- Eczema (Atopic Dermatitis) During Pregnancy: What You Need to Know
- The Link Between Pregnancy and Eczema
- Ruling Out Other Skin Conditions When You’re Pregnant
- Tips for Treating Eczema When You’re Pregnant
- Lifestyle Changes That Can Help Tame Eczema Symptoms
- One Last Thing on Managing Pregnancy Eczema
- Eczema herpeticum in early pregnancy
- Skin problems in pregnancy
- Itchy rashes during pregnancy
- Cholestatic pruritus
- Prurigo of pregnancy
- Pruritic Urticated Papules and Plaques of Pregnancy
- Pemphigoid gestationis
- Types of Eczema
- Causes of Pregnancy Eczema
- Signs and Symptoms Eczema during Pregnancy
- Who can be more Prone to Eczema during Pregnancy?
- How is the Diagnosis Done?
- Does Eczema Affect the Baby?
- Treatment and Medication
- Management of Eczema while Pregnant
- Things you can do to Rebuild Healthy Skin
- Eczema During Pregnancy
- What causes eczema during pregnancy?
- What you can do
- More In This Series
- What solutions are off-limits
- 9 Ways to Stop Eczema from Interrupting Your Pregnancy Glow
- Eczema in Pregnancy
- Pregnancy affects eczema differently in women
- Safe treatments for pregnant women with eczema
- When menopause triggers eczema
Eczema (Atopic Dermatitis) During Pregnancy: What You Need to Know
It’s not only your body that changes during pregnancy — your skin can go through a roller coaster of changes, too. In fact, more than 90 percent of women report having significant skin changes during pregnancy due to the shifts that occur within the body’s endocrinological, immunological, metabolic, and vascular systems while growing a baby, according to a study published in the October–December 2014 issue of the Journal of Family Medicine and Primary Care.
The effect pregnancy can have on the skin varies from woman to woman. Some women might see improvements to their complexion, giving them what many call the “pregnancy glow,” according to the American Pregnancy Association. Others may experience worse symptoms of preexisting skin conditions.
If you do notice your skin start to change, chances are it’s related to eczema, aka atopic dermatitis, a condition marked by red, itchy patches of skin, according to the Mayo Clinic. “Eczema is the most common skin disorder of pregnancy,” says Daniel P. Friedmann, MD, a board-certified dermatologist with Westlake Dermatology in Austin, Texas. It accounts for between 33 and 50 percent of skin issues that develop during this time in a woman’s life, according to the National Eczema Society.
RELATED: 7 Common Myths About Eczema You Shouldn’t Believe
The Link Between Pregnancy and Eczema
Eczema flares are the result of different environmental and internal triggers, and it appears pregnancy is one of them, according to a past study published in The BMJ. This is especially true if you’ve dealt with eczema before. “Women with a history of eczema prior to pregnancy have a significant risk of an eczema flare during pregnancy,” Dr. Friedmann says.
About 20 to 40 percent of women who experience eczema while expecting have had it before, according to the National Eczema Society. For these women, it tends to worsen during the second trimester (Friedmann suspects because of the immunological changes that occur as the fetus grows), though it can occur in the first or third trimesters as well.
Unfortunately, not having experienced eczema before doesn’t mean you’re in the clear — it’s entirely possible for eczema to appear for the first time while pregnant, Friedmann says.
So, why does pregnancy seem to exacerbate eczema symptoms? Blame those shifting hormones. “Eczema symptoms during pregnancy are largely related to the impact of female sex hormones on the immune system,” says Natalie Yin, MD, an assistant professor of dermatology with Columbia University Medical Center in New York City. She explains that during pregnancy, the immune system shifts from a Th1 response to a Th2 response in order to protect the fetus.
These T responses belong to the same family of white blood cells and are major sources of hormone messengers called cytokines. Th1-type cytokines are known for producing proinflammatory responses, while Th2-type cytokines have more of an anti-inflammatory response, according to a study published in Mediators of Inflammation. Friedmann says this slight change in the way the T cells function is associated with an increase in eczema. What’s more, the Th2 response can also worsen asthma and food allergies, Dr. Yin says.
RELATED: A Comprehensive Guide to Estrogen
Ruling Out Other Skin Conditions When You’re Pregnant
Complicating the picture is that pregnant women are prone to developing other rashes that might look similar to eczema. For example, pruritic urticarial papules and plaques of pregnancy (PUPPP) is another common pregnancy rash. The itchy, red patches tend to first appear toward the end of pregnancy around stretch marks, though they can spread to the arms, legs, and butt, according to The University of Texas Southwestern Medical Center.
That’s different from eczema because eczema during pregnancy usually appears on the face, chest, or neck, per the aforementioned study in the Journal of Family Medicine and Primary Care. And about 75 percent of the time, pregnancy eczema occurs during the first and second trimesters, according to the BMJ research.
If you’re not sure what type of rash you’re dealing with, consult your dermatologist to have it checked out, Yin suggests.
RELATED: No, Eczema Isn’t Contagious, But Here’s How Secondary Infections Can Be Spread
Tips for Treating Eczema When You’re Pregnant
If you’ve dealt with eczema before, you may have treated it with topical ointments, oral medication, over-the-counter skin-care products, or prescriptions. And while they may have been safe to use before, that may no longer be the case during your pregnancy. The BMJ study notes that pregnant women should avoid some eczema treatment options, such as methotrexate and phototherapy (psoralens plus ultraviolet A).
Yin advises that during pregnancy, it’s best to approach very potent topical steroids, oral steroids, topical calcineurin inhibitors, and oral immunosuppressive agents with extreme caution. If you’re taking one of these drugs, be sure to work closely with your doctor.
Most topical steroids combined with moisturizers can be safe to use during your pregnancy, so long as they’re mild or moderately potent, according to the National Eczema Society. “There is a risk of low birth weight with topical steroid use, but this typically occurs with application of over 300 grams during the entire pregnancy, which is rarely necessary,” Yin says.
Because steroids with a high potency can be dangerous, stay on the safe side by diluting the potent steroid with moisturizer so it’s one part steroid and four parts moisturizer, suggests the National Eczema Association.
