CLINICAL OBSTETRICS AND GYNECOLOGY Volume 58, Number 1, 119–124 Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
Physiological Skin Changes During Pregnancy KELLY H. TYLER, MD, FACOG Division of Dermatology, The Ohio State University, Columbus, Ohio Abstract: Physicians may often mistake normal physiological skin changes in pregnancy for pathologic changes, so being able to recognize the skin manifestations unique to pregnancy is of the utmost importance to avoid unnecessary testing and stress for the obstetric patient. Most physiological skin changes will resolve postpartum, so reassurance and expectant management is indicated in almost all cases. Key words: pregnancy, hyperpigmentation, striae, melasma, hirsutism, varicosities
Increased activity of the maternal adrenal and pituitary glands along with a contribution from the developing fetal endocrine glands, increased cortisone levels, accelerated metabolism, and enhanced production of progesterone and estrogenic hormones are responsible for most skin changes in pregnancy.1 This review includes a discussion of the most common skin changes as well as the underlying physiological mechanisms.
Introduction Pigmentary Changes
There are a variety of skin diseases that are associated specifically with pregnancy, but it is important for clinicians to be able to distinguish normal skin changes in pregnancy from such disease processes. A temporary shift in immunologic, metabolic, and hormonal factors during pregnancy leads to physiological dermatologic manifestations including hyperpigmentation, hair and nail changes, vascular changes, and shifts in apocrine and eccrine gland activity.
HYPERPIGMENTATION
Up to 90% of pregnant women will show signs of hyperpigmentation during pregnancy, and it is typically generalized and mild.2 There also tends to be an accentuation of normally hyperpigmented areas such as the genitals, perineum, neck, axillae, inner thighs, periumbilical skin, and areolae.2,3 In many women, the skin in the midline of the abdomen, the linea alba, becomes darkly pigmented to form the linea nigra (Fig. 1), which extends from the umbilicus to the symphysis pubis.4 Nevi, freckles,
Correspondence: Kelly H. Tyler, MD, FACOG, 540 Officenter Place, Suite 240, Gahanna, OH. E-mail: [email protected] The author declares that there is nothing to disclose. CLINICAL OBSTETRICS AND GYNECOLOGY
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FIGURE 2. Melasma. MELASMA
FIGURE 1. Linea nigra.
and recent scars may darken and sometimes become larger during pregnancy.2,5–8 Dark-skinned individuals have pigmentary demarcation lines known as Voigt or Futcher lines along the outer portion of the posterior legs and/or upper arms which can become more pronounced, and vulvar melanosis may also develop during pregnancy.9 Although there is some disagreement among investigators, increased melanogenesis during pregnancy is thought to be due to increased levels of b and a melanocyte-stimulating hormone, estrogen, progesterone, and b-endorphin.9 Estrogen and progesterone are both strong melanogenic stimulants,2 and hyperpigmentation while on oral contraceptive pills may be predictive of women who will develop hyperpigmentation during pregnancy.1 The pigmentation often fades postpartum, but it is less likely to completely regress.10 www.clinicalobgyn.com
Previously termed cholasma or the ‘‘mask of pregnancy,’’ melasma is a symmetric, blotchy but sharply marginated tan to dark brown hyperpigmentation of the face that occurs during the second half of pregnancy in 45% to 75% of women and in one third of women taking oral contraceptive pills (Fig. 2).3,9,11,12 It can occur in a malar, mandibular, or centrofacial pattern. The entire central face, including the chin, nose, upper lip, cheeks, and forehead, is affected in most patients even though the malar pattern is considered most typical.9 The cause of melasma is likely a combination of sun exposure, genetics, cosmetics, and an increase in melanocyte-stimulating hormone, estrogen, and progesterone,13,14 and it is classified histologically by the location of the melanin, either epidermal or dermal.3 Fortunately, melasma of pregnancy regresses in up to 90% of patients within 1 year postpartum.3,9 If it persists, it is typically treated with topical hydroquinone or topical tretinoin after pregnancy, and treatment during pregnancy consists of use of sunscreen along with avoidance of ultraviolet radiation and irritant cosmetics.9 STRIAE DISTENSAE (STRIAE GRAVIDARUM)
Striae or ‘‘stretch marks’’ occur in up to 90% of white women and less frequently in black or Asian women during the second
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delivery and may continue for up to 1 to 2 years before hair regrowth occurs.6,7 Usually, unless another underlying disease is present, the prognosis is excellent for complete hair regrowth, thus the key to management is reassurance.1,3 Rarely, some women may develop male-pattern baldness in late pregnancy, and complete regrowth of hair is generally not expected in this subgroup.1,3 FIGURE 3. Striae gravidarum.
and third trimester of pregnancy (Fig. 3).2 They are linear atrophic pink to violaceous bands most commonly appearing in the areas of maximum stretch such as the thighs, breasts, and abdomen, and they typically regress to persistent flesh-colored atrophic bands postpartum.1,3 A combination of genetics, hormonal changes, and weight gain likely contribute to the formation of striae. The increase in corticosteroids, estrogen, and relaxin decreases adhesiveness between collagen fibers and promotes formation of ground substance, which results in striae in areas of distention.3 Histologically, there is rupture and retraction of elastic fibers within the reticular dermis.1
Hair and Nail Changes TELOGEN EFFLUVIUM
Normally, approximately 80% of the hair on the scalp are in the anagen or active hair growth phase, but during pregnancy the number of hair converting from anagen to telogen (resting phase) is decreased, resulting in a higher percentage of hair in the anagen phase. Postpartum, there is a rapid transition from anagen to telogen, resulting in a large percentage of hair in the telogen phase. When the hair in telogen shed, the result is moderate to severe hair loss, which is termed telogen effluvium.1 The shedding of hair usually begins 1 to 5 months after
HIRSUTISM
Hirsutism, or the appearance in women of terminal and vellus hair in a male pattern, is present to some degree in most pregnant women.15 Unwanted hair usually becomes visible early in pregnancy and can appear on the face, lower abdomen, chest, legs, arms, back, and buttocks.15,16 It tends to be more noticeable in women with dark hair or more abundant body hair.9 Caused by increased ovarian production of androgens, hirsutism during pregnancy most often disappears postpartum as a result of telogen effluvium.9 If severe hirsutism occurs during pregnancy, one should consider other causes such as theca lutein cysts, luteomas, and androgen-secreting tumors of the ovary.2 NAIL CHANGES
Starting as early as the sixth week of pregnancy, nail changes in pregnancy can consist of distal onycholysis, brittleness, leukonychia, softening, transverse grooving (Beau’s lines), and subungual keratoses.2,7,17 Longitudinal melanonychia has also been reported (Fig. 4).18 The cause of most of these changes is unknown, so external causes such as infections and nail cosmetics should be ruled out, and if nails are brittle or prone to onycholysis, they should be kept short.2
Vascular Changes SPIDER ANGIOMATA
First appearing in the second to fifth months of pregnancy, spider angiomata www.clinicalobgyn.com
122
Tyler The prevalence was reported in 1 large series to be 67% of white and 11.3% of black pregnant patients as opposed to 15% of normal nonpregnant white women.19 They tend to increase in number and size until delivery at which time 75% will fade by 7 weeks’ postpartum, but they rarely completely disappear.1,2 High levels of circulating estrogenic hormones are thought to be the cause of vascular spiders during pregnancy.2 PALMAR ERYTHEMA
FIGURE 4. Longitudinal melanonychia.
are one of the most common vascular changes in pregnancy (Fig. 5).1 They most often appear in the skin drained by the superior vena cava, including the neck, throat, face, and arms, and they can be described as slightly raised or flat telangiectatic red puncta with surrounding erythema and radiating branches.2
FIGURE 5. Spider angioma.
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Along with spider angiomata, palmar erythema is one of the most common vascular changes during pregnancy, and they often occur together in the same patient (Fig. 6).19 Palmar erythema often has an earlier onset and can appear in 1 of 2 forms. The first form is an erythematous area localized to the hypothenar or thenar eminences separated sharply from surrounding the normal skin, and the second form is mottling of the entire palm.1,3 The prevalence in a large series was 35% of black and 62.5% of white pregnant patients.19 Palmar erythema rapidly disappears within 1 week after delivery, and similar to spider angiomata, the cause appears to be the high level of circulating estrogen during pregnancy.1,3
FIGURE 6. Palmar erythema.
