Information
Pregnancy results in a variety of physiological and pathological changes to the skin. The latter can be divided into two categories – those that can occur outside pregnancy and those that are unique to pregnancy. Idiopathic pruritus without obvious skin eruption is a common problem.
The four dermatoses of pregnancy are:
- atopic eruption of pregnancy
- pemphigoid gestations
- polymorphic eruption of pregnancy
- intrahepatic cholestasis of pregnancy (often referred to as obstetric cholestasis)
Diagnosis and management are dependent upon a structured history and examination and understanding of serious and/or common dermatoses that may require referral to a dermatologist.
M.A & K.H – 07-05-26
Who to refer :
In general women should be referred to an obstetric consultant if they have symptoms and signs of the following dermatoses in pregnancy:
- Pemphigoid gestationis.
- Intrahepatic cholestasis of pregnancy.
Consider referring to dermatology
- Pemphigoid gestationis.
- Polymorphic eruption of pregnancy, atopic eruption of pregnancy or a localised area of itching or skin eruption where initial management fails.
- Skin eruptions associated with systemic symptoms.
Ideally, patients with any skin eruption should be seen in a joint obstetric/dermatology clinic. We do not have a joint clinic set up in NHS Lothian in the current time. Non-urgent referrals can be made to the Obstetric Medicine Specialty clinic obstetricmedicine@nhslothian.scot.nhs.uk or the Locality Obstetric Consultant clinic. If urgent review is required, the patient should be referred to obstetric triage.
No rash
Intrahepatic Cholestasis of Pregnancy (ICP, also referred to as Obstetric cholestasis)
Intrahepatic Cholestasis of Pregnancy (ICP) should be considered as a diagnosis of exclusion in any pregnant woman presenting with itch in the absence of a rash. It affects approximately 1% of pregnancies in the UK but may affect a higher proportion of women from Indian or Pakistani-Asian ethnic origin. Itch is usually focussed in the palms of the hand and soles of the feet, but may also affect the scalp, anus, vulva and abdomen. ICPcan increase the risk of stillbirth.
Serum total bile acid (TBA) should be taken as a random (not fasting) sample, alongside LFTs. Normal values for pregnancy:
- ALT 10-40 U/L (falling to 30 U/L in third trimester)
- ALP <500 U/L
- GGT 5-35 U/L (raised by 20% in obstetric cholestasis)
- Bilirubin 2-16 umol/L (not commonly raised in obstetric cholestasis
- Total bile acids <19 micromol/L
TBA results can take a few days to come back from the lab. Raised ALT or GGT and/orbile acids >19 would be suggestive of ICP.
Women with ICP should be referred to their community midwife in the first instance. Ongoing care may be arranged in the Day Assessment Unit at the Royal Infirmary of Edinburgh (0131 242 2656), or Day Beds at St John’s Hospital Livingston for monitoring (01506 524110). Most patients can be managed in the outpatient setting.
Postnatal follow up:
Ensure TBA/LFT return to normal by 6 weeks after birth. If not, investigate for underlying liver disease. Consider genetic screening if family history of hepatobiliary disease, early onset or severe disease.
Idiopathic pruritis
Idiopathic pruritus without obvious skin eruption is a common problem. Therapies to help control the itch include:
- Calamine lotion
- Aqueous cream with 1%menthol
- Chlorphenamine (Pirton) 4mg 4-6hourly (max 24mg daily) or Cetirizine 10mg daily
Rash
Initiate treatment to offer relief from symptoms and refer women to a dermatologist.
| Dermatoses of pregnancy | Areas affected | Risk factors | Recurrence risk | Management | Pregnancy outcome |
| Atopic eruption of pregnancy | Face, neck, chest and extensor surfaces of the limbs and trunk | Family history of atopy | Limited data | Oatmeal baths, Topical emollients Topical anti-pruritics Topical steroids Antihistamines Ultraviolet light Topical acne treatment | No adverse effect on mother or fetus |
| Polymorphic eruption of pregnancy | Abdominal striae with periumbilical sparing Can progress to trunk and extremities, sparing palms, soles and face | Nulliparity, multiple pregnancies Any cause of overdistension of skin | Rarely recurs | Topical steroids (first-line) Topical emollients Antihistamines Oral steroids | No adverse effect on mother or fetus |
| Pemphigoid gestationis | Appears around umbilicus unlike PEP Can progress to trunk, extremities, palms and soles with mucosal sparing | Recognised correlation with the haplotypes HLA-DR3 and HLA-DR4 Other autoimmune conditions | May recur in subsequent pregnancies, with earlier onset and increasing severity Also, may recur with oral contraception/menstruation | Topical/oral corticosteroids Antihistamines Antibiotics Immunophoresis Immunosuppressants | IUGR Preterm labour Self-limiting skin lesions in neonate |
- Skin eruptions specific to pregnancy: an overview. Maharajan A, Aye, C, Ratnavel R, Burova E. TOG volume 15. Issue 4 October 2013 Pages 233-240.
https://doi.org/10.1111/tog.12051 - Intrahepatic cholestasis of pregnancy – Girling – 2022 – BJOG: An International Journal of Obstetrics & Gynaecology – Wiley Online Library
- Intrahepatic cholestasis of pregnancy | RCOG
- ICP Support (patient information and support)
