II. Signs: General Skin, Hair and Nail Changes

  1. Hair Changes
    1. Hirsutism
      1. Associated with increased Anagen phase
      2. Results in scalp hair thickening, and Hirsutism on the face, extremities and back
    2. Telogen Effluvium
      1. Onset in the Postpartum Period and resolves within 12 to 18 months
    3. Androgen-Related hair changes
      1. Male pattern baldness and Hypertrichosis may occur during or after pregnancy but is uncommon
  2. Nail changes (e.g. Onycholysis, brittle nails, grooves)
    1. Nails become more brittle and grow more quickly in pregnancy (resolves after delivery)
    2. Onychommycosis is more common in pregnancy
  3. Vascular changes
    1. Hyperestrogenic state results in venous dilation and congestion, and small vessel proliferation
    2. Telangiectasias or Spider Angiomas (67% of pregnancies)
    3. Palmar erythema (67% of pregnancies, esp. lighter skin)
    4. Varicose Veins (40% of pregnancies)
    5. Chadwick Sign
      1. Darkened or erythematous vulva and vagina
    6. Goodell Sign
      1. Purple or blue discoloration of the Cervix
      2. Results from pelvic vessel congestion
    7. Gingival Hyperplasia
      1. Results from increased Gingival edema and hyperemia
      2. Optimize Dental Hygiene to prevent Gingivitis
  4. Other common skin changes in pregnancy
    1. Hyperpigmentation in Pregnancy (e.g. Melasma)
    2. Striae Gravidarum

IV. Causes: Conditions Exacerbated by Pregnancy

  1. Acne Vulgaris (up to ~40% of pregnancies)
    1. Associated with increased androgen levels in second and third trimesters
    2. Topical Benzoyl Peroxide, Azelaic Acid, Erythromycin Topical 2% (Erygel), Clindamycin Topical 1% (Cleocin-T)
    3. In severe cases, may consider oral Erythromycin, oral Prednisone <20 mg/day for <1 month or pulsed Light Therapy
  2. Condylomata acuminata (Genital Warts)
    1. Start with Cryotherapy, and consider laser therapy if persistent
    2. Consider Imiquimod or surgical excision for extensive or refractory cases
    3. Avoid Podophyllotoxin-based agents in pregnancy
    4. Genital Warts do not contraindicate Vaginal Delivery unless obstructing pelvic outlet or significant bleeding risk
  3. Genital Herpes
    1. See Genital Herpes in Pregnancy
    2. Genital Herpes recurs during pregnancy in 75% of women with known genital HSV
    3. High risk of vertical transmission with primary outbreak in third trimester
    4. Viral suppression (Acyclovir or Valacyclovir) from 36 weeks until delivery
    5. Cesarean Section if active lesions or prodromal Genital Herpes symptoms at time of delivery
  4. Hidradenitis Suppurativa
    1. May worsen (20%) or improve (24%) with pregnancy
    2. Worsens for 60% in the Postpartum Period
    3. Topical Benzoyl Peroxide or Clindamycin Topical 1% (Cleocin-T) and oral Cephalexin or Amoxicillin-clavulanate
    4. Severe, refractory cases may be treated with intralesional Corticosteroid, laser therapy, surgical excision
  5. Pityriasis Rosea (RR 3 in pregnancy)
    1. Average duration in pregnancy 45 days, treating with supportive care, and resolves spontaneously
    2. Miscarriage rates may be >60% when it occurs <15 weeks gestation (esp. high titers, systemic symptoms, >50% BSA)
  6. Psoriasis
    1. Most Psoriasis improves during pregnancy and worsens postpartum (but variable across pregnancies)
    2. Start with topical Skin Lubricants and low to moderate potency Topical Corticosteroids, followed by UVB Phototherapy
    3. In severe cases after first trimester, TNF Inhibitors, Cyclosporine and Systemic Corticosteroids may be considered
  7. Impetigo Herpetiformis (Pustular Psoriasis of Pregnancy)
  8. Skin Tags
    1. May develop or hypertrophy in pregnancy
    2. Typically regress after pregnancy

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