Dermatology Retinoids worsen melanocytic nevi

Pregnancy dermatoses

Other skin diseases during pregnancy

Since no pregnant woman is immune from the onset of skin diseases, every disease in this book that does not exclusively manifest itself in men can also affect a pregnant woman. Of 505 pregnant patients with pruritus, 20% suffered from a skin disease that happened to coincide with pregnancy. Half of these were inflammatory dermatoses such as acne, pityriasis rosea, urticaria, psoriasis and lichen planus, 25% were cutaneous infections and the remaining 25% were mostly drug eruptions and contact dermatitis.

Dermatoses Affected by Pregnancy

While some dermatoses are completely unaffected by pregnancy, others can improve and others can worsen. In addition to hormonal influences, this can be attributed in particular to the shift in the immunological reaction situation typical of pregnancy to an increased Th2 modulation, which is intended to prevent fetal rejection. Thus, under the influence of cortisol, progesterone and estrogen, the cellular immune response is reduced and the production of Th1 cytokines such as IL-2, INF-γ and IL-12 is suppressed, as well as an increased humoral immune response with increased secretion of Th2- Cytokines (IL-4, IL-10).

psoriasis

During pregnancy, this Th1-mediated disease improves in 40–60% of the time, but often relapses again after delivery. To treat localized forms, topical corticosteroids and small areas of calcitriol or calcipotriol can be used, with no impairment of calcium metabolism when used as directed (<100 g / week). UVB (narrow and broadband) is considered to be the safest therapy for extensive psoriasis. Oral PUVA therapy should be avoided because of the possible mutagenic effects of psoralen; however, external use as a bath PUVA appears to be acceptable. In severe refractory cases, the use of ciclosporin is possible, other system therapeutics such as retinoids, methotrexate and fumaric acid are contraindicated, the experience with biologics is currently insufficient.

Impetigo herpetiformis is a severe pustular variant of psoriasis during pregnancy and is now referred to as generalized pustular psoriasis of pregnancy (GPPP) (Chapter Psoriasis).

Autoimmune diseases

Diseases with a strong Th2 immunity, such as lupus erythematosus, tend to exacerbate during pregnancy and typically improve after delivery; When Ro / SSA or La / SSB antibodies enter the fetal circulation, the manifestation of neonatal lupus erythematosus with the risk of congenital heart block and transient skin changes (spotty, often figured, scaly erythema) can occur (Chapter Lupus erythematosus) . The antiphospholipid syndrome is characterized by livedo racemosa, recurrent thrombophlebitis, hemorrhagic necrosis and lower leg ulcers and is associated with a high risk of miscarriage (Chapter vasculitis). Pregnancies in patients with systemic scleroderma usually proceed without major complications; However, if there is a kidney dysfunction, there is a risk of EPH gestosis (Chapter Scleroderma).

Facial dermatoses

These can get better as well as worsen during pregnancy. Acne usually improves, but occasionally there is also a massive exacerbation in the form of acne gravidarum. Azelaic acid, benzoyl peroxide (up to 5%), erythromycin, but also clindamycin and metronidazole can be used for topical therapy; systemically, beta-lactam antibiotics and macrolides are the antibiotics of choice (Chapter Acne and Rosacea). The tetracyclines often used in acne therapy are considered to be the second choice; In principle, they can be used up to the 15th week of pregnancy, after which they are contraindicated because they attach to calcium ions in tooth structures and bones and can lead to tooth changes and growth disorders. Retinoids are strictly contraindicated both topically and systemically.

Perioral dermatitis can be very persistent, and it is not uncommon for rosacea and even rosacea fulminans to develop, the latter requiring the combined systemic use of macrolides and prednisolone.

Erythema nodosum

It manifests itself primarily in younger women and is associated with pregnancy in 2% (erythema nodosum gravidarum (Bombardieri et al. 1977)). While the clinic is identical, the pregnancy-associated form usually lacks the typical medication or infection history; Recurrences in subsequent pregnancies and with oral contraception are possible. Therapy is often not necessary, but if the pain is severe, as described in Chap. Diseases of the adipose tissue are described. The analgesic of choice in pregnancy is paracetamol.

Melanocytic tumors

Apart from a symmetrical enlargement, especially of the mamma and abdomen, due to an increase in volume and an occasional discreet general increase in pigmentation (darkening) due to hormonal stimulation, contrary to previous opinions, melanocytic nevi hardly change during pregnancy. Therefore, any asymmetrical increase in size or pigmentation or changes in nevi in ​​locations other than those mentioned above should require close dermatoscopic control and / or excision of the suspicious lesion. In about 5% of patients with melanoma of the skin, the tumor is diagnosed in close connection with pregnancy. The incidence varies between 0.14 and 2.8 cases / 1000 deliveries.

