Saturday, 6 February 2010

Eczema in pregnancy

This is the commonest dermatosis associated with pregnancy. Eczema is a multifactorial disease controlled by genetic predisposition & environmental factors.

Effect of pregnancy on Eczema
25% of pregnant women with eczema improve but more than 50% deteriorate.
Deterioration occur at anytime but more common in second trimester.


Effect of Eczema on pregnancy

Generally eczema doesn't affect fertility or the pregnancy.Genetic & environmental factors determine the development of eczema in a child.It is important to recognize & treat eczema herpeticum as this could lead to serious maternal mortality & morbidity.Aciclovir should be commenced on clinical suspicion and the diagnosis can be confirmed by viral swab.

Preconceptional counselling

(i)Optimize the control of eczema by avoiding the irritants & allergens,using emollients & topical steroids.

(ii)Patients who had systemic treatment should ensure adequate drug free interval
Example conception should be avoided for three months after methotrexate (males & females)


During pregnancy:


The streroids should be used in minimum strengths & quantities.

Sedative antihistamine would help with sleep.

Secondary infections often require systemic antibiotics therapy.

The following are safe treatments options :
emollients,topical steroids (mild, moderate, or potent),Ultraviolet B

These options are relatively contraindicated:very potent topical steroids,oral steroids,Ciclosporin,azathioprine,topical calcineurin inhibitors
The following options are contraindicated:methotrexate,psoralens plus ultraviolet A (PUVA)


ciclosporin crosses the placenta but data from transplant patients indicate it is relatively safe.These patients need regular assessment of full blood count,renal function & blood pressure.

Azathioprine crosses the placenta but the fetal liver lacks the enzyme to convert it into active metabolite.Patients on azathioprine has to have regular full blood count & liver function tests.


More information on topical calcineurin inhibitors

Example :tacrolimus and pimecrolimus

Systemic therapy is teratogenic but absorption from topical treatment is very small.The patient should be counseled about the risk.



Eczema of nipple

Emollients & low to moderate potency steroids are first line treatment.These are applied after breast feeding and should be washed away just before the next feed.
Ultraviolet B is safe but methotrexate & ciclosporin should be avoided.

What are emollients? more information on emollients?


Cochrane review on topical steroids in pregnancy


An excellent article on common skin disorders in pregnancy


Another article




A link on skin diseases in pregnancy

How to treat skin problems in pregnancy?





References
(1)Treatment of Recurrent Eczema Herpeticum in Pregnancy With Acyclovir Richard A. Lattacorresponding author1 and David A. Baker2 .Infect Dis Obstet Gynecol. 1996; 4(4): 239–242. doi: 10.1155/S1064744996000452.

2.Eczema Herpeticum in Pregnancy and Neonatal Herpes Infection,DiCarlo, Angela; Amon, Erol MD; Gardner, Morey MD; Barr, Susan MD; Ott, Kelly MD, Obstetrics & Gynecology: August 2008 - Volume 112 - Issue 2, Part 2 - pp 455-457, doi: 10.1097/AOG.0b013e318169ce19, Case Reports.













3.Weatherhead S, Robson SC, Reynolds NJ. Eczema in pregnancy. BMJ. 2007 7;335(7611):152-154-An excellent review on this topic.








4.Oxford text book of medicine,third edition,Voulme 2 pp1805.