RELATED: The Best Soothing Creams and Moisturizers to Help Tame Eczema
Always consult your doctor first to get the okay on any medication you’re taking. “I always recommend patients run products by their board-certified dermatologist or ob-gyn in order to confirm that they are safe to use while pregnant,” Friedmann says. Even if you currently take medication to help with eczema and are not pregnant yet, but plan to become pregnant in the near future, share your plans with your doctor. There may be a minimum amount of time that needs to pass between stopping treatment and becoming pregnant safely, notes the National Eczema Society.
Lifestyle Changes That Can Help Tame Eczema Symptoms
Also keep in mind that many of the eczema treatments involving lifestyle tweaks can be safely incorporated regardless of whether you’re pregnant. “The treatment of eczema during pregnancy begins with warm (not hot) showers and the use of moisturizers and synthetic soaps (no true soaps) in order to limit overdrying of the skin,” Friedmann says.
The Mayo Clinic also suggests:
- Applying moisturizer within three minutes of showering
- Moisturizing twice a day
- Covering the area in bandages
- Taking warm baths with baking soda, uncooked oatmeal, or colloidal oatmeal sprinkled in the water
- Using a humidifier
RELATED: How Stress Can Worsen Eczema Symptoms and How to Find Relief
One Last Thing on Managing Pregnancy Eczema
With your doctor’s guidance, you can weigh the benefits and drawbacks of any medication, as well as be sure you’re getting needed treatment to avoid or manage any skin infection. If you’re seeing a dermatologist for pregnancy eczema, be sure to keep your ob-gyn in the loop, especially about any medication you’re taking.
Eczema herpeticum in early pregnancy
A 25 year-old woman with a history of atopic dermatitis presented to the emergency department with a generalized skin rash. She was at 12 weeks gestation in her first pregnancy. The skin lesions first appeared on her chest in an area where she had symptomatic eczema. These lesions were painful and diffuse, and were located on her face (Figure 1A), trunk and extremities (Figure 1B). The lesions consisted of crusted plaques and vesicles that drained clear fluid. Her body temperature was 101.1°F (38.4°C), her heart rate was 137 beats/min, and her leukocyte count was 11.8 K/μL (11.8 × 109/L).
Skin rash, consisting of crusted plaques and vesicles, on the face and neck (A) and the right hand (B) of a 25-year-old woman at 12 weeks gestation with eczema herpeticum.
Given her history of atopic dermatitis and diffuse vesicular lesions, we considered eczema herpeticum in the initial differential diagnosis and started acyclovir intravenously. Pelvic ultrasonography confirmed a 12-week-old viable intrauterine pregnancy. A Tzanck test from a skin scraping showed multinucleated giant epithelial cells. Levels of antibodies for herpes simplex virus (HSV) immunoglobulins M and G were elevated for HSV type 1.
By day 4, the patient had been afebrile for 48 hours and her skin eruptions had improved. We changed treatment with acyclovir from intravenous to oral (200 mg five times daily) for a total of 10 days of treatment, and the patient was discharged home.
Eczema herpeticum is a diffuse skin infection caused by HSV-1/2. It generally occurs in individuals with chronic skin disorders, such as atopic dermatitis. It can be spread by direct contact of susceptible skin with HSV or reactivated from previous infection. Immunosuppression and pregnancy may predispose patients to severe visceral dissemination of HSV that can spread rapidly and is associated with high mortality. 1 Delayed diagnosis and treatment in women who are pregnant can lead to fulminant infection, which further increases risk of maternal death, preterm labour, neonatal HSV infection or fetal death.
Acyclovir, valacyclovir and famciclovir have been used safely in the first trimester of pregnancy for infections caused by HSV.2 There are no controlled studies or current guidelines on managing this infection with antiviral agents in pregnant women; however, it appears safe to transition from intravenous to oral therapy when the skin rash improves and the patient has been afebrile for at least 48 hours.
Competing interests: None declared.
This article has been peer reviewed.
The authors have obtained patient consent.
- Schiffer JT,
- Corey L
. Herpes simplex virus. Mandell, Douglas, and Bennette’s Principles and Practice of Infectious Disease. 8th ed. Philadelphia: Elsevier Saunders; 2014:1721,1729.
- Pasternak B,
- Hviid A
. Use of acyclovir, valacyclovir, and famciclovir in the first trimester of pregnancy and the risk of birth defects. JAMA 2010;304:859–66.
Skin problems in pregnancy
Hormonal changes in pregnancy may result in physiological alterations in the skin, hair and nails. For example:
- Appearance or darkening of a vertical band down the middle of abdominal skin (linear nigra), which may normally appear paler than normal skin (linear alba)
- Darkening of areola, nipple and genital skin
- Increased redness of palms (palmar erythema) and vasomotor instability (flushing)
- Telangiectasia (dilated small re blood vessels), venulectasia (dilated bigger blue-coloured vessels) and varicose veins
- Telogen effluvium (hair shedding after the baby has been born)
- Striae gravidarum (stretch marks)
- Skin tags on the neck, in the armpit and groin
- Hyperhidrosis (increase in sweating)
Phyisological skin changes in pregnancy
Pregnancy may result in an increase in prevalence or severity of some common and uncommon skin problems. These include:
- Facial pigmentation (melasma)
- Atopic dermatitis
- Vesicular hand dermatitis
- Acne (in early pregnancy)
- Perioral dermatitis
- Pyogenic granuloma
- Generalised pustular psoriasis
- Systemic lupus erythematosus
Some skin conditions are reported to improve in pregnancy (at least sometimes).
- Atopic dermatitis
- Psoriasis (may worsen, improve or stay the same)
- Acne (in late pregnancy)
- Hidradenitis suppurativa
- Fox-Fordyce disease
When prescribing for skin diseases, safety of medicines in pregnancy must be carefully considered.
Itchy rashes during pregnancy
Itching is relatively prevalent in pregnancy. Causes include scabies, atopic eczema, contact irritant dermatitis etc. Some specific conditions that arise in pregnancy follow.