Physiological Skin Changes During Pregnancy GRANULOMA GRAVIDARUM
Granuloma gravidarum or ‘‘pregnancy tumor’’ is an oral lesion that is similar to a pyogenic granuloma and can be described as an oval pedunculated erythematous friable nodule (Fig. 7).1 It typically begins around the third month of pregnancy and enlarges continually during the remainder of the pregnancy.1 The cause of granuloma gravidarum in unknown, but management consists only of reassurance as they commonly recede following delivery.1 They only need to be excised if the patient has excessive bleeding, pain, or if the lesion is extremely large.1 VARICOSITIES
Varicosities occur in the legs, vulva, vagina, and anus in up to 40% of pregnant women.3 Varicosities in the legs are the most common and typically cause swelling and, less commonly, thrombosis.2 Hemorrhoidal varicosities are also common, cause pain and bleeding, and frequently thrombose during pregnancy.20 Therapy is targeted toward symptomatic relief and collapsing the distended superficial veins while avoiding impairment of circulation.20 Avoidance of prolonged sitting or standing, elastic stockings, and leg elevation can help alleviate swelling of the legs,9 whereas sitz baths, topical anesthetics, astringent compresses, and laxatives may be helpful for hemorrhoids.2
FIGURE 7. Pyogenic granuloma.
123
Varicosities result from reduced vessel tone and incomplete venous return due to partial obstruction of the vessels from the gravid uterus.3 Varicosities typically regress partially postpartum, so any surgical therapy should be delayed until after delivery.2,15 MOLLUSCUM FIBROSUM GRAVIDARIUM
Molluscum fibrosum gravidarum resemble skin tags and appear in the axillae, anterior chest, sides of the face, inframammary areas, feet, or the neck during the second half of pregnancy.2 The lesions are pedunculated, flesh colored, soft, slightly pigmented, and 1 to 5 mm in size.2 Endocrinologic changes during pregnancy have been implicated as the cause, and many regress postpartum, although some patients may experience persistent lesions that increase in size in subsequent pregnancies.1,2
Glandular Activity Apocrine gland activity is reduced during pregnancy, which accounts for the temporary improvement of hidradenitis suppurativa and Fox-Fordyce disease.2,3 Unfortunately, both disease processes can rebound postpartum.2,3 Eccrine gland activity, with the exception of the palm glands, increases at the end of pregnancy, which can result in dyshidrotic eczema, miliaria, and hyperhidrosis.3,15 Finally, sebaceous gland activity increases late in pregnancy, which sometimes results in acne exacerbations and can cause the appearance of Montgomery tubercles.2,9 Montgomery tubercles are brown papules on the areola that appear in 30% to 50% of women in early pregnancy, resulting from hypertrophy of the sebaceous glands, and they regress postpartum.2,3,9 The cause of altered glandular activity in pregnancy is unclear. Some investigators attribute it to increased thyroid activity or weight gain.2 The decrease in www.clinicalobgyn.com
124
Tyler
palmar sweating may be due to increased adrenocortical activity.2
Conclusions There are a variety of complex physiological changes in the skin of pregnant patients, and it is important to be able to distinguish normal changes from pathologic changes to avoid unnecessary testing and stress for the patients. Fortunately, many of these changes will regress or resolve postpartum, so reassurance is the only indicated treatment in most cases.
References 1. Wade TR, Wade SL, Jones HE. Skin changes and diseases associated with pregnancy. Obstet Gynecol. 1978;52:233–242. 2. Wong RC, Ellis CN. Physiologic skin changes in pregnancy. J Am Acad Dermatol. 1984;10: 929–940. 3. Barankin B, Silver SG, Carruthers A. The skin in pregnancy. J Cutan Med Surg. 2002;6: 236–240. 4. Cunningham FG, Leveno KJ, Bloom SL, et al. Williams Obstetrics. 22nd ed. New York: McGraw-Hill:2005;126. 5. Fourcar E, Bentley TJ, Laube DW, et al. A histopathologic evaluation of nevocellular nevi in pregnancy. Arch Dermatol. 1985;121:350–354. 6. Parmley T, O’Brien TJ. Skin changes during pregnancy. Clin Obstet Gynecol. 1990;33:713–717.
