery.26Specific dermatoses of pregnancy妊娠特异性皮肤病27Pruritic 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 subsequent preg

19、nancies 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 faceSerologic and immu

20、nofluorescence 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,although several theories

21、including the role of sex hormones and abdominal wall distension caused by pregnancy282930Prurigo 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 described as papular dermatitis

22、 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 result of physiologic pruritus

23、in women with an atopic backgroundTreatment:Moderately potent topical corticosteroids,antihistaminesPrognosis:No adverse effects to mother or infant;resolution postpartum31Herpes gestationis 妊娠疱疹Autoimmune bullous disorder,closely related to bullous pemphigoid(BP)Rare with incidence of approximately

24、 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 pregnancy)Pruritic erythematous plaque

25、s,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 insufficiencyHistopathologic features:Simila

26、r 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 indirect immunofluorescence using salt-s

27、plit 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 potent topical steroids;most cases require systemic

28、 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 phase323334Pruritic folliculitis of pregnancy妊娠瘙痒性毛囊炎 Pruritic erythem

29、atous follicular papules and urticarial lesions on limbs and abdomen in most cases Onset in second and third trimester with resolution within 2 to 3 weeks postpartum Histopathologic features:Acute folliculitis with mixed inflammatory cells,upper dermal edema and spongiosis;negative Grams stain Pathophysiology:Unknown;maternal androgens not implicated as previously suggested Prognosis:Maternal and fetal outcome normal35