Atopic eruption of pregnancy

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Definition 

Atopic eruption of pregnancy (AEP) is a pruritic skin condition associated with pregnancy, manifesting as eczematous or papular lesions in individuals with an atopic background. It often begins during early pregnancy, with 75% of cases occurring before the third trimester. AEP includes eczema in pregnancy, prurigo of pregnancy, and pruritic folliculitis of pregnancy, previously classified as separate conditions. While most cases involve new-onset atopic changes, some represent exacerbations of pre-existing atopic dermatitis. The disorder is not linked to adverse fetal outcomes and tends to recur in subsequent pregnancies.

 

Epidemiology

AEP is the most common pregnancy-related dermatosis, accounting for over 50% of such cases. Its exact incidence is unclear but may range from 1 in 5 to 1 in 20 pregnancies. It is more prevalent in individuals with a personal or family history of atopy, such as asthma, allergic rhinitis, or atopic dermatitis.

 

Etiology

AEP is linked to immunologic changes during pregnancy. Pregnancy is characterized by reduced T-helper 1 (Th1) cytokine production (e.g., IL-12, interferon-γ) and enhanced T-helper 2 (Th2) cytokine production (e.g., IL-4, IL-10). This shift toward a Th2-dominant immune response exacerbates the existing imbalance in atopic individuals, potentially triggering the development of AEP. While a connection to a history of atopy is recognized, its role remains debated.

 

Clinical Features

AEP typically manifests during the first or second trimester. About 80% of patients experience new-onset atopic changes, while 20% have a recurrence of pre-existing atopic dermatitis.

  • Eczematous Lesions (E-Type AEP):

Most cases involve widespread eczematous eruptions affecting the face, neck, and flexural areas. These lesions may appear as patches or excoriated papules. Severe dryness and signs of atopy are common.

  • Prurigo of Pregnancy (P-Type AEP):

Characterized by grouped erythematous papules or nodules on extensor surfaces, abdomen, and trunk, which may be excoriated or crusted. Lesions typically resolve postpartum.

  • Pruritic Folliculitis:

Rare presentations involve follicular papulopustular eruptions resembling steroid-induced acne. These lesions, initially appearing on the abdomen, may spread and are mildly pruritic. They generally resolve within weeks postpartum.

 

Diagnosis

AEP is primarily diagnosed clinically, based on characteristic lesions and a history of atopy. Skin biopsy is rarely helpful due to nonspecific findings but may be performed if the diagnosis is uncertain or to rule out conditions like pemphigoid gestationis. Elevated serum IgE levels are seen in up to 70% of cases. Folliculitis should be cultured to exclude bacterial or fungal infections.

 

Management

The treatment of AEP focuses on symptom relief:

  1. Topical Corticosteroids:

Low- to mid-potency corticosteroids are the first-line treatment for cutaneous lesions.

  1. Emollients and Hydration:

Regular use of emollients helps maintain skin hydration.

  1. Oral Antihistamines:

Chlorpheniramine, loratadine, or cetirizine can alleviate pruritus.

  1. Other Topical Treatments:

Tacrolimus for sensitive areas (e.g., face, intertriginous zones), urea-based creams, and menthol-containing products are safe during pregnancy.

  1. Severe Cases:

UVB therapy may be considered. Secondary bacterial infections should be treated with pregnancy-safe antibiotics like penicillins or cephalosporins.

 

Prognosis

AEP does not adversely affect the fetus and typically resolves postpartum, although symptoms may persist for a few weeks. The condition often recurs in subsequent pregnancies.

  

Written by: 

Raneem Alahmadi, Medical Intern.

Revised by:

 Naif Alshehri, Medical Intern

Resources:

Bologina 5th edition

UpToDate