Intrahepatic cholestasis affects about 1% of pregnancies. It results in unexplained pruritus (itch) during the second and third tremesters, with raised blood levels of bile acids and/or liver enzymes. Intrahepatic cholestasis is associated with:
- Increased risk of preterm delivery
- Stillbirth (rare)
- Increased risk of later hepatobiliary cancer (2–3 times greater than the risk in women in whom pregnancy occurred without intrahepatic cholestasis)
- Increased risk of later thyroid disease, diabetes, psoriasis, Crohn disease and cardiovascular disease
Prurigo of pregnancy
Prurigo of pregnancy (papular dermatitis of pregnancy) presents as scattered itchy/scratched papules at any stage of pregnancy. It should be managed with emollients, and topical steroids may help individual papules.
Prurigo of pregnancy
Pruritic Urticated Papules and Plaques of Pregnancy
PUPPP is an acronym for Pruritic Urticated Papules and Plaques of Pregnancy, and is also known as polymorphous eruption of pregnancy. Features include:
- Onset of PUPPP is in the 3rd trimester and remission occurs within a few days of delivery
- It more frequently arises in primigravidae and multiple pregnancies
- Itchy erythematous papules and plaques first appear on abdominal striae and then spread to trunk and proximal limbs; umbilicus is spared
- Direct immunofluorescence is negative (unlike pemphigoid gestationis)
- Emollients, medium potency topical steroids and sedative oral antihistamines provide relief of symptoms. In severe cases, systemic steroids may be necessary.
Pruritic Urticated Papules and Plaques of Pregnancy (PUPPP)
Pemphigoid gestationis is a rare blistering disease due to circulating IgG autoantibodies similar to those found in bullous pemphigoid, targeting a basement membrane zone protein BPAG2 (BP180) within the hemidesmosome. Features include:
- The onset of pemphigoid gestationis is most often in the 2nd trimester (weeks 13 to 26), but it may arise at any stage and may even be worse postpartum
- It can recur with menstruation, with oral contraceptives and in further pregnancies
- The itchy papules mainly affect the abdomen, including umbilicus, but may generalise, with grouped or annular red papules, plaques and blisters
- Direct immunofluorescence (a test done as part of a skin biopsy) shows deposition of C3 and or IgG or other antibodies
- Severe pemphigoid gestationis should be treated by oral corticosteroids.
Pregnancy is a combination of excitement and stress. But when the stress begins to surpass and take over, it can manifest itself in a variety of forms, including eczema. During pregnancy, your doctor may not recommend all the necessary medication required to control eczema and taking care of your skin will be a personal responsibility in that regard. Eczema and rashes can be easily misinterpreted. Also, certain studies have shown about 50% percent women out of 500 suffer from eczema during pregnancy, with most of them having eczema it the very first time.
Types of Eczema
Here are some common types of eczema during pregnancy:
1. Contact Dermatitis
In contact dermatitis, the skin irritation is triggered when the skin makes contact with the typical triggering element. Most of the elements are specific soaps, or fragrances, certain kinds of fabrics that are synthetic, dyes, dust, or other things. Once these objects come in contact with the skin, they may trigger eczema. On replacing the entity causing the trigger, further aggravation can be prevented.
2. Atopic Dermatitis
Atopic dermatitis is slightly different from contact dermatitis. This isn’t due to skin contact as such, so it cannot be easily combated. Such kind of dermatitis may occur due to sensitivity towards a specific type of food, any allergens in the environment, or even abrupt weather changes. At times, the change in hormones in a pregnant woman’s body can cause the skin to inflame, and itch, resulting in eczema.
Causes of Pregnancy Eczema
- In pregnancy, eczema usually occurs in the earlier months. Primarily, in the early stages of pregnancy, the mother’s immunity is lower than usual since the body is working beyond its usual capacity to prepare for the changes yet to come.
- As the foetus is undergoing formation and requires as much protection as possible, the mother’s body is left vulnerable in ensuring absolute safety of the newborn child.
- In such a case, the body’s immunity system develops antigens that aggressively attack any and every sign of attack. This results in them, at times, attacking the cells of the body itself, which results in such results.
- Tiny red bubbles form on the skin which itches a lot with a burning sensation and turns red. These are the tell-tale signs of eczema. With undue stress and any chronic disease, this condition can continue existing or worsen further.
- Inflamed oral cavities, sinusitis, and a number of other diseases that cause various pathogens to exist in the body, further increase the aggression of the antigens. This aggression then causes eczema to grow further.
Signs and Symptoms Eczema during Pregnancy
- Multiple rashes
- Red bumps that are rough and itchy
- Bumps that often grouped together in a cluster
- Bumps that have a crust-like layer
- Visibility of certain pustules
- Previous history of eczema
Who can be more Prone to Eczema during Pregnancy?
In most cases, pregnancy-induced eczema is the first time that most women have experienced eczema in their lives. Furthermore, any history of eczema earlier in life could cause it to flare up again during pregnancy. Estimates point at roughly 20-40 percent of cases being of women who have experienced eczema before. Nearly 60-80 percent women experience eczema for the first time, during their pregnancy.
How is the Diagnosis Done?
The diagnosis of eczema is generally done by visual examination itself. Most doctors can instantly tell the presence of eczema by looking at the skin. In certain cases, a biopsy might be conducted to confirm the same.
The doctor might ask you to recall any changes you noticed in your body in the months of your pregnancy. They will primarily work towards ruling out any other causes that might cause similar red spots to appear, ensuring your baby is safe.
It’s best to personally note the specific time around when you first spotted the changes in your skin if any lifestyle or routine changes have been undertaken following which the spots began to appear, any particular aspect that helped reduce eczema or worsened it, and so on.
Do remember to tell your doctor all the medication you are currently taking during pregnancy, as well as any treatment you might have tried previously for eczema.
Does Eczema Affect the Baby?
Eczema directly does not harm the baby at all, since it cannot reach the foetus via the placenta. The presence of eczema, however, can irritate the mother and cause stress, which could affect the baby. Being emotionally and mentally stable without undue stress is highly required for the baby.
Treatment and Medication
In a majority of the cases, eczema cream for pregnancy is generally recommended along with moisturizers and ointments to keep it under control.
- A prescription for a steroid ointment might be authorized in case the eczema is too severe. Though topical steroids are safe during pregnancy, it’s best to reconfirm the same from your doctor.
- Certain people have undertaken UV light therapy to clear eczema, too.
- Any treatment methods involving Trexail, Rasuva or PUVA are harmful to the foetus and should be avoided.
For eczema during pregnancy home remedies also exists, which can give you relief and reduce the intensity of the irritation.
- Warm showers should be preferred over hot showers.
- Use moisturizers right after the shower to keep the skin hydrated.
- Opt for clothing that is made from 100% cotton. Clothes made from hemp or wool might end up irritating your skin.
- Make sure your clothes are not snug or right, but loose and comfortable.
- Replace soaps with moisturising gels.
- If your home is in a hot area, try using humidifiers inside to keep your air from drying up.
- Regularly drink a good amount of water for yourself and the baby.
Management of Eczema while Pregnant
Here are some things you can do to manage eczema during pregnancy.
1. Avoid Irritants
The first step is to remove the triggering entity that causes eczema in the first place. It is always in your favour to see if replacing your soaps or lotions can keep it in check. Sometimes, cleaning detergents or certain food items could also be the culprits. These might not be the only reason behind your eczema. However, replacing them can prevent chances of it occurring again and keep it in check.
2. Curbing the Itch
The itching sensation is extremely irritating and any itching done to the affected area will further aggravate it. It can, however, be curbed in a few ways.
- Massage the area by applying pressure with your fingertips instead of scratching it.
- Use a washcloth to rub the area to get some instant relief.
- Wet pyjamas or gloves, wring out the water, and place them on the area. The coolness will soothe the itch and help moisture enter the skin.
- Using peppermint oil is yet another way to combat the itch. Start by applying some coconut oil or olive oil over the entire area. Then, add just a single drop of peppermint oil and spread it as widely as possible. This dilution is necessary to prevent any further irritation. Do not use it where the skin has broken since it will sting a lot. Avoid using this oil once you are in the third trimester of pregnancy.
- Dip in a bath with some baking soda in it. Remember to moisturize immediately after.
- This is admittedly a weird option but certain people have known to receive soothing after an oatmeal bath.
- The standard coconut oil is also a great moisturizer and also prevents the broken skin from catching any infection.
- Go for cotton woven pyjamas and bedsheets. The smooth texture will help the skin recover sooner.
- Wear cotton socks in case eczema has affected your feet. For hands and palms, utilizing long-sleeved shirts and cotton gloves goes a long way.
- Contrary to popular opinion, the sun can actually help in reducing the itch and heal the skin sooner. Without letting yourself get burnt, try staying out in the sun for slightly longer than usual.
Things you can do to Rebuild Healthy Skin
The constant scratching and itching can break down the skin completely and render it unable to hold the moisture required. It’s necessary to reduce the chances of dry skin by rebuilding healthy skin for yourself.
- Drinking judicious quantities of water is necessary. It shouldn’t be a lot since it does not directly hydrate the skin, but remember to consume the daily quota that’s required.
- Moisturizing the skin is similar to rebuilding the first line of defence for the skin. With a damaged lipid barrier failing to hold the skin’s moisture, a moisturizer helps keep the skin soft. Don’t use the ones with alcohol in it as they can sting the skin. Go for homemade lotions or ones with pure oil ingredients without preservatives.
- Pumpkin seed oil, when consumed appropriately, can help rebuild the lipid barrier. This would require you to confer with your doctor first before deciding on the quantity of consumption.
- Showers, when long and hot, dry out the skin than keeping it wet. Go for small warm showers and use moisturizers right after you’re done.
- Avoid manual shavers and go for electric razors instead.
- Vitamin D supplements are useful in these cases as well, as long as you aren’t taking more than your daily requirement.
- In extreme cases, your doctor may recommend a steroid cream to accelerate the healing of the skin. Generally, this is avoided during pregnancy and, hence, should be completely the doctor’s opinion alone.
Eczema and pregnancy are not meant to go hand-in-hand but usually end up so. As irritating as it might be, it is necessary to remember and maintain a positive attitude while fighting against it. Keeping eczema in check and keeping your spirits high are the best ways to maintain your health and the baby’s, too.
Rashes during Pregnancy
Dry Skin during Pregnancy
The specific dermatoses of pregnancy occur exclusively in pregnancy and the postpartum period; all are associated with pruritus. They were reclassified in 2006 by Ambros-Rudolph and coworkers and now include polymorphic eruption of pregnancy (PEP), also known as pruritic papules and plaques of pregnancy, intrahepatic cholestasis of pregnancy (ICP), atopic eruption of pregnancy (AEP), and pemphigoid gestationis (PG), formerly named herpes gestationis (Fig 1). PEP and AEP are treated symptomatically with topical corticosteroids and antihistamines, whereas systemic steroids are usually needed to control PG. Patients with ICP may benefit from ursodeoxycholic acid. Because polymorphic eruption of pregnancy and pemphigoid gestationis are discussed elsewhere in this section, we will focus on intrahepatic cholestasis of pregnancy and atopic eruption of pregnancy.
Detail showing tense vesicles on urticarial plaques in a patient with pemphigoid gestationis
Intrahepatic Cholestasis of Pregnancy (obstetric cholestasis)
Intrahepatic cholestasis of pregnancy results from hormone-induced cholestasis mostly in the third trimester. Prevalence in Europe is 1 in 50 to 1 in 500 pregnancies. Bile salts are insufficiently excreted and accumulate in serum. ICP is associated with severe pruritus; any skin changes are secondary to scratching. Mutations in biliary transporter proteins have been identified as predisposing genetic factors. In addition, hormones and exogenous factors are discussed as trigger factors. ICP is more common in multiple pregnancies and women older than age 35 years. ICP is associated with adverse fetal outcomes, because excessive bile salts in the serum of the mother may cause placental hypoxia and cardiac depression with an increased risk for preterm labor, intrapartum fetal distress, neonatal respiratory distress syndrome, and stillbirth.
Pruritus in ICP typically starts on the palms and soles and generalizes quickly. Any skin changes originate from extensive scratching and present as excoriations, prurigoform skin lesions, crusted erosions, and lichenification. Jaundice may be an additional sign in patients with severe cholestasis and extrahepatic involvement. Pruritus typically subsides quickly after delivery and laboratory abnormalities return to normal within a few weeks.
