Dermatoses

of

Pregnancy

Source : George Kroumpouzos, MD,a and Lisa M. Cohen, MDb,c., Continuing Medical Education Dermatoses of Pregnancy Boston, Massachusetts, J AM
ACAD DERMATOL . JULY 2001

Intrahepatic Cholestasis
of Pregnancy (ICP)
Sinonim

Trimester

Predileksi
Lesi & Gejala
Klinis

(1) generalized pruritus with or

without jaundice
(2) absence of primary skin
lesions
(3) biochemical abnormalities
consistent with cholestasis,
and
(4) resolution after delivery.

Laboratorium
&
Histopatologi

Peninggian serum bile

acids (mean, 1349 g/100
mL), predominantly cholic
acid, and mild
abnormalities of the liver
function tests, including
elevated cholesterol,
triglycerides,
phospholipids, alkaline
phosphatase, 5nucleotidase,

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Herpes Gestationes (HG)

Pruritic Urticarial Papules

Prurigo of Pregnancy
and Plaques of Pregnancy
(PP)
(PUPPP)
Pemphigoid Gestationes
- Toxemic rash of pregnancy
- Besniers prurigo
- Nurses late prurigo of pregnancy
gestationis
toxemic erythema of pregnancy - Nurses early prurigo of
- Polymorphic eruption of
pregnancy
pregnancy
- Papular dermatitis of
Spangler
Second or third trimester Primigravida trimester 3 (hamil all trimesters
(mean onset, 21 weeks) but
35minggu) kadang pada
has been reported in the
postpartum.
first trimester
Pruritic/gatal, lesi urticarial
Erupsi mulai di striae abdomen,
Ekstrensor extremitas,
di abdomen. Lesi
periumbilikal sparing. Ruam
kadang di abdomen.
berkembang cepat menjadi
menyebar dlm bbrp hari ke paha, Lesi papul eritem atau
erupsi bulosa generalisata,
bokong, dada, and lengan,
nodul, dapat krusta atau
sedikit di wajah, mukosa,
wajah, palms,and soles are
eksoriasi
palmar dan plantar/ soles.
commonly spared.
Lesi berupa bula tegang
Lesi awal berupa small urticarial
pada dasar eritem.
papules within erythematous
striae.
Erupsi
polymorphous,erythematous,
papul urtika dan plak kadang
dengan vesicles, purpura, lesi
target dan lesi polycyclic.
Saat menyebar PUPPP dapat
membentuk toksik eritema.
Sembuh dengan tampilan
eczematous.
Durasi erupsi 6 minggu,
meskipun jarang berat
>1minggu
DIF shows IgG deposits.
Tes serologis and
DIF is negative.
antibody belongs to the
immunofluorescence negatif,
serologic tests are
IgG1 subclass and the
Direct Imunofluoresen normal.
normal, histopathologic
antigen is a 180-kd protein
Histopatologi menunjukkan
features are nonspecific,
(bullous pemphigoid antigen dermatitis spongiotik
showing a
2, BPAG2). Antigen
perivascular or upper dermal
chronic inflammatory cell
increased serum antithyroid
infiltrasi sel inflamasi,
infiltrate in the upper
and antigastric parietal cell
parakeratosis, exocytosis, mild
dermis
antibodies and acute phase
acanthosis. sedikit eosinophils.
with occasional
reactants.
membedakan dengan temuan
epidermal changes.
Histopathologic: vesikel
ambigu deposit C3 pd pembuluh

Pruritic Folliculitis of
Pregnancy (PFP)
-

Bulan ke 4 hingga 9
kehamilan
Generalisata,
erythematous, papul
folikular. gejalanya
Asymptomatic

histopathologic features
are those of a sterile
folliculitis, and DIF is
negative. hormonal levels
were normal for gestational
age

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Genetic factors HLA

subtypes A31 and B8, and
a Mendelian dominant
inheritance has been
proposed. Positive family
history in up to 50% of
cases,131 and occurrence
of ICP in twin pregnancies.

subepidermal dengan
limfosit perivaskular and
eosinophils or a nonspecific,
mixed cellular infiltrate with
numerous eosinophils. DIF of
perilesional skin shows C3
with or without IgG in a
linear band along the BMZ.
Salt-split skin specimens,
the antibody binds to the
roof of the vesicle. Indirect
immunofluorescence is
negative, it may reveal the
capacity to fix complement
to the BMZ.
Antibody titers and DIF for
C3 may remain positive
even after clearance
of the skin lesions, raising
speculation that factors
other than antibody to
BPAG2 may contribute to
blister formation in HG.

