What are the causes and management of rash in pregnancy?

From the Guidelines

Rashes during pregnancy can be concerning, but most are harmless and treatable, and any new rash warrants medical evaluation to ensure both maternal comfort and fetal safety. The causes of rash in pregnancy can be varied, including pregnancy-specific conditions such as pruritic urticarial papules and plaques of pregnancy (PUPPP), atopic eruption of pregnancy (AEP), polymorphic eruption of pregnancy (PEP), pemphigoid gestationis (PG), and intrahepatic cholestasis of pregnancy (ICP) 1.

Management of Rash in Pregnancy

The management of rash in pregnancy depends on the underlying cause. For example, PUPPP can be managed with topical corticosteroids like hydrocortisone 1% cream applied twice daily, and oral antihistamines such as diphenhydramine 25-50mg every 6 hours or loratadine 10mg daily. Cholestasis of pregnancy causes intense itching without visible rash and requires medical attention. For general itching, use mild, fragrance-free soaps, apply moisturizer regularly, wear loose cotton clothing, and take cool oatmeal baths. Avoid scratching to prevent skin damage and infection.

Serious Conditions

Some rashes during pregnancy can indicate more serious conditions like pemphigoid gestationis or indicate infections that could affect the baby, such as chickenpox or measles. Pemphigus in pregnancy is rare and requires close cooperation between dermatologist, obstetrician, and neonatologist, with careful selection and monitoring of immunosuppression during pregnancy 1. Prednisolone alone is the most common treatment for pemphigus in pregnancy, and certain second-line treatments have been safely used when needed 1.

Key Considerations

Hormonal changes, increased blood volume, and immune system adjustments during pregnancy make skin more reactive and susceptible to rashes. Prednisolone is the preferred corticosteroid in pregnancy due to its high inactivation by the placenta, reducing the risk to the fetus 1. It is essential to consult a healthcare provider promptly for proper diagnosis and treatment of any new rash during pregnancy to ensure the best possible outcomes for both mother and baby.

From the FDA Drug Label

Pregnancy Teratogenic Effects Category C Corticosteroids are generally teratogenic in laboratory animals when administered systemically at relatively low dosage levels. The more potent corticosteroids have been shown to be teratogenic after dermal application in laboratory animals There are no adequate and well-controlled studies in pregnant women on teratogenic effects from topically applied corticosteroids. Therefore, topical corticosteroids should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Drugs of this class should not be used extensively on pregnant patients, in large amounts, or for prolonged periods of time

The causes of rash in pregnancy are not directly addressed in the provided drug label. Management of rash in pregnancy is not explicitly stated, but it can be inferred that if a rash occurs due to the use of topical corticosteroids, the drug should be discontinued and appropriate therapy instituted 2.

• If irritation develops, topical corticosteroids should be discontinued
• In the presence of dermatological infections, the use of an appropriate antifungal or antibacterial agent should be instituted
• If a favorable response does not occur promptly, the corticosteroid should be discontinued until the infection has been adequately controlled.

From the Research

Causes of Rash in Pregnancy

• Pruritus is the leading dermatological symptom during pregnancy, occurring in 18% of women 3, 4
• Pregnancy-specific dermatological diseases that can cause rash include:
  • Polymorphic eruption of pregnancy (PEP) 3, 4, 5, 6
  • Pemphigoid (herpes) gestationis 3, 4, 5, 7, 6
  • Pruritus gravidarum 3, 4
  • Pruritic urticarial papules and plaques of pregnancy (PUPPP) 5, 6
  • Intrahepatic cholestasis of pregnancy 5, 6
  • Pustular psoriasis of pregnancy 5
• Preexisting skin conditions can also cause rash during pregnancy, such as:
  • Atopic dermatitis 4, 5, 6
  • Psoriasis 5, 6
  • Acne vulgaris 5
  • Condylomata acuminata 5
  • Herpes simplex 5
  • Hidradenitis suppurativa 5

Management of Rash in Pregnancy

• Treatment of pruritus in pregnancy requires prudent consideration due to potential effects on the fetus 3, 4
• Topical treatments, such as:
  • Emollients 3
  • Topical anti-pruritics 3
  • Topical corticosteroids 3, 5
• Systemic treatments, such as:
  • Systemic corticosteroids 3, 4, 7
  • Antihistamines 3, 4
  • UV phototherapy 3, 4
• Management of specific conditions, such as:
  • Pemphigoid gestationis: requires a suitable pharmacotherapy regimen, close observation, and collaboration with a multi-disciplinary treatment team 7
  • Intrahepatic cholestasis of pregnancy: requires antepartum surveillance 5, 6