Laboratory investigations should include serum bile acid levels, because routine liver function tests often are within normal limits. Bilirubin is elevated in 10-20 % of patients. A recent study from Cork, Ireland investigated normal serum bile acid levels throughout pregnancy in 219 women excluding women with liver problems, alcohol intake, or excessive obesity body mass index (BMI) >40) . Serum bile acid levels ranged in all but 3 of 219 pregnant women between 0.3 to 9.8 μmol/l without any significant changes throughout pregnancy but a decrease after delivery. These results confirm current reference ranges with a cutoff at 11 μmol/l for serum bile acids in pregnancy, which is slightly higher than the normal range of 0-6 μmol/l in normal population. Levels >40 μmol/l are considered as extensively elevated associated with adverse fetal outcome.
The mechanisms mediating cholestatic pruritus are only partially understood. Until recently, mainly bile salts and opioids have been implicated as pruritogens in cholestatic pruritus , but levels of bile salts and opioids do not correlate with intensity of pruritus. Antihistamines have little effect on cholestatic pruritus, ruling out histamine as relevant mediator.
Recently, lysophosphatidic acid has been identified as possible pruritogen in cholestatic pruritus based on an in vitro assay. A neuroblastoma cell line (SH-SY5Y cells) was stimulated with sera from cholestatic patients with and without pruritus and from healthy controls to identify pruritogenic substances. Subsequent intradermal injection of lysophosphatidic acid in a rodent animal model induced dose-dependent itch as reflected by scratching of the animals . In addition, autotaxin, an enzyme responsible for conversion of lysophosphatidylcholine to lysophosphatidic acid, is increased in patients with ICP, further pointing toward a potential role of lysophosphatidic acid as pruritogen in cholestatic pruritus and a potential target for therapy . Furthermore, progesterone metabolites are discussed as possible mediators of cholestatic pruritus and of particular interest in cholestasis of pregnancy. Treatment of ICP with ursodeoxycholic acid not only lowers levels of serum bile acids but also of steroid disulfated progesterone metabolites through increased hepatobiliary secretion, which is paralleled by improving pruritic symptoms .
Ursodeoxycholic acid is used worldwide to treat ICP although this is not strictly evidence-based. Experimental data point toward a protective role of ursodeoxycholic acid on syncytial clot formation and villous edema associated with placental hypoxia in ICP . In addition, in vitro and animal studies have shown a protective effect of ursodeoxycholic acid on cardiomyocytes causing fetal arrhythmias .
In small clinical studies, ursodeoxycholic acid in a dose of 750 mg/day has been found to decrease elevated liver enzymes and bile acids in patients with ICP as well as ameliorate pruritus . A recent larger trial from Great Britain included 111 women with ICP randomized to ursodeoxycholic acid (2 × 500 mg/day up to 2 g/day) versus placebo showed a significant reduction of pruritus (−16 mm on Visual Analog Scale scale) in the treatment group, but this was below the −30 mm difference thought to be clinically significant; 32 % in the treatment group compared with 16 % in the placebo group had a reduction of at least 30 mm on pruritus VAS. Elevated liver enzymes and bilirubin levels were significantly reduced by ursodeoxycholic acid treatment, whereas the effect on bile acid levels was less pronounced and failed to reach statistical significance.
Looking at fetal outcome, babies born to mothers taking the placebo were significantly more likely to have meconium-stained amniotic fluid (a sign of fetal distress) compared with mothers taking ursodeoxycholic acid treatment. There was a trend to reduced gestational age at the time of delivery in the placebo group, but this was due to a higher number of twin pregnancies in this group. Looking at singleton pregnancies only, there was no difference in time of delivery. All other fetal parameters were not different between the groups as were adverse events.
In conclusion, ursodeoxycholic acid is a promising therapeutic option for the treatment of ICP with potential positive effects on fetal outcome and proven effect on maternal pruritus and laboratory values, although it remains “off-label use.” Cholestyramine and other bile acid exchange resins should be avoided, because they cause vitamin K malabsorption and increase the risk of hemorrhage.
Atopic Eruption of Pregnancy (prurigo gestationis, pruritus folliculitis in pregnancy)
Atopic eruption of pregnancy (AEP) summarizes a spectrum of pruritic disease in pregnancy, including prurigo of pregnancy Besnier and pruritic folliculitis of pregnancy. The term has widely been accepted in Europe, but some authors argue that the old classification was more specific and patients with true atopic eczema might be wrongly classified as AEP .
AEP usually presents during the first or second trimester with pruritic eczematous or papular skin lesions. Eczematous lesions (so-called E-type AEP) present most frequently on face, neck, and flexural surfaces, whereas papular lesions (so-called P-type AEP) are mainly located on trunk or as prurigoform nodules on shins and extensor surfaces of the arms. Most women have a history of atopic disease or show typical minor signs of atopy . An enhanced Th2 immune response in pregnancy is thought to trigger flare-ups of preexisting atopic eczema and AEP. Sometimes it is impossible to differentiate between atopic eruption of pregnancy and a flare up of preexisting atopic eczema with long remission or minimal symptoms in the past. Prognosis is good for mother and child, and recurrence in subsequent pregnancies is common.
Treatment of AEP is similar to atopic dermatitis with intensive basic therapy, topical corticosteroids and sometimes antihistamines. UVB phototherapy may be used in severe cases.
Eczema During Pregnancy
Eczema, or atopic dermatitis (aka rash), is a common, chronic skin condition. In mild cases, skin is dry and itchy; severe cases can cause the skin to become raw and even leak fluid. The (only) good news: Eczema is not contagious.
What causes eczema during pregnancy?
The most common variety, atopic dermatitis, is often hereditary and probably triggered by exposure to environmental allergens that are harmless to others (aren’t you the lucky one?). Chances are if you’ve got atopic eczema, you (or someone in your family) probably suffer from asthma, hay fever, allergies and/or food allergies as well. Other types of eczema (such as contact dermatitis) are caused by irritants such as chemicals, detergents, yeast, and metals (your rings — if they still fit — might start bugging you).
If you have eczema, it’s likely your raging pregnancy hormones are making the situation better…or worse. No one’s sure exactly why some women experience flare-ups during pregnancy, while other lucky ladies go into remission.