The old hypothesis that melanoma would have a poorer prognosis during pregnancy has been refuted by current studies that found no differences between pregnant women with melanoma and non-pregnant women in terms of overall survival rates. However, pregnancy often leads to delayed diagnosis and therapy, which is why the diagnostic and therapeutic measures according to the guidelines should also be carried out immediately during pregnancy. For staging examinations, ultrasound (abdomen, lymph nodes) and chest x-rays or MRI (excluding brain metastases) are considered safe or justifiable. Some studies even show that, if carried out correctly, CT and lymph scintigraphy do not lead to an increased fetal mortality or malformation rate, with the same indications for a sentinel lymph node removal for pregnant patients as for non-pregnant women.

Whenever possible, local anesthetic procedures are preferred for surgical interventions, with lidocaine with or without the addition of epinephrine being considered safe if the usual limit doses are observed. Adjuvant therapy with interferon-α is not indicated during pregnancy; The indication for cytostatic or radiotherapy in advanced melanoma is to be made individually and ideally in an interdisciplinary team. Careful inspection of the placenta is important after delivery because, although rare, there is a possibility of transplacental metastasis.

Infections in Pregnancy

Viral infections in particular play an important role in pregnancy. If infections with viraemia occur in early pregnancy, there is an increased risk of miscarriages and malformations. Localized infections at the time of birth can be transmitted to the child. Frequently "banal" infections and infestations represent a therapeutic challenge, since the usual dermatological standard therapy is contraindicated during pregnancy.

Herpes simplex virus

While extragenital herpes infections play a subordinate role in pregnancy (local measures are sufficient; in the case of extensive peri- / postpartum infections, mother and child may be separated until the lesions have completely healed), genital herpes infection harbors considerable risks for mother and child. A primary herpes infection (HSV-1 or HSV-2) is found in 2% of all pregnancies and is often more severe than in non-pregnant women. Viraemia can lead to transplacental virus transmission to the fetuses (especially before the 20th week of pregnancy) with malformations and fetal death; In late pregnancy, primary infections, an initial clinical episode and recurrences can lead to the infection of the fetus, particularly through direct contact during childbirth and the subsequent severe symptoms of neonatorial herpes. The risk of transmission to the newborn varies between 30% in the case of first manifestation and <1% in the case of a recurrent occurrence. Asymptomatic viral shedding around the due date after the first clinical episode in the third trimester and not yet completed seroconversion also carries a risk of infection for the fetus.

Both initial manifestation and recurrence of genital herpes should be treated systemically with acyclovir (FDA pregnancy category C), which is considered safe during pregnancy based on long experience in use. A florid event at the time of birth is an indication for a caesarean section. In the case of recurrent events, continuous acyclovir suppression therapy from the 36th week of pregnancy has proven its worth (Chapter Human Herpesviruses).

Varicella zoster virus

Infections with varicella zoster virus (VZV) during pregnancy lead to different scenarios depending on the immune status of the mother and the time of infection (Fig. 7). Herpes zoster (reactivation of a latent VZV infection, no viraemia) in a pregnant woman does not usually pose a risk to the fetus and topically drying - and if necessary analgesic - therapy is usually sufficient. Complicated courses (ophthalmic zoster / oticus, dissemination) require acyclovir systemically. A primary VZV infection occurs in 5 / 10,000 pregnancies, endangers mother (increased risk of pneumonia, encephalitis, hepatitis) and child, and always requires systemic therapy with acyclovir. If the mother is seronegative after significant exposure to VZV, immediate (<96 h) passive immunization with VZV immunoglobulin (VZIG) can prevent the outbreak of varicella or at least a severe course in 90%.
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Varicella in the first half of pregnancy (especially between the 13th and 20th week of pregnancy) lead in 1–2% to the congenital varicella syndrome (incidence: 0.8 / 100,000 live births / year), a multisystemic deformity with manifestations particularly on the skin / extremities, eyes and Central nervous system.

Varicella in the second half of pregnancy, on the other hand, can lead to the usually uncomplicated infantile zoster, while peripartum varicella in the mother (especially 5 days before to 2 days after birth) can cause the severe clinical picture of neonatal varicella. The latter scenario requires tocolysis, immediate passive immunization and acyclovir therapy of the mother as well as the administration of VZIG in asymptomatic newborns and high-dose acyclovir therapy in case of manifest symptoms (see chapter Human Herpesviruses).