The pruritus associated

with mild cholestasis
responds to bland
-antipruritic emollients,
soothing baths, primrose
oil, and topical
antipruritics. Epomediol
and silymarine, -S-denosylL methionine. severe cases
have
been treated with ionexchange resins :
-Cholestyramine needs to
be administered for several
days before pruritus is
alleviated.
-Ursodeoxycholic acid

-Allergic contact dermatitis,

-drug eruption
-pruritic urticarial papules
and plaques of pregnancy
(PUPPP).
Systemic corticosteroids 0.5
mg/kg of prednisone daily.
Dosis maksimal 80mg/hari
Kombinasi dengan
anthistamin
(dapsone,sulfapyridine,
pyridoxine, or cyclosporine)
or adjuvants (methotrexate,
azathioprine,
cyclophosphamide, or gold).
Dapson kontraindikasi
menyebabkan penyakit
hemolitik.
Pyridoxine is similarly
unhelpful. Plasmapheresis
can be considered in severe
cases. Ritodrine,a -agonist

- and lipoprotein X

Occasionally, there is mild

to moderate bilirubin
elevation (2-5 mg/dL in
jaundiced patients) liver
biopsy reveals changes of
mild cholestasis, namely,
dilated bile canaliculi,
staining of parenchyma
with bile pigments, and
minimal inflammation

Etiopatogene
sis

DD

Terapi

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darah dan linear or granular C3

dan pada dermoepidermal
junction.

Distensi dinding abdomen yg

cepat menyebabkan kerusakan
connective tissue di striae dan
mentriger respon inflamasi.
Penambahan berat badan ibu
dan fetus serta kehamilan
kembar. Selama trimester 3,
plasenta melepaskan substansi
ke sirkulasi maternal mentriger
proliferasi fibroblas.

- Antipruritic topical
(menthol,doxepin)
- Antihistamines
- Kortikosteroid topikal
- Prednisone oral
- UVB therapy

cause of PP is unknown.
The condition may be
related to an atopic
background or ICP or
both. Several patients
with PP have elevations
in serum IgE, which is
consistent with the
theory that PP arises as a
result of pruritus
gravidarum in women
with an atopic
predisposition.
-Arthropod bites,
-scabies
-drug eruptions

no evidence of any
immunologic
or hormonal abnormalities
in this condition

-mid-potency topical
corticosteroids
-antihistamines.

-topical corticosteroids,
-benzoyl peroxide,
-UVB therapy.

-folliculitis
-PUPPP, HG, and PP.

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Prognosis

given orally at a dose of 15

mg/kg per day for 3 weeks.
-oral corticosteroids.
No maternal risks
associated with ICP, other
than those associated with
deficiency of vitamin K in
severe cases (uterine and
intracranial hemorrhage).
leading to a prolonged
prothrombin time.
Sebaiknya PT dimonitor
secara rutin and pemberian
vitamin K intramuskular.

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used for the treatment of

premature labor, was
successful in one patient.
Resolves during the later
part of gestation and flares
at the time of delivery. No
maternal risk in HG other
than symptomatic
complaints. Neonatal HG
has been reported179 in up
to 10% of cases, but the
disease is mild and selflimited. no increase in fetal
morbidity or mortality.

The eruption will resolve after

delivery, self-limited.

The maternal and fetal

prognosis is excellent,
the birth weight normal,
and the condition usually
resolves postpartum

No morbidity to the mother

or fetus, and usually
resolves after delivery

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