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LIVE BLOG: The Dermatoses of Pregnancy with Ted Rosen, MD

Dr. Ted Rosen is trained in both Internal Medicine and Dermatology.  He is currently Chief of the VA Dermatology Clinic Professor at Baylor.  Recently served on the board of the AAD.  He has written over 275 peer review articles and 3 textbooks.  
Dermatoses of pregnancy is a rarely-covered topic, and we know that OB/GYN professionals rarely know how to handle skin-related issues during pregnancy.  In this live blog, we cover the highlights of Dr. Rosen’s lecture.
“A Ship under sail and a big-bellied Woman, Are the handsomest two things that can be seen…” ~Benjamin Franklin
Physiologic Skin Changes During Pregnancy
Glowing Skin (due to more blood flow)
Hair grows faster (but post-partem loss)
Nails grow faster, are harder
Diff. forms of pigmentation, espeicaialy down the abdomen (75% of women get it…it almost always goes away normally)
Spider veins (50%)
Stretch marks
Melasma – exclusive to pregnancy
Rx strategy? Use sunscreen (broad UVA-UVB), Combination Therapies (laser therapy with others)
Topical steroids
Effluvium – Post-partum
Massive hair loss post-partem
Starts about 3 months after delivery, lasts 3-6 months
Hair collection >150 hairs/day (vs. 50 per/day normally)
Hair pull should be 2-10 extracted 
Most need: Just reassurance, often needs no intervention
Striae (Stretch Marks)
50-90% of Preganancies
Those at risks?  If mom got stretch marks, daughter will.  
Obesity and ethnicity risks = conflicting
Prevention? A lot in “cult literature” on moisturization, but in random controlled trials, it showed no benefit.  It’s gonna happen, if it’s gonna happen.
Stretch Marks: Therapy?  
If they have red-purple stretch marks to the extreme…lasers used to treat red will make them better.  Topical tretinoin 0.1% or glycol acid 20% have shown to be helpful.
Latest rend is to use a FRAXEL laser: may benefit even late, white atrophic stretch marks.  Shows 25-50% improvement.  Warn patients that it will take multiple treatments, and is costly.  
“Poor Person’s Fraxel”
Use of a micro needle device that penetrates to 1.5mm depth.  From Korea.  Instead of using high-priced tech, let’s use low-priced tech!  3 sessions, 1 month apart. Investigator showed 44% excellent improvement.  
When pregnant, immunity of Th-1 is decreased, Th-2 is increased.  Things that are handled by the body don’t do as well. For example, may see: fungal infections, vaginal candidiasis.  Additionally, recurrent genital warts may reappear and may grow rapidly, and may be painful.  
Genital warts cause neonatal problems during vaginal delivery.  They may bleed or cause a blockage in the birth canal.  Can cause neonatal laryngeal papillomatosis
Treatment is justified for all of the above reasons.  Consensus is that CO2 laser ablation is effective for treating external genital warts.  3 studies show 75%-92% success (1990, 2001, 2003)
HSV During Pregnancy
Trying to prevent neonatal HPV in baby, this can be deadly.
Do anti-viral prophylaxis in 3rd TriMester.  Showed:
Less likely to recur at delivery, less likely to culture at delivery, less likely to over attack and necessitate cesarean section.  BUT, 
Recommended: Acyclovir 400mg TID Valacylovir 1.0g/d
Lupus and Preganancy
Often can be brought on during pregnancy.
Outcomes often unfavorable!
46% preterm labor and delivery
39% low birth weight
8% stillbirth; 7% spontaneous abortion
Recommendations? Continue all meds for SLE during pregnancy and adjust as clinical situation dictates
Melanoma and Pregnancy
There should be no rec that melanoma patients shouldn’t get pregnant. That’s old and wrong.
Prognosis depends on thickness/depth of melanoma, regardless of pregnancy.
Overall: Specific Dermatoses of Pregnancy
+ Very small number of diseases
+ Literature confusion is huge.  There’s different names for diff diseases.
current trend started in 1980s is to group disorders, not make it more complicated.  So there’s just a few disease states assoc with preg to consider.
1. Intrahepatic Cholestasis of Pregnancy
+ Intractable itching usually in the 3rd Tri-Mester
+ 1 in 150; more common if twin, triplet –> subsequent preg will likely happen again.  BC can cause it to happen again.  Also common if in family history.
+ Administer Ursodeoxycholic Acid (Ursodiol): Drug of choice = Actigall 300mg
             –> even some OBs don’t know about this.  
+ Helps mom, protects baby.  May cause some GI upset.  
+ Metanalysis just published, 454 patients in 9 RCT…also used for gall-stones, or sludge in gallbladder ducts
2. Herpes (Pemphigoid) Gestationis 
+ Not common: 1 in 30,000
+ Auto-immune disease; starts late in 2nd-3rd Trimester (post-partum 20-25%)
+ Itching, then red urticaria plaques, then tense blisters
+ Resolution post partum
+ IgG-1 antibody against BP180ag (BP antigen 2)
+ Maternal risk: for other auto-immune diseases such as Grave’s disease (thyroid disease), alopecia areata, Vitiligo, Ulcerative colitis; Recurs w/ pregnancies
+ Fetal Risk: minor: Neonatal blisters (10%) –> but these will go away; major: can be small for gestational age, premature delivery
+ Treatment: Systemic steroids!
3. Pruritic Urticarial (PUPPP)
This is the most common of all the specific eruptions associated with pregnancy.
+ 1 in 130 to 1 in 300 (risk with twin/triplet pregnancy)
+ Unknown etiology
+ Late 3rd Trimester (post-partem onset rare)
+ Itchy urticarial papules in striae to start, then…small itchy papules
+ May resemble erythema multiforme
+ Can be quite polycyclic
+ Serology is normal
+ Has nonspecific pathology
+ Maternal risk: None (may recur in next pregnancy)
+ Fetal risk: None (Treatment should therefore be conservative…)
+ Treatment: Topical steroids (ultrapotent, spray)
            –> You can be a hero in less than a week, and relieve systems!
3. Prurigo of Pregnancy (PP)
This is the 2nd most common of all the specific eruptions associated with pregnancy.

+ Used to be named other things. 
+ Reported in 1 in 300 to 1 in 450
+ (Possible increased risk if history of atopic dermatitis)
+ Unknown etiology
+ 3rd Trimester (post-partem onset is rare)
Maternal risk: None (may recur in subsequent pregnancies)
+ Fetal risk: None (Treatment should therefore be conservative…)
Treatment: Topical steroids 

4. Impetigo Herpetifiormis
A unique form of pustular psoriasis that occurs within pregnancy
Recurs with subsequent pregnancy
Very rare (only 200 known cases)
Early 3rd trimester
Maternal risk: Eloctrolyte abnormalities
+ Fetal risk: Abortion, stillbirth
Treatment: Systemic steroids or cyclosporine


[Image by Laura Maye]

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