www.clinicalobgyn.com
7. Muzaffar F, Hussain I, Haroon TS. Physiologic skin changes during pregnancy: a study of 140 cases. Int J Dermatol. 1998;37:429–431. 8. Lee HJ, Ha SJ, Lee SJ, et al. Melanocytic nevus with pregnancy-related changes in size accompanied by apoptosis of nevus cells: a case report. J Am Acad Dermatol. 2000;42:936–938. 9. Jones SV. Physiologic skin changes of pregnancy. In: Black MM, ed. Obstetric and Gynecologic Dermatology. 3rd ed. Maryland Heights: Mosby; 2008:23–30. 10. Eudy SF, Baker GF. Dermatopathology for the obstetrician. Clin Obstet Gynecol. 1990;33: 728–737. 11. Errickson CV, Matus NR. Skin disorders of pregnancy. Am Fam Physician. 1994;49:605–610. 12. Rook A, Wilkinson DS, Ebling FJS. Textbook of Dermatology. 5th ed. Oxford: Blackwell Science Ltd:1993;3269. 13. Resnick S. Melasma induced by oral contraceptive drugs. JAMA. 1967;199:95–99. 14. Esoda E. Cholasma from progestational oral contraceptives. Arch Dermatol. 1963;87:486. 15. Torgerson RR, Marnach ML, Bruce AJ, et al. Oral and vulvar changes in pregnancy. Clin Dermatol. 2006;24:122–132. 16. Kroumpouzos G, Cohen LM. Dermatoses of pregnancy. J Am Acad Dermatol. 2001;45:1–19. 17. Jones S, Black M. Pregnancy dermatosis. J Am Acad Dermatol. 1999;40:233–241. 18. Fryer JM, Werth VP. Pregnancy-associated hyperpigmentation: longitudinal melanonychia. J Am Acad Dermatol. 1992;26:493–494. 19. Bean WB. Vascular Spiders and Related Lesions of the Skin. 59-77:Springfield: Charles C. Thomas:1958;94–110. 20. Benson RC. Current Obstetric and Gynecologic Diagnosis and Treatment. Los Altos: Lange Medical Publications:1982;626.
Physiological Skin Changes During Pregnancy KELLY H. TYLER, MD, FACOG Division of Dermatology, The Ohio State University, Columbus, Ohio Abstract: Physicians may often mistake normal physiological skin changes in pregnancy for pathologic changes, so being able to recognize the skin manifestations unique to pregnancy is of the utmost importance to avoid unnecessary testing and stress for the obstetric patient. Most physiological skin changes will resolve postpartum, so reassurance and expectant management is indicated in almost all cases. Key words: pregnancy, hyperpigmentation, striae, melasma, hirsutism, varicosities
Increased activity of the maternal adrenal and pituitary glands along with a contribution from the developing fetal endocrine glands, increased cortisone levels, accelerated metabolism, and enhanced production of progesterone and estrogenic hormones are responsible for most skin changes in pregnancy.1 This review includes a discussion of the most common skin changes as well as the underlying physiological mechanisms.
Introduction Pigmentary Changes
There are a variety of skin diseases that are associated specifically with pregnancy, but it is important for clinicians to be able to distinguish normal skin changes in pregnancy from such disease processes. A temporary shift in immunologic, metabolic, and hormonal factors during pregnancy leads to physiological dermatologic manifestations including hyperpigmentation, hair and nail changes, vascular changes, and shifts in apocrine and eccrine gland activity.
HYPERPIGMENTATION
Up to 90% of pregnant women will show signs of hyperpigmentation during pregnancy, and it is typically generalized and mild.2 There also tends to be an accentuation of normally hyperpigmented areas such as the genitals, perineum, neck, axillae, inner thighs, periumbilical skin, and areolae.2,3 In many women, the skin in the midline of the abdomen, the linea alba, becomes darkly pigmented to form the linea nigra (Fig. 1), which extends from the umbilicus to the symphysis pubis.4 Nevi, freckles,
Correspondence: Kelly H. Tyler, MD, FACOG, 540 Officenter Place, Suite 240, Gahanna, OH. E-mail: [email protected] The author declares that there is nothing to disclose. CLINICAL OBSTETRICS AND GYNECOLOGY
/
VOLUME 58
/
NUMBER 1
/
MARCH 2015
www.clinicalobgyn.com | 119
120
Tyler
FIGURE 2. Melasma. MELASMA
FIGURE 1. Linea nigra.
