Dermatoses of pregnancy

The dermatoses of pregnancy represent a heterogeneous group of pruritic inflammatory skin diseases related to pregnancy and/or the postpartum period. Whereas some dermatoses are distressing only to the mother because of severe pruritus, others are associated with fetal risks including fetal distress, prematurity, and stillbirth. Early diagnosis and prompt treatment are essential for improving maternal and fetal prognosis. This review discusses the various pregnancy dermatoses in detail and offers an algorithmic approach to their diagnosis and management.     

Dermatoses of pregnancy.

The dermatoses of pregnancy can be classified into the following 3 groups: physiologic skin changes in pregnancy, dermatoses and cutaneous tumors affected by pregnancy, and specific dermatoses of pregnancy. Correct diagnosis and classification are essential for the treatment of these disorders, when necessary. Laboratory investigations are required when the diagnosis remains in question despite a careful history and thorough physical examination. A discussion with the pregnant woman about the nature of her skin condition, and the possible fetal risks associated with it, is imperative.     

副肿瘤性皮肤病

副肿瘤性皮肤病包括一组出现内脏恶性肿瘤的非遗传性皮肤病,如黑棘皮、获得性鱼鳞病、皮肌炎、副肿瘤性天疱疮、坏死松解游走性红斑、Sweet综合征、坏疽性脓皮病、渐进性坏死性黄色肉芽肿、硬化黏液性水肿等。认识这些疾病可为内脏恶性肿瘤的早期诊断和治疗及监视肿瘤的发生提供机会。本文对黑棘皮病等13种副肿瘤性皮肤病的临床与病理表现进行了介绍。     

Pregnancy Dermatoses

Some aspects regarding the etiology and the nosologic classification of various pregnancy dermatoses are highly controversial. While some authors highlight the existence of premises allowing several skin disorders to be re-grouped within broader disease concepts, others underline the absence of clear, undisputed etiopathogenetic data that could support such classifications. This review exhaustively analyzes the various pregnancy dermatoses (pemphigoid gestationis, intrahepatic cholestasis of pregnancy, impetigo herpetiformis, polymorphic eruption of pregnancy, and the papular dermatoses of pregnancy [prurigo of pregnancy, pruritic folliculitis of pregnancy, and the new classification, atopic eruption of pregnancy]) in an attempt to shed light over this confusing and disputed domain, while subsequently offering an algorithmic approach to their diagnosis and management. While for pemphigus gestationis, intrahepatic cholestasis of pregnancy, and impetigo herpetiformis, specific diagnostic tests such as histopathology, immunofluorescence, or laboratory investigations will confirm the diagnosis, the identification of the other types of pregnancy dermatoses is based only on clinical criteria. In this context, the review argues for the inclusion of the whole group represented by the papular dermatoses of pregnancy within the broad spectrum of polymorphic eruption of pregnancy, separating each of these entities by focusing on their onset: early-onset polymorphic eruption of pregnancy (comprising prurigo of pregnancy, pruritic folliculitis of pregnancy, and atopic eruption of pregnancy) and late-onset polymorphic eruption of pregnancy. In light of the same practical approach guiding it, the review provides updated treatment strategies for each of these conditions.     

Neutrophilic Dermatoses

Sweet syndrome, pyoderma gangrenosum, and subcorneal pustular dermatosis are neutrophilic dermatoses – conditions that have an inflammatory infiltrate consisting of mature polymorphonuclear leukocytes. The neutrophils are usually located within the dermis in Sweet syndrome and pyoderma gangrenosum; however, in subcorneal pustular dermatosis, they are found in the upper layers of the epidermis. Sweet syndrome, also referred to as acute febrile neutrophilic dermatosis, is characterized by pyrexia, elevated neutrophil count, painful erythematous cutaneous lesions that have an infiltrate of mature neutrophils typically located in the upper dermis, and prompt clinical improvement following the initiation of systemic corticosteroid therapy. Classical, malignancy-associated, and drug-induced variants of Sweet syndrome exist. Pyoderma gangrenosum is characterized by painful, enlarging necrotic ulcers with bluish undermined borders surrounded by advancing zones of erythema; its clinical variants include: ulcerative or classic, pustular, bullous or atypical, vegetative, peristomal, and drug-induced. Subcorneal pustular dermatosis is an uncommon relapsing symmetric pustular eruption that involves flexural and intertriginous areas; it can be idiopathic or associated with cancer, infections, medications, and systemic diseases. Since Sweet syndrome, pyoderma gangrenosum, and subcorneal pustular dermatosis share not only the same inflammatory cell but also similar associated systemic diseases, it is not surprising that the concurrent or sequential development of these neutrophilic dermatoses has been observed in the same individual. Also, it is not unexpected that several of the effective therapeutic interventions – including systemic drugs, topical agents, and other treatment modalities – for the management of these dermatoses are the same. The treatment of choice for Sweet syndrome and idiopathic pyoderma gangrenosum is systemic corticosteroids; however, for subcorneal pustular dermatosis, dapsone is the drug of choice. Yet, tumor necrosis factor-α antagonists are becoming the preferred choice when pyoderma gangrenosum is accompanied by inflammatory bowel disease or rheumatoid arthritis. Potassium iodide and colchicine are alternative first-line therapies for Sweet syndrome and indomethacin (indometacin), clofazimine, cyclosporine (ciclosporin), and dapsone are second-line treatments. Cyclosporine is effective in the acute management of pyoderma gangrenosum; however, when tapering the drug, additional systemic agents are necessary for maintaining the clinical response. In some patients with subcorneal pustular dermatosis, systemic corticosteroids may be effective; yet, systemic retinoids (such as etretinate and acitretin) have effectively been used for treating this neutrophilic dermatosis – either as monotherapy or in combination with dapsone or as a component of phototherapy with psoralen andUVAradiation. Topical agents can have an adjuvant role in themanagement of these neutrophilic dermatoses; however, high-potency topical corticosteroids may successfully treat localized manifestations of Sweet syndrome, pyoderma gangrenosum, and subcorneal pustular dermatosis. Intralesional corticosteroid therapy for patients with Sweet syndrome and pyoderma gangrenosum, hyperbaric oxygen and plasmapheresis for patients with pyoderma grangrenosum, and phototherapy for patients with subcorneal pustular dermatosis are other modalities that have been used effectively for treating individuals with these neutrophilic dermatoses.     

妊娠期特异性皮肤病

妊娠期特异性皮肤病的命名及分类一直存在争议,最新的分类将其分为妊娠性类天疱疮、妊娠肝内胆汁淤积、疱疹样脓疱病、妊娠性多形疹、妊娠丘疹性皮肤病(包括妊娠痒疹、妊娠瘙痒性毛囊炎及妊娠特应性皮肤病)五类。本文主要介绍妊娠期特异性皮肤病的分类、临床特点、诊断和鉴别诊断、治疗、预后及对胎儿的影响等方面的研究进展。