What you can do
- Talk to your doctor. Certain topical steroids are considered safe during pregnancy but must be used in small quantities under strict medical supervision. Antihistamines may help you cope with itchiness, but check with your practitioner before you use anything to treat your eczema.
- Stay away from known triggers. Limit contact with potential irritants including wool, pet dander, juices from meats and fruits, plants and jewelry. And avoid personal-care products that contain alcohol.
- Avoid fragranced products. These may aggravate your already sensitive skin and your heightened sense of smell.
- Don’t soak. Try to avoid spending too much time in the water (showers, baths, swimming pools), and don’t wash your hands too often (but definitely wash them as needed — pregnancy and germs don’t mix!).
- Moisturize early and often. This helps lock in your skin’s own moisture and prevents dryness and cracking.
- Stay cool. Try not to get too hot or sweaty —two of the most common eczema triggers. Easier said than done when you’re already one hot mama? That means wearing loose, cotton clothes and avoiding synthetic fabrics, wool or any material that feels rough to the touch. (Your partner’s oversize T-shirt is a great choice for your sensitive skin and your growing belly!) Avoid overheating by favoring that layered look — and peeling off layers as you start to warm up.
- Take smart care of your clothing. Use only fragrance-free, neutral pH detergents, and double-rinse your laundry to help prevent flare-ups. Another tip: Wash new clothes before wearing to remove excess dyes and fabric finishers and cut out any tags or labels that rub against the skin.
- Beware of sudden changes in temperature and humidity. A sudden temperature spike can make you sweaty, while a drop in humidity can dry out your skin and lead to a flare-up. In other words, no steam rooms, saunas, or Bikram yoga — all of which are off-limits for expectant moms anyway.
- Use a cool compress — and not your fingernails — to curb the itch. Scratching makes the condition worse and can puncture the skin, allowing bacteria to enter and cause an infection (which is potentially dangerous during pregnancy). While you’re at it, keep nails short and rounded to decrease the likelihood that when you do inevitably scratch, you won’t puncture the skin. If you tend to scratch in your sleep, try wearing a pair of cotton gloves to bed.
- Stay calm. Stress is a common eczema trigger, so try to avoid situations that make you tense. When you feel anxiety creeping in, focus on how incredible your baby will be or how delicious he or she will smell.
One more thing: Research suggests that breastfeeding may prevent eczema from developing in a child, another good reason to nurse your baby if you can.
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What solutions are off-limits
Cyclosporine has long been used on severe cases of eczema that don’t respond to other treatment, but current research indicates that it may be associated with an increased rate of premature birth. The bottom line: It’s a no-no now. Some topical and systemic antibiotics may also not be safe for use during pregnancy, so check with your practitioner first.
Protopic and Elidel are a new type of topical prescription medication known as TIMs, or topical immunomodulators, which reduce inflammation. The good news is that since they don’t contain steroids, TIMS don’t cause thinning of the skin (which leads to sores and bleeding). The bad news: They’re still off-limits during pregnancy because they can suppress the immune system. No luck with the oral forms of TIMS either — they cross the placenta and show up in breast milk.
Nonprescription remedies such as herbal or Chinese medicine should definitely be discussed with your practitioner in advance.
9 Ways to Stop Eczema from Interrupting Your Pregnancy Glow
Before you resort to medication to manage your eczema, try making some simple changes to your daily routine and see if your symptoms improve.
Here are a few options for relief:
As with any other dry, itchy spot on your skin, moisturizer can work wonders to counteract the dryness of eczema. You can use your regular moisturizer or buy one specifically designed to soothe itchy skin.
You could also try an oil to help with skin barrier recovery — coconut oil and sunflower oil are two options many people swear by.
Take cool showers
As relaxing as a hot shower might feel, it’s not doing your skin any favors (whether or not you have eczema). Long, hot showers can dry out your skin even further.
Try to take shorter showers and keep the water lukewarm or cool. You can still curl up under a blanket afterward for serious cozy vibes in the colder months.
Take an oatmeal bath
Don’t worry: We’re not actually suggesting you submerge yourself in a mushy mass of breakfast cereal.
Instead, use ground oatmeal powder — also known as colloidal oatmeal — which gives baths a milky, luxurious texture. The colloidal oatmeal should help soothe and repair that itchy skin.
Invest in a humidifier
This tip works particularly well during the winter months, when the dry air can irritate your skin.
Using a humidifier in your home will add moisture and prevent excessive dryness.
Wear soft, loose-fitting clothes
As a pregnant person, you’re probably thinking “Duh!” But use this as an extra excuse to rock those cozy pants.
To prevent an eczema rash from rubbing against your T-shirt or sweater, stick to fabrics that don’t further irritate your skin.
Cotton and silk are both gentle materials, especially when they don’t fit close to your body. Much as we love them in winter, thicker fabrics like wool can rub against your eczema and make it worse.
Avoid inflammatory foods
If you have any known food intolerances, now’s the time to avoid those foods. Processed foods and inflammatory ingredients can aggravate your immune system and bring on eczema symptoms.
Food intolerances can also change slightly as you go through pregnancy, so pay attention to what you’re eating to see if you can spot any triggers.
Your diet during pregnancy can affect your baby’s health, so be sure to talk to your doctor before making any major changes.
Bacterial imbalances in your skin can contribute to eczema breakouts. The quickest way to restore an abundance of good bacteria to your system? Probiotics!
Probiotics are likely available at your local pharmacy or grocery store, but talk to your doctor before you start using them regularly.
While research has shown that probiotics are generally safe during pregnancy, it’s always important to assess what’s best for your body specifically.
Eat foods rich in omega-3s
Omega-3 fatty acids are anti-inflammatory and great for restoring your gut’s natural balance, which (surprisingly) affects your skin.
Nuts, seeds, and green vegetables are all high in omega-3s, as is fish — but it’s best to limit your fish consumption during pregnancy due to the risk of heavy metal contamination.
For natural, safe omega-3s, try sticking to plant-based sources. Otherwise, do your research before consuming fish or fish oil to make sure you’re choosing a source that’s safe for you.
Apply a steroid cream
If natural treatments aren’t helping, your doctor may prescribe a steroid cream to treat your symptoms.
Topical corticosteroid creams are generally thought to be safe during pregnancy, but be sure to get your doctor’s advice on what will work best.
With a combination of these treatments, you can lessen or even get rid of your eczema symptoms. Rest assured that the condition will likely improve once you’ve given birth and won’t affect your baby in any way.
While eczema can be uncomfortable, it’s a common part of many people’s pregnancy experiences, and there’s no reason to fear serious long-term effects.
But it can definitely mess with your glow — so break out that moisturizer and go to town!
Eczema in Pregnancy
Eczema is an irritating skin condition that can get worse, or even flare up out of nowhere, during pregnancy. But there are ways to ease the discomfort even if medicines are off limits.
What are the causes?
I developed eczema in my mid-twenties and pregnancy really got it raging. I’d never had it as a child but it does run in my family on both sides. As with so many other changes in pregnancy, hormones are often the cause of an eczema flare-up. But it’s not always bad news.
“While over half of women with eczema find that their eczema gets worse during pregnancy, about one in four finds it improves”, explains Dr Sarah Jarvis, GP and Clinical Consultant at Patient.co.uk.
For betsygrub, on our forum, her eczema got better during pregnancy, “I have always had bad eczema, it has got better whilst I have been pregnant…”.
I’m not sure that the fact my eczema got worse, especially on my hands and legs, during my pregnancy was actually anything to do with the pregnancy itself, but more likely the fact that I stopped using my usual topical steroid creams which I didn’t want to use while I was pregnant.
Camlo chatting on the MFM forums says, “I had it with my 1st son and it lasted for a few years after. Nothing with my 2nd and now I am 17 weeks and it has flared up again really bad. It’s only on my fingers and I’ve had to remove my wedding ring and it’s driving me crazy”.
Which over the counter remedies can I use?
“Moisturisers are the mainstay of treatment for anyone with eczema, and pregnancy is no exception”, explains Sarah. “While you don’t need huge quantities, you do need to apply them frequently – they replace fluid lost from the upper layers of the skin and also prevent fluid being lost”.
She also recommends using unscented, uncoloured moisturisers to reduce the chance of further irritation and inflammation. “ Using a soap substitute such as aqueous cream is safe and will reduce the drying effect of frequent washing”.
And there are lots of suggestions to try from suffers on our forums. Betsygrub suggests “try oatmeal baths, put porridge oats in a muslin and secure with a bobble, or use the end of an old pair of tights and put it in your bath as you run it, it makes it really creamy”.
Balisugar says, “I used to try and wrap my legs up in bandages to stop me from attacking them during the night which did help. Another good thing to use, which is completely natural, is aloe from an aloe vera plant. I used to cut off the stems and rub the gel on my eczema, this really soothes and also really helps clear it up”.
Can I use steroid creams? Are they safe?
“While high dose steroids – such as those used for people who need to take steroid tablets – can have a variety of side effects, milder steroid creams rarely cause side- effects if they’re used sensibly”, explains Sarah.
However, most GPs and midwives usually recommend that, if possible, you avoid using the strongest forms of topical steroid cream during pregnancy. There is some evidence that the steroids can be absorbed into your bloodstream and affect your baby’s growth.
“It is usually recommended that you use the lowest dose you can, in the smallest amount and for the shortest time possible to control your symptoms”, explains Sarah.
Lelly did use steroid cream to treat her pregnancy eczema she says, “I have had eczema and I have used my steroid creams all through pregnancy….under my Drs direction, I have Eumovate at the moment which works perfectly and I just make sure I keep thoroughly moisturised as well!”.
I opted to ditch my steroid creams and used a simple aqueous cream during the whole of my pregnancy. I paid for it in the fact that my eczema got worse, but it made me feel more comfortable.
Faithie says, “I got eczema on my feet while I was pregnant and the GP said that she would try non steriod creams first as it is preferable to avoid steroid creams in pregnancy but if it didn’t respond it was a case of weighing up the benefits to mum against the potential risk to the baby (which is minimal anyway)”.
Is it something I’m using that is causing my eczema?
Washing powder is often blamed for eczema, but in fact it’s rarely a culprit. Soap and cleaning products, though, play a major role. “Soap and many bath products have a drying effect on the skin and contain Sodium Laurel Sulphate, used to create bubbles in many products, which tends to make eczema worse”, says Sarah.
She adds, “But your environment also plays a role. Heat, cold, too much water or a dry environment (such as the dry atmosphere created by central heating), as well as wind, can all dry the skin out, making symptoms worse”.
So it’s gloves in winter, avoid over-washing your hands, and slap on the moisturiser as many times as you can during the day. I had a large pot in my bathroom as well as an easy-to-carry tube in my handbag, so that it was always with me.
Will my baby have eczema?
Unfortunately, it’s impossible to predict which genes your baby will get from you and your partner, so you can’t change the chances of your baby inheriting eczema from you.
So far, my daughter has shown no signs of eczema and I really hope that she escapes it, but as I didn’t get mine until my twenties, who knows?
As a precaution, try to keep your newborn’s skin well moisturised with a simple lotion, and make sure his or her clothes are made from soft natural fabrics such as cotton. Use a mild washing powder or liquid and always rinse clothes thoroughly.
Ah, the joys of pregnancy! While some women sail right through it, others endure morning sickness, varicose veins and hemorrhoids, to name just a few common afflictions of that blessed state. And a history of eczema may add one more source of distress into the mix.
The worsening of eczema symptoms during pregnancy has to do with the influence of female sex hormones—specifically estrogen—on a woman’s immune system, said Dr. Jenny Murase, a dermatologist on the faculty of the University of California-San Francisco.
“During pregnancy, a shift takes place in a woman’s body from Th1-dominant to Th2-dominant immunity,” Murase explained. “Th1 cells specialize in defending our bodies against foreign invaders such as bacteria, viruses and anything recognized as ‘non-self’ that try to penetrate our cells. Half of the fetus’s genetic material comes from the mother and half from the father. So the Th1-dominant response, left to its own devices, will mount an attack against the half that’s from the father and cause the fetus to abort.
“To protect the growing fetus,” Murase continued, “a pregnant woman’s body temporarily shifts to Th2-dominant immunity. Th2 cells are all about fighting off allergens and toxins that circulate outside our cells.”
