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Eczema During Pregnancy

Effective, safe treatments are available.

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Eczema is the most common dermatosis of pregnancy, accounting for almost half of all skin disorders reported by expectant mothers. Only 20% to 40% of women who develop eczema during pregnancy have a history of pre-existing eczema.1

Among women with a prepregnancy history of eczema, about half may experience a worsening in their eczema during pregnancy, but 25% see an improvement in symptoms. Higher rates of worsening symptoms may occur in the second trimester, but severity can fluctuate throughout pregnancy.2

Many patients are unsure about how to manage their eczema during pregnancy due to fears of adverse side effects. Healthcare providers such as PAs and NPs play a critical role in advising pregnant patients that effective options are available and will not harm the fetus.                                                                                              

Etiology

The cause of changes in skin quality during pregnancy is the subject of several theories. During pregnancy, immunity tends to shift toward a type 2 T helper response, a subgroup of lymphocytes. This type 2 response has also been linked with atopy, hence the tendency for flareups.3 Another theory suggests that variations in the expression of the protein filaggrin, which is common in eczema, is further altered and produces eczema.4 And a third theory is that skin reactivity to irritants may increase during pregnancy, leading to an increased inflammatory response.5

Presentation

In adults, eczema is generally localized or may be occur only on the hands and feet. The most common location for adult eczema is the flexor regions, such as the antecubital fossa, popliteal fossa and the neck. Common characteristics of eczema in adulthood are thickened skin, lichenification and excoriated papules. The presence of pustules often suggests infection with Staphylococcus aureus.

Dry skin develops in all presentations of eczema. Pruritis is the most characteristic symptom, and it is usually severe. Secondary changes due to scratching and rubbing of the skin are common.6 Postinflammatory hyperpigmentation or hypopigmentation is common, especially in patients with darker skin. Hyperpigmentation is sometimes severe at sites of lichenification because the epidermis thickens here.7

Management

The most effective way to manage eczema is to avoid irritants and triggers. For patients with pre- existing atopic dermatitis, triggers should be easy to identify.

Conservative treatments include diet changes, oatmeal baths and avoiding the use of drying soaps. The use of emollients (i.e., creams, ointments and humectants including alpha hydroxy acids) is important to maintain moisture of the skin and reduce irritation.

In terms of prescription treatment, the standard for mild to moderate eczema is low- to medium-potency topical steroids such as hydrocortisone 0.5% to 2.5% or triamcinolone acetonide 0.1% ointment, combined with topical moisturizers. This is the appropriate therapy even during pregnancy.8 Severe or unrelenting eczema warrants a different method of treatment, but many options are still viable during pregnancy.

In a randomized controlled study, narrowband ultraviolent B therapy applied twice a week for 12 weeks reduced the severity of eczema by 30%.9 This therapy can be applied in a medical setting or at home. Potent topical steroids, such as amcinonide 0.1% cream, are also safe during pregnancy.

Use with Caution

Potent topical steroids such as betamethasone dipropionate 0.05% should be used with caution and only in small quantities applied to the affected areas. Systemic steroids are to be used with caution, because studies are inconclusive about the possible effects on the fetus. Oral steroids have been linked with fetal growth restriction in humans and cleft lip and palate defects in mice.8 These medications should be used with caution during the third trimester.10

Topical calcineurin inhibitors such as tacrolimus and pimecrolimus may be considered if first-line treatments and UVB therapy are ineffective or contraindicated. The manufacturers of both products advise against their use during pregnancy. Although systemic tacrolimus is teratogenic, the bioavailability of the topical form is less than 5% and it has not been associated with fetal abnormalities.11 Use should be restricted only to affected areas.

If more intense systemic options are needed, cyclosporine is likely to be the safest option. In a double-blind, randomized controlled trial, eczema improved 59% in 8 weeks in patients who were not pregnant.12 Cyclosporine readily crosses the placenta, but in a study of pregnant mothers receiving organ transplants, results showed that it is relatively safe.11 Fetal growth was restricted, but this could be due to other maternal factors. The drug should be avoided during breastfeeding because it is a potent immunosuppressant. It should only be used if levels in milk and infant serum are monitored.13

Avoid

Methotrexate has been proven effective in moderate to severe eczema, but it should be avoided during pregnancy because it is a known teratogen and has recently been used to induce miscarriage.14 Methotrexate should also be avoided in mothers who are breastfeeding. In patients with established use of methotrexate, the literature recommends