and recent scars may darken and sometimes become larger during pregnancy.2,5–8 Dark-skinned individuals have pigmentary demarcation lines known as Voigt or Futcher lines along the outer portion of the posterior legs and/or upper arms which can become more pronounced, and vulvar melanosis may also develop during pregnancy.9 Although there is some disagreement among investigators, increased melanogenesis during pregnancy is thought to be due to increased levels of b and a melanocyte-stimulating hormone, estrogen, progesterone, and b-endorphin.9 Estrogen and progesterone are both strong melanogenic stimulants,2 and hyperpigmentation while on oral contraceptive pills may be predictive of women who will develop hyperpigmentation during pregnancy.1 The pigmentation often fades postpartum, but it is less likely to completely regress.10 www.clinicalobgyn.com
Previously termed cholasma or the ‘‘mask of pregnancy,’’ melasma is a symmetric, blotchy but sharply marginated tan to dark brown hyperpigmentation of the face that occurs during the second half of pregnancy in 45% to 75% of women and in one third of women taking oral contraceptive pills (Fig. 2).3,9,11,12 It can occur in a malar, mandibular, or centrofacial pattern. The entire central face, including the chin, nose, upper lip, cheeks, and forehead, is affected in most patients even though the malar pattern is considered most typical.9 The cause of melasma is likely a combination of sun exposure, genetics, cosmetics, and an increase in melanocyte-stimulating hormone, estrogen, and progesterone,13,14 and it is classified histologically by the location of the melanin, either epidermal or dermal.3 Fortunately, melasma of pregnancy regresses in up to 90% of patients within 1 year postpartum.3,9 If it persists, it is typically treated with topical hydroquinone or topical tretinoin after pregnancy, and treatment during pregnancy consists of use of sunscreen along with avoidance of ultraviolet radiation and irritant cosmetics.9 STRIAE DISTENSAE (STRIAE GRAVIDARUM)
Striae or ‘‘stretch marks’’ occur in up to 90% of white women and less frequently in black or Asian women during the second
Physiological Skin Changes During Pregnancy
121
delivery and may continue for up to 1 to 2 years before hair regrowth occurs.6,7 Usually, unless another underlying disease is present, the prognosis is excellent for complete hair regrowth, thus the key to management is reassurance.1,3 Rarely, some women may develop male-pattern baldness in late pregnancy, and complete regrowth of hair is generally not expected in this subgroup.1,3 FIGURE 3. Striae gravidarum.
and third trimester of pregnancy (Fig. 3).2 They are linear atrophic pink to violaceous bands most commonly appearing in the areas of maximum stretch such as the thighs, breasts, and abdomen, and they typically regress to persistent flesh-colored atrophic bands postpartum.1,3 A combination of genetics, hormonal changes, and weight gain likely contribute to the formation of striae. The increase in corticosteroids, estrogen, and relaxin decreases adhesiveness between collagen fibers and promotes formation of ground substance, which results in striae in areas of distention.3 Histologically, there is rupture and retraction of elastic fibers within the reticular dermis.1
Hair and Nail Changes TELOGEN EFFLUVIUM
Normally, approximately 80% of the hair on the scalp are in the anagen or active hair growth phase, but during pregnancy the number of hair converting from anagen to telogen (resting phase) is decreased, resulting in a higher percentage of hair in the anagen phase. Postpartum, there is a rapid transition from anagen to telogen, resulting in a large percentage of hair in the telogen phase. When the hair in telogen shed, the result is moderate to severe hair loss, which is termed telogen effluvium.1 The shedding of hair usually begins 1 to 5 months after
HIRSUTISM
Hirsutism, or the appearance in women of terminal and vellus hair in a male pattern, is present to some degree in most pregnant women.15 Unwanted hair usually becomes visible early in pregnancy and can appear on the face, lower abdomen, chest, legs, arms, back, and buttocks.15,16 It tends to be more noticeable in women with dark hair or more abundant body hair.9 Caused by increased ovarian production of androgens, hirsutism during pregnancy most often disappears postpartum as a result of telogen effluvium.9 If severe hirsutism occurs during pregnancy, one should consider other causes such as theca lutein cysts, luteomas, and androgen-secreting tumors of the ovary.2 NAIL CHANGES
Starting as early as the sixth week of pregnancy, nail changes in pregnancy can consist of distal onycholysis, brittleness, leukonychia, softening, transverse grooving (Beau’s lines), and subungual keratoses.2,7,17 Longitudinal melanonychia has also been reported (Fig. 4).18 The cause of most of these changes is unknown, so external causes such as infections and nail cosmetics should be ruled out, and if nails are brittle or prone to onycholysis, they should be kept short.2
Vascular Changes SPIDER ANGIOMATA
First appearing in the second to fifth months of pregnancy, spider angiomata www.clinicalobgyn.com
122
Tyler The prevalence was reported in 1 large series to be 67% of white and 11.3% of black pregnant patients as opposed to 15% of normal nonpregnant white women.19 They tend to increase in number and size until delivery at which time 75% will fade by 7 weeks’ postpartum, but they rarely completely disappear.1,2 High levels of circulating estrogenic hormones are thought to be the cause of vascular spiders during pregnancy.2 PALMAR ERYTHEMA
FIGURE 4. Longitudinal melanonychia.
