From the Guidelines
Evaluation of a rash during pregnancy requires a prompt and thorough assessment to distinguish between benign conditions and those that may threaten maternal or fetal health, with the initial approach including a detailed history and physical examination, as noted in the most recent guidelines 1. The initial evaluation should note the rash's appearance, distribution, timing, associated symptoms, and any potential exposures.
- Common benign rashes in pregnancy include pruritic urticarial papules and plaques of pregnancy (PUPPP), atopic eruption of pregnancy, and prurigo of pregnancy.
- More concerning conditions include pemphigoid gestationis (autoimmune blistering disease), intrahepatic cholestasis of pregnancy (presents with pruritus without primary rash), and HELLP syndrome or preeclampsia (may present with rash-like symptoms). Laboratory testing should be guided by clinical suspicion and may include liver function tests, complete blood count, and skin biopsy in unclear cases, as suggested by recent studies 1. Management depends on the specific diagnosis - topical corticosteroids and antihistamines are often first-line for symptomatic relief of benign conditions, while more serious conditions may require systemic corticosteroids, ursodeoxycholic acid for cholestasis, or delivery planning, with careful consideration of the potential risks and benefits of each treatment option, as discussed in the context of pemphigus in pregnancy 1. Any rash with systemic symptoms (fever, abdominal pain, headache) warrants urgent evaluation to rule out serious conditions that could affect pregnancy outcomes, emphasizing the need for a thorough and prompt assessment 1.
From the Research
Evaluation Approach for a Rash in Pregnancy
The evaluation approach for a rash in pregnancy involves a comprehensive diagnostic framework to identify specific dermatoses that pose fetal risks 2. The following steps can be taken:
- Consider non-pregnancy specific conditions when approaching pruritus or a pruritic rash in pregnancy
- Consider pregnancy-specific dermatoses, which have been reclassified into four categories:
- Polymorphic eruption of pregnancy
- Pemphigoid gestationis
- Intrahepatic cholestasis of pregnancy (ICP)
- Atopic eruption of pregnancy
- Note that ICP begins with pruritus, and skin changes are secondary 2
- Be aware that ICP and pemphigoid gestationis are associated with fetal risks such as prematurity and stillbirth 2
Diagnostic Considerations
When evaluating a rash in pregnancy, the following diagnostic considerations should be taken into account:
- A thorough history and physical examination are essential 3, 4
- Laboratory investigations may be required when the diagnosis remains in question despite a careful history and thorough physical examination 3
- The rash can be categorized based on visual and tactile characteristic patterns, such as petechial/purpuric, erythematous, maculopapular, and vesiculobullous 4
- The presence or absence of fever and distribution of skin lesions should be assessed 4
Pregnancy-Specific Dermatoses
Pregnancy-specific dermatoses are a heterogenous group of disorders that include: