Diagnosing Dermatoses in Pregnant Patients: 8 Cases to Test Your Skills

Michelle Henry, MD Contributor Information

February 19, 2014

Many cutaneous eruptions are associated with pregnancy, and a host of inflammatory and infectious entities present atypically or more severely in the pregnant woman. The consequences of these conditions can affect the fetus, necessitating rapid treatment. Recognizing the associated dermatoses is the first step to treating these patients appropriately and effectively. This 24-year-old woman, currently in the second trimester of her second pregnancy, developed unilateral lichen planus along Blaschko lines during both pregnancies. Image courtesy of Kumar et al.[1]
Slide 1.
Atopic eruption of pregnancy (AEP) is the most common pruritic skin condition in pregnancy and is noted in almost 50% of patients affected with pregnancy-specific dermatosis. AEP can include eczema (shown), prurigo, and pruritic folliculitis. These patients present with atopic skin changes for the first time during pregnancy, but they often have a history of atopic diathesis and family members with eczema, asthma, and/or seasonal allergies. AEP usually develops during the first half of pregnancy (75% before the third trimester).[2] Image courtesy of Wikimedia Commons.
Slide 2.
What is the most likely cause of this eruption in a 21-year-old pregnant woman?
A. Pruritic urticarial papules and plaques of pregnancy
B. Pemphigoid gestationis
C. Impetigo gestationis
D. Pruritic folliculitis of pregnancy
E. Contact dermatitis

Image courtesy of Jeffrey P. Callen, MD.
Slide 3.
Answer: A. Pruritic urticarial papules and plaques of pregnancy

Pruritic urticarial papules and plaques of pregnancy (PUPPP, shown) are commonly seen during the third trimester or immediate postpartum period. They are seen most commonly in primigravidas. The lesions usually involve the striae and spare the umbilicus (while pemphigoid gestationis does not). There is no maternal or fetal risk. Image courtesy of Jeffrey P. Callen, MD.
Slide 4.
What laboratory abnormalities will likely be found in this 31-year-old woman with the skin and eye findings shown?
A. Elevated lipase
B. Elevated serum level of beta-carotene
C. Elevated serum lycopene
D. Elevated transaminases
E. Elevated creatinine
Slide 5.
Answer: D. Elevated transaminases

Cholestasis of pregnancy is a liver disorder involving pruritus, often commencing with pruritus of the palms of the hands and soles of the feet. Patients with cholestasis of pregnancy often present with elevated transaminases, elevated bile acids, and jaundice, usually in the late second or early third trimester of pregnancy. Maternal outcomes for patients are good; however, fetal outcomes can be devastating and often require early delivery. Ursodeoxycholic acid reduces risk of premature delivery (shown) and improves symptoms. Ultraviolet B treatment may help with pruritus. Dexamethasone can help with laboratory abnormalities and pruritus. Cholestasis of pregnancy usually recurs with subsequent pregnancies. Image courtesy of Wikipedia Commons.
Slide 6.
What condition is shown in this 33-year-old pregnant woman?
A. PUPPP vesicular variant
B. Cholestasis of pregnancy
C. Pemphigoid gestationis
D. Pustular psoriasis of pregnancy
E. Linea alba
Slide 7.
Answer: C. Pemphigoid gestationis

Pemphigoid gestationis has been associated with autoimmune diseases, such as Graves disease, alopecia areata universalis, vitiligo, and hemorrhagic rectocolitis. This image shows urticarial or hivelike plaques on the posterolateral neck of this woman in her third trimester, as can be observed in patients with pemphigoid gestationis. Pemphigoid gestationis occurs late in the third trimester and the immediate postpartum period. Recurrence during subsequent pregnancies is common; recurrence also can occur with menstruation and use of oral contraceptives. There also is a risk of bullous lesions in the neonate, prematurity, and tendency for small-for-gestational age births.
Slide 8.
A 21-year-old woman presents with the facial skin changes shown. She is currently 28 weeks pregnant. Which medications would best treat her condition?
A. A fixed triple combination, including 4% hydroquinone, 0.05% retinoic acid, and 0.01% fluocinolone acetonide
B. 4% hydroquinone alone
C. 1% tretinoin
D. Broad-spectrum sunscreen
Slide 9.
Answer: D. Broad-spectrum sunscreen

Melasma usually begins after the third month of gestation and improves in the postpartum period but may persist or recur with oral contraceptives. First-line therapy for persistent melasma includes a combination medication of hydroquinone, retinoic acid, and a mild topical steroid. Hydroquinone alone will help. However, such medications should never be given during pregnancy or lactation. Broad-spectrum sunscreen and sun avoidance are therefore preventive measures during and after pregnancy. Image courtesy of Wikipedia Commons.
Slide 10.
A 26-year-old patient in her second trimester presents with this lesion on her hand. Image courtesy of Wikipedia Commons.
What is the lesion?
A. Amelanotic melanoma
B. Atypical mycobacterial infection
C. Lichen planus
D. Pyogenic granuloma
Slide 11.
Answer: D. Pyogenic granuloma

Pyogenic granulomas (technically a capillary hemangioma, shown) occur relatively frequently during pregnancy. They are also known as pregnancy epulis, epulis gravidarum, or granuloma gravidarum. They most commonly develop during the second trimester. The lesions correspond to a benign hyperplasia of mucosal capillaries and fibroblasts as likely caused by physical trauma or irritation; approximately 75% occur on the gingiva. Spontaneous regression can be seen in the postpartum period. Image courtesy of Jeffrey P. Callen, MD.
Slide 12.
During pregnancy, hair cycle changes result in fewer anagen hair follicles entering the telogen phase, which leads to the thickening and brightening of hairs.

