Specific pregnancy dermatoses Therapy as gentle as possible for the fetus By Sarah Grieb and Daniela Bruch-Gerharz / The nine months of pregnancy go to the skin over its mark. While the physiological changes in the skin are well known, mostly reversible and without danger to the fetus, are the so-called specific pregnancy dermatoses represent a potential risk for the child. Early diagnosis and specific treatment are essential. DISPLAY Specific pregnancy dermatoses go exclusively with pregnancy and / or the early postpartum period, ie the period after birth, accompanied (Table). They are strictly distinguished from existing dermatoses such as autoimmune disorders or tumors, as well as from randomly occurring in the course of a pregnancy dermatoses, such infection. Table: Classification of clinical-morphological aspects diagnosis clinic laboratory findings trimester
pemphigoid gestationis Redness, grouped standing sores and blisters DIF: C3 at the basement membrane zone, IgG1 in serum (HG factor) II, III polymorphic rash Redness, eczema, sores – III prurigo gestationis Nodes, scars – III Intrahepatic of pregnancy
No / secondary lesions, nausea, vomiting, jaundice Pathological increase of bilirubin and γ-GT III Among the specific pregnancy dermatoses today are four conditions as secured, which can be clearly diagnosed due to clinical, histological and laboratory findings: Pemphigoid gestationis, polymorphic eruption of pregnancy (PUPP syndrome) prurigo gestationis intrahepatic of pregnancy Pemphigoid gestationis is a bullous autoimmune dermatosis, usually occurring in late pregnancy or immediately after birth. Typical Symtom is a fierce itching. When lesions are found partly in groups arranged vesicles and tense blisters, which begin at the belly button and can spread to the entire skin surface (Figure 1). In most cases, pemphigoid gestationis runs but without bubbles. The polymorphic eruption of pregnancy (PUPPP, pruritic urticarial papules and plaques of pregnancy) got its name from its manifold clinical picture of redness, blisters and eczema-like lesions.
Usually the disease begins in the abdominal stretch marks (striae) and spreads from there over the abdomen and thigh (Figure 2). Itching belongs also the leading symptoms. Plate prurigo gestationis is the occurrence of multiple, often boisterous knots at the extremities stretch sides and the belly that heal with scarring and hyperpigmentation. Unlike the above three conditions are found in the intrahepatic of pregnancy only secondary lesions that are caused by massive itching with subsequent scratching. Complicating occur nausea and vomiting. In severe cases, it takes a few weeks after the itch to cholestatic jaundice, clinically characterized by hepatomegaly, dark urine and pale stools. By crossing toxic bile acids in the fetal circulation results in an increased incidence of premature births and stillbirths. The diagnosis of specific of pregnancy will be provided, including the history, the clinical, laboratory and histological findings and possibly also by means of direct (DIF) and indirect immunofluorescence (IIF). Systemic with glucocorticosteroids In the treatment of pregnancy dermatoses such as pemphigoid gestationis, polymorphic rash and prurigo gestationis glucocorticosteroids and antihistamines play a central role. First is the knowledge of physiological Glucocorticosteroidspiegel important for a proper use of systemic steroids. Thus, in the course of pregnancy, an increase in levels of both bound and free cortisol recorded (from 20 to 25 g / dl at 50 to 70 g / dl). The produced cortisol originates to 90 percent of the mother and only 10 percent from the fetus itself.
The fetus, however, is mainly exposed to the cortisol produced by himself, since maternal cortisol is inactivated in the placenta through the type II hydroxysteroid. Therefore, the effect of this enzyme can be used in the selection of a glucocorticosteroid preparation and therapeutically. In addition, the expected under a glucocorticosteroid therapy side effects must be considered. teratogenic in animal studies In animal experiments, a teratogenic effect has been demonstrated in a systemic treatment with glucocorticosteroids during the first trimester: most pronounced in triamcinolone, undetectable for methylprednisolone. A central position is occupied by dexamethasone and prednisolone. Figure 1: pemphigoid gestationis In humans, however, a higher overall rate of malformations was not sufficiently substantiated. However, there is an increased risk of cleft lip and palate clefts. In the second and third trimester intrauterine growth retardation, placental insufficiency and premature birth and transient hypoglycemia, hypotension and electrolyte disturbances may occur in the newborn; the chances of this happening increases from a dose of 10 mg prednisolone per day. In principle, the indication for glucocorticosteroid therapy system should therefore be provided strictly. Whereas, in order to guarantee adequate drug levels in the pregnant woman, on the other hand to obtain the lowest possible serum levels in the fetus, the effect of type II hydroxysteroid should also be used therapeutically in the choice of a suitable preparation. Prednisolone treatment of choice
To ensure maximum security, preparations high in animal experiments teratogenem potential must be strictly avoided. So currently a recommendation for prednisolone is pronounced as drug of choice. If you plan to long-term therapy, the usual dose is 20 to 40 mg prednisolone and should not exceed 10 mg prednisolone as a maintenance daily dose for the prevention of fetal growth restriction. After the end of treatment an adrenal insufficiency should always be excluded in mother and child. Postpartum is through the physiological drop in cortisol levels recurrence of of pregnancy possible and can be treated by re Glukocorticosteroid administration. Figure 2: Polymorphic rash Practical recommendations concerning the topical application of glucocorticosteroids are based on the fundamentals of a systemic application. The reason: Particularly in inflammation with subsequent disruption of the epidermal barrier therapeutic serum levels can be achieved by absorption. Therefore, especially in the first trimester and for external application, the need for a clear justification. Drugs of choice are compounds which are also available for systemic therapy during pregnancy are available or can be cleaved in the skin to systemically administered compounds. An application recommendation is for methylprednisolone before as Class II steroid, can alternatively be applied mometasone furoate as Class III steroid in time and geographically limited therapy; the striae (stretch marks) should always be left out. H1 Rezptorenblocker itching Particularly in addition present the pruritus with antihistamines may be contemplated.
Due to the long application experience classical H1-receptor blockers are preferred with sedating active component the newer, nonsedating preparations principle. In the first trimester older antihistamines are considered relatively safe; in the second and third trimesters of their administration is even classified as safe. In the treatment of intrahepatic of pregnancy, the treatment with the hydrophilic bile acid ursodeoxycholic acid (UDCA) has been proven. The effect is due to a stimulation of bile secretion, while protecting the epithelium against cytotoxic effects of bile and anti-apoptotic effects. This results in the improvement of pruritus and liver. Accompanying measures indispensable Regardless of the etiology and severity of the patients of pregnancy should be made aware of general measures which affect the success of treatment significantly. Thus, an additional drying of the skin due to frequent washing must be avoided, because the dry skin itch-scratch cycle activated, promotes the development of dehydration and eczema may be associated with worsening of pregnancy dermatoses. Therefore, in addition to specific systemic and topical therapy a consistent, regular topical therapy with nursing-hydrating emollient is particularly important. are this different bases available, which can be adjusted by various additives to the individual needs of patients, depending on skin condition. As harmless applies the local anesthetic polidocanol; it is used for the symptomatic treatment pruritogener dermatoses. As is also harmless urea in different concentrations (3 to 10 percent); He is appreciated for its hydrating and penetration enhancing effect. /
literature . . . At the draftsman Address of the authors: Professor Dr. Daniela Bruch-Gerharz Dermatology Clinic of the University Hospital Moore Street 5 40225 Dusseldorf bruch-gerharz@med. uni-duesseldorf.