The upshot is that Th2-dominant immunity keeps the fetus safe but makes the mother more sensitive to allergens—in other words, to triggers that aggravate asthma, food allergies and eczema.
In her research, Murase has found that the high levels of estrogen seen in pregnancy are responsible for the shift from Th1- to Th2-dominant immunity. Estrogen, then, is at least partly to blame when the happiest of events turns a woman’s skin inflamed and itchy and her nights sleepless and miserable.
Learn more about managing eczema at every stage of life from world-class experts at Eczema Expo.
Pregnancy affects eczema differently in women
Carol Kim, a 28-year-old Asian American from Puyallup, Washington, has had eczema all her life. As a child, she’d scratch in the creases inside her elbows and behind her knees. “Usually, a small application of steroid cream would keep it under control,” she said. “In fact, my eczema was only a minor problem until I got pregnant with my first child about two years ago.”
Kim was “ecstatic” about the pregnancy. But soon, her eczema reared its ugly head, and it erupted full force after her son was born. “A couple of months into breastfeeding, I woke up covered with eczema from top to bottom. The skin all over my face and body was flaking, oozing, itchy and painful. I had cuts at each corner of my mouth and on my earlobes and eyes. My eyes were so swollen that they wouldn’t close.
“At its worst,” she added, “I couldn’t sleep, get out of bed, go out in public and, worst of all, I couldn’t be the mother I wanted to be with my newborn baby.”
Kim made several visits to an urgent care facility, where she received corticosteroid shots. These provided relief, but when their effects wore off, her eczema returned with a vengeance. Soon after a new treatment was approved, she went on the new biologic and experienced “five glorious months of normal skin.” But Kim couldn’t tolerate the side effects she experienced, so she had to stop taking it.
Thankfully, her eczema isn’t as severe now as it was right after giving birth. She still struggles with her “full face of eczema” and outbreaks here and there on her body. Topical steroids help her stay afloat while she considers other options, such as immunosuppressants. And she hasn’t given up hope that one day, she’ll find her way back to something resembling normal skin.
Meg Waterston* hasn’t given up either. The 24-year-old from London gave birth to a baby boy a little more than a year ago. But unlike Kim, whose skin erupted after childbirth, eczema hit hard during Waterston’s pregnancy. “Sometimes, my skin itched so bad that I’d scratch until I bled. I also developed a staph infection and a bad case of hives. At a certain point, I decided to go on oral steroids,” she said.
That’s when anxiety started to take over. Waterston was told by her doctors that her son might be born addicted to steroids, in which case he’d need steroid injections right after birth and for some time thereafter. Torn between her urgent need for relief and her baby’s risk for addiction, she took the steroids and hoped for the best.
To Waterston’s relief, her newborn son didn’t need injections after all. And his skin is “perfect,” she said. “As for my own skin, I’m under the care of a really good dermatologist now. I’m taking oral steroids once a week or once every two weeks, and that seems to be keeping my eczema under control**.”
*Not her real name.
** Note: Routine use of oral or injectable steroids is generally discouraged and should be reserved for special circumstances.
Safe treatments for pregnant women with eczema
Dr. Peter Lio, a member of the faculty of Northwestern University’s Feinberg School of Medicine, who has a clinical practice in Chicago, estimates that about 50 percent of pregnant women with a history of eczema experience worsening symptoms during pregnancy.
He often prescribes phototherapy for his pregnant patients with eczema, insisting that they also take folic acid, an important nutrient that can easily become depleted by light treatment.
According to Murase, topical steroids are safe to use during pregnancy, especially at low-to-medium potency levels. “There’s a slightly higher incidence of low birth weight with steroid use, but only if a woman were to apply more than 300 grams of it over the course of her entire pregnancy,” she said. “That’s more than most patients would ever need.”
To stay on the safe side, Murase suggests diluting a topical steroid with moisturizer to achieve a ratio of four parts moisturizer to one part steroid. “I advise my patients to avoid using it on areas that will expand during pregnancy, such as the belly and breast. That’s because topical steroids can worsen the appearance of stretch marks.”
Both Lio and Murase stressed the importance of keeping eczema under control during pregnancy. A sleep-deprived mother offers a less-than-favorable environment for her unborn child, and the negative effects of maternal stress on the developing fetus have been well documented, Murase said.
Having a healthy pregnancy is within reach, even when eczema is on the warpath. During pregnancy and after childbirth, a woman needs to be well-nourished, well-rested and as free from stress as possible. Excellent self-care, the doctors agreed, is the greatest gift a woman can give herself and her newborn.
When menopause triggers eczema
As if eczema weren’t enough of a burden, the widespread idea that it’s a “silly” disease bothers Allison Cast almost as much as the condition itself does.
A 59-year-old from Houston, Texas, Cast had eczema as a teenager, but it went away—until two years ago, when it came back full-tilt.
During adolescence, she had painful outbreaks of eczema between her fingers and in the crooks of her elbows. Now, it attacks different places—mainly, her palms and forearms. “I’ve tried many things, but it never seems to heal,” Cast said.
Cast has two grown children and two grandsons. She also works full-time. “Being covered with welts and bruises is embarrassing, especially at work,” she said. She’s also self-conscious about the blood blisters that form under her skin when she scratches, aware that her skin has become more fragile since menopause.
Having treated hundreds of older patients, Murase noted that the immune system tends to deteriorate with age. As in pregnancy, a shift takes place in the older body from Th1 to Th2 immunity, making older adults—both men and women—more vulnerable to eczema flares, even after many years without symptoms.
“Know your triggers,” Murase advised, “including surfactants, emulsifiers, preservatives and perfumes. And go beyond a regular allergy test to a comprehensive patch test, which covers a broader range of potential allergens than prick testing.
“Some of my older patients turn out to have contact dermatitis, a condition that can mimic atopic dermatitis but is far easier to treat. In any case, avoiding triggers is the first line in eczema treatment as well.”
Fluctuating hormone levels during and even after menopause may be partly responsible for the re-emergence of eczema, but, said Murase, more research is needed to confirm or rule out estrogen as a major driver of eczema flares later in life.
Because eczema is never “silly” at any age.