Which of the following is true during the postpartum period?
A. A permanent scarring alopecia can occur.
B. Increased hair density is always maintained.
C. Nonpermanent hair loss can occur and last for many months.
D. An increase in gray hairs is commonly found.

Image courtesy of Wikipedia Commons.
Slide 13.
Answer: C. Nonpermanent hair loss can occur and last for many months.

In the postpartum period, scalp hair enters a prolonged telogen phase, causing increased shedding. This condition is called telogen effluvium. It may begin 2-4 weeks after delivery and last 3-4 months, usually resolving in 6-15 months.
Slide 14.
What is the next appropriate step after locating this lesion?
A. Biopsy to rule out melanoma.
B. Check stool ova and parasites to rule out parasitic infection.
C. Inform the patient that the lesion may darken as the pregnancy progresses.
D. Inform the patient of the importance of managing weight gain to avoid progression.

Image courtesy of Wikipedia Commons.
Slide 15.
Answer: C. Inform the patient that the lesion may darken as the pregnancy progresses.

Linea nigra is a dark line that occurs on the abdomen during ~75% of pregnancies. It runs along the midline of the abdomen from the pubis to the umbilicus, but can extend to the abdomen. Linea nigra is due to increased melanocyte-stimulating hormone made by the placenta (which is also the cause of melasma and areolar darkening). Image courtesy of Wikipedia Commons.
Slide 16.
A 25-year-old woman who is 32 weeks pregnant presents with concern about these areolar lesions (arrows). Image courtesy of Wikipedia Commons.

What is the next appropriate step for these lesions?
A. Biopsy to rule out mammary Paget disease.
B. Reassure the patient that the lesions are benign.
C. Incise and drain the lesions to prevent abscess.
D. Inform the patient that the lesions are secondary to vascular congestion and need to be removed.
Slide 17.
Answer: B. Reassure the patient that the lesions are benign.

Montgomery tubercles are sebaceous glands of the areolae of the breast that become prominent during pregnancy; this is a normal finding. In contrast, a patient with mammary Paget disease is shown. Patients with mammary Paget disease present with a relatively long history of an eczematous skin lesion or persistent dermatitis in the nipple and adjacent areas. This patient presented with a scaly, erythematous, crusty, and thickened plaque on the nipple. Image courtesy of Wikipedia Commons.
Slide 18.

Contributor Information


Michelle Henry, MD
Fellow, Procedural Dermatology
Department of Dermatology
Lahey Clinic
Harvard Medical School
Boston, Massachusetts

Disclosure: Michelle Henry, MD, has disclosed no relevant financial relationships.


Mark P. Brady, PA-C
Adjunct Faculty and Preceptor
Physician Assistant Program
University of New England
Physician Assistant
Department of Emergency Medicine
Cambridge Hospital, Cambridge Health Alliance
Cambridge, Massachusetts

Disclosure: Mark P. Brady, PA-C, has disclosed no relevant financial relationships.


Steven Brett Sloan, MD
Assistant Professor
Department of Dermatology, University of Connecticut School of Medicine
Residency Site Director, Connecticut Veterans Affairs Healthcare System
Volunteer Clinical Instructor, Yale University School of Medicine
Farmington, Connecticut

Disclosure: Steven Brett Sloan, MD, has disclosed no relevant financial relationships.


  1. Kumar S, Okade R, Rahman YA. Unilateral Blaschkoid lichen planus in successive pregnancies. Dermatol Reports 2011;3:2.
  2. European Academy of Dermatology and Venereology. Atopic eruption of pregnancy. Available at: http://www.eadv.org/patient-corner/leaflets/eadv-leaflets/atopic-eruption-of-pregnancy-aep/. Accessed November 14, 2012.
  3. Vaughan Jones SA, Black MM. Pregnancy dermatoses. J Am Acad Dermatol 1999;40:233-241.
  4. Roger D, Vaillant L, Fignon A, et al. Specific pruritic diseases of pregnancy. A prospective study of 3192 pregnant women. Arch Dermatol 1994;130:734-739.
  5. Pierson JC. Pruritic urticarial papules and plaques of pregnancy: Medscape Reference. Available at: //emedicine.medscape.com/article/1123725-overview. Accessed November 12, 2012.