Obstetric Dermatology: A Practical Guide

182 Pages·2009·7.839 MB·English

by  Professor Arieh Ingber (auth.)

Obstetric Dermatology
Arieh Ingber
Obstetric Dermatology
A Practical Guide
Foreword by Mark Lebwohl
Professor Arieh Ingber
Clinical Associate Professor of Dermatology
Head, Department of Dermatology and Venereology
Hadassah University Hospital
Faculty of Medicine, Hebrew University
Jerusalem 91120
Israel
ISBN: 978-3-540-88398-2 e-ISBN: 978-3-540-88399-9
DOI: 10.1007/978-3-540-88399-9
Library of Congress Control Number: 2008937139
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Dedication
To my wife, Tova, my children and my grandchildren.
A piece of evidence that I did something important when I wasn’t
with them.
Foreword
There are many changes in the skin, hair, and nails during and after pregnancy. Patients
are certainly aware that those changes are occurring, but few physicians and even fewer
patients know how to predict the course of those changes. Pigmentary changes occur, but
are they permanent? Can they be prevented or reversed? Hair may become thicker during
pregnancy, only to fall out in the postpartum period. When will hair stop falling out? Will
it grow back? What hormonal changes are occurring to produce these effects on the skin,
hair, and nails? Will those hormonal changes affect other organs?
Some cutaneous manifestations of pregnancy are common and recognized by most
physicians. Abdominal striae, for example, are easily identified, but physicians have many
questions about them. Why do they develop? Can they be prevented or treated?
Other cutaneous manifestations of pregnancy are less common and recognized by few.
For example, pruritic urticarial papules and plaques of pregnancy is a debilitating condition
that is treatable once diagnosed. Even more important than the treatment, the knowledge
imparted to a worried mother that her child will be fine and that the condition is self-
limited is priceless; but the condition must first be recognized by the patient’s physician.
All of these questions and conditions are addressed in this extraordinary book. Pigmen-
tary disorders are addressed in detail in Chap. 2. Not only are readers told of the existence
of disorders such as melasma, but the condition and its variable presentations are explained
along with extensive discussion of the pathophysiology of the disorder as well an appropri-
ately lengthy discussion of treatments. Disorders of hair and nails are covered extensively in
Chap. 3, and all the questions raised in this foreword are answered well as are a multitude
of other issues involving hair and nails during pregnancy. Chapter 1 offers a comprehensive
review of hormonal changes in pregnancy that will serve students and residents in dermatol-
ogy and obstetrics very well. These are elaborated on further in Chaps. 5 and 6, which discuss
the physiologic changes caused by the hormonal alterations during pregnancy.
Much of the remainder of the book is devoted to specific pregnancy-related diseases.
Each of these chapters combines a comprehensive review of the literature with clinical
expertise that could only be written by a master clinician. The chapters on the various pruritic
disorders of pregnancy could stand alone as classic references on a symptom complex that
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viii Foreword
troubles many patients and their physicians. Undoubtedly, many patients will benefit from
the information in this book, and many physicians will find answers to their perplexing
questions about dermatologic disorders of pregnancy.
Some cutaneous manifestations of pregnancy are trivial and others are life-threatening
to the mother and the fetus. The impact of pregnancy on diseases of the skin, and the impact
of those diseases and their treatments on pregnancy are so varied and numerous that this
subject is certainly worthy of a major textbook. Arieh Ingber has created a comprehensive
work that will help obstetricians and dermatologists recognize and treat the many different
conditions affecting the skin, hair, and nails during pregnancy. This should indeed become
an important textbook for obstetricians, dermatologists, and students and residents.
Mark Lebwohl
The Sol and Clara Kest Professor of Dermatology
Chairman of Dermatology
The Mount Sinai School of Medicine
Preface
During pregnancy the skin may develop many changes: physiologic as well as pathologic.
Most physicians are not familiar with these skin changes and have difficulty recognizing
and diagnosing them correctly.
This book is a comprehensive overview guide for gynecologists, dermatologists, family
physicians, and everyone who is interested in the appearance of the skin in pregnancy.
The information in this book is based on 30 years’ experience of the author with preg-
nant women with skin conditions and on up-to-date literature.
I believe that this book will be the gold standard in the field of obstetrics and the skin.
Israel, 2008 Arieh Ingber
ix
Contents
1 Endocrine and Immunologic Alterations During Pregnancy . . . . . . . . . . . 1
1.1 Hormonal Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 Immunologic Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
2 Hyperpigmentation and Melasma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
2.1 Hyperpigmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
2.2 Melasma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2.3 Pathogenesis of Pigmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2.4 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
3 Hair and Nails . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
3.1 Hair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
3.1.1 Hirsutism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
3.1.2 Telogen Effluvium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
3.1.3 Male-Pattern Baldness and Hypotrichosis . . . . . . . . . . . . . . . . . . . . . . 22
3.2 Nails . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
4 Connective Tissue Physiologic Changes During Pregnancy . . . . . . . . . . . . 25
4.1 Striae Distensae (Linea Striae, Linea Gravidarum,
Linea Alba, Striae Gravidarum) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
4.2 Molluscum Fibrosum Gravidarum . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
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5 Physiologic Vascular Changes During Pregnancy . . . . . . . . . . . . . . . . . . . . 33
5.1 Vascular Spiders (Spider Angiomas, Arterial Spiders,
Nevi Aranei, Spider Nevi) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
5.2 Palmar Erythema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
5.3 Hemangiomas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
5.4 Cutis Marmorata, Purpura, and Petechia . . . . . . . . . . . . . . . . . . . . . . . 37
5.5 Edema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
5.6 Carpal Tunnel Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
5.7 Varicosities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
5.8 Pregnancy Gingivitis (Papillomatous Hypertrophy
of the Gums, Stomatitis Gravidarum, Hypertrophic Gingivitis
of Pregnancy, Marginal Gingivitis) . . . . . . . . . . . . . . . . . . . . . . . . . . 40
5.9 Granuloma Gravidarum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
5.10 Unilateral Nevoid Telangiectasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
6 Physiologic Glandular Changes During Pregnancy . . . . . . . . . . . . . . . . . . . 45
6.1 Eccrine Glands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
6.2 Apocrine Gland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
6.3 Sebaceous Gland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
6.3.1 Acne Vulgaris . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
6.3.2 Breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
7 Inflammatory Skin Conditions During Pregnancy . . . . . . . . . . . . . . . . . . . 49
7.1 Atopic Dermatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
7.2 Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
7.3 Urticaria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
7.4 Hereditary Angioedema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
7.5 Erythema Nodosum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
7.6 Contact Dermatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
8 Autoimmune Conditions During Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . 63
8.1 Systemic Lupus Erythematosus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
8.2 Systemic Sclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
8.3 Dermatomyositis/Polymyositis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
8.4 Pemphigus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
9 Tumors in Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
9.1 Mycosis Fungoides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
9.2 Neurofibromatosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78