are one of the most common vascular changes in pregnancy (Fig. 5).1 They most often appear in the skin drained by the superior vena cava, including the neck, throat, face, and arms, and they can be described as slightly raised or flat telangiectatic red puncta with surrounding erythema and radiating branches.2
FIGURE 5. Spider angioma.
www.clinicalobgyn.com
Along with spider angiomata, palmar erythema is one of the most common vascular changes during pregnancy, and they often occur together in the same patient (Fig. 6).19 Palmar erythema often has an earlier onset and can appear in 1 of 2 forms. The first form is an erythematous area localized to the hypothenar or thenar eminences separated sharply from surrounding the normal skin, and the second form is mottling of the entire palm.1,3 The prevalence in a large series was 35% of black and 62.5% of white pregnant patients.19 Palmar erythema rapidly disappears within 1 week after delivery, and similar to spider angiomata, the cause appears to be the high level of circulating estrogen during pregnancy.1,3
FIGURE 6. Palmar erythema.
Physiological Skin Changes During Pregnancy GRANULOMA GRAVIDARUM
Granuloma gravidarum or ‘‘pregnancy tumor’’ is an oral lesion that is similar to a pyogenic granuloma and can be described as an oval pedunculated erythematous friable nodule (Fig. 7).1 It typically begins around the third month of pregnancy and enlarges continually during the remainder of the pregnancy.1 The cause of granuloma gravidarum in unknown, but management consists only of reassurance as they commonly recede following delivery.1 They only need to be excised if the patient has excessive bleeding, pain, or if the lesion is extremely large.1 VARICOSITIES
Varicosities occur in the legs, vulva, vagina, and anus in up to 40% of pregnant women.3 Varicosities in the legs are the most common and typically cause swelling and, less commonly, thrombosis.2 Hemorrhoidal varicosities are also common, cause pain and bleeding, and frequently thrombose during pregnancy.20 Therapy is targeted toward symptomatic relief and collapsing the distended superficial veins while avoiding impairment of circulation.20 Avoidance of prolonged sitting or standing, elastic stockings, and leg elevation can help alleviate swelling of the legs,9 whereas sitz baths, topical anesthetics, astringent compresses, and laxatives may be helpful for hemorrhoids.2
FIGURE 7. Pyogenic granuloma.
123
Varicosities result from reduced vessel tone and incomplete venous return due to partial obstruction of the vessels from the gravid uterus.3 Varicosities typically regress partially postpartum, so any surgical therapy should be delayed until after delivery.2,15 MOLLUSCUM FIBROSUM GRAVIDARIUM
Molluscum fibrosum gravidarum resemble skin tags and appear in the axillae, anterior chest, sides of the face, inframammary areas, feet, or the neck during the second half of pregnancy.2 The lesions are pedunculated, flesh colored, soft, slightly pigmented, and 1 to 5 mm in size.2 Endocrinologic changes during pregnancy have been implicated as the cause, and many regress postpartum, although some patients may experience persistent lesions that increase in size in subsequent pregnancies.1,2
Glandular Activity Apocrine gland activity is reduced during pregnancy, which accounts for the temporary improvement of hidradenitis suppurativa and Fox-Fordyce disease.2,3 Unfortunately, both disease processes can rebound postpartum.2,3 Eccrine gland activity, with the exception of the palm glands, increases at the end of pregnancy, which can result in dyshidrotic eczema, miliaria, and hyperhidrosis.3,15 Finally, sebaceous gland activity increases late in pregnancy, which sometimes results in acne exacerbations and can cause the appearance of Montgomery tubercles.2,9 Montgomery tubercles are brown papules on the areola that appear in 30% to 50% of women in early pregnancy, resulting from hypertrophy of the sebaceous glands, and they regress postpartum.2,3,9 The cause of altered glandular activity in pregnancy is unclear. Some investigators attribute it to increased thyroid activity or weight gain.2 The decrease in www.clinicalobgyn.com
124
Tyler
palmar sweating may be due to increased adrenocortical activity.2
Conclusions There are a variety of complex physiological changes in the skin of pregnant patients, and it is important to be able to distinguish normal changes from pathologic changes to avoid unnecessary testing and stress for the patients. Fortunately, many of these changes will regress or resolve postpartum, so reassurance is the only indicated treatment in most cases.
References 1. Wade TR, Wade SL, Jones HE. Skin changes and diseases associated with pregnancy. Obstet Gynecol. 1978;52:233–242. 2. Wong RC, Ellis CN. Physiologic skin changes in pregnancy. J Am Acad Dermatol. 1984;10: 929–940. 3. Barankin B, Silver SG, Carruthers A. The skin in pregnancy. J Cutan Med Surg. 2002;6: 236–240. 4. Cunningham FG, Leveno KJ, Bloom SL, et al. Williams Obstetrics. 22nd ed. New York: McGraw-Hill:2005;126. 5. Fourcar E, Bentley TJ, Laube DW, et al. A histopathologic evaluation of nevocellular nevi in pregnancy. Arch Dermatol. 1985;121:350–354. 6. Parmley T, O’Brien TJ. Skin changes during pregnancy. Clin Obstet Gynecol. 1990;33:713–717.
www.clinicalobgyn.com
7. Muzaffar F, Hussain I, Haroon TS. Physiologic skin changes during pregnancy: a study of 140 cases. Int J Dermatol. 1998;37:429–431. 8. Lee HJ, Ha SJ, Lee SJ, et al. Melanocytic nevus with pregnancy-related changes in size accompanied by apoptosis of nevus cells: a case report. J Am Acad Dermatol. 2000;42:936–938. 9. Jones SV. Physiologic skin changes of pregnancy. In: Black MM, ed. Obstetric and Gynecologic Dermatology. 3rd ed. Maryland Heights: Mosby; 2008:23–30. 10. Eudy SF, Baker GF. Dermatopathology for the obstetrician. Clin Obstet Gynecol. 1990;33: 728–737. 11. Errickson CV, Matus NR. Skin disorders of pregnancy. Am Fam Physician. 1994;49:605–610. 12. Rook A, Wilkinson DS, Ebling FJS. Textbook of Dermatology. 5th ed. Oxford: Blackwell Science Ltd:1993;3269. 13. Resnick S. Melasma induced by oral contraceptive drugs. JAMA. 1967;199:95–99. 14. Esoda E. Cholasma from progestational oral contraceptives. Arch Dermatol. 1963;87:486. 15. Torgerson RR, Marnach ML, Bruce AJ, et al. Oral and vulvar changes in pregnancy. Clin Dermatol. 2006;24:122–132. 16. Kroumpouzos G, Cohen LM. Dermatoses of pregnancy. J Am Acad Dermatol. 2001;45:1–19. 17. Jones S, Black M. Pregnancy dermatosis. J Am Acad Dermatol. 1999;40:233–241. 18. Fryer JM, Werth VP. Pregnancy-associated hyperpigmentation: longitudinal melanonychia. J Am Acad Dermatol. 1992;26:493–494. 19. Bean WB. Vascular Spiders and Related Lesions of the Skin. 59-77:Springfield: Charles C. Thomas:1958;94–110. 20. Benson RC. Current Obstetric and Gynecologic Diagnosis and Treatment. Los Altos: Lange Medical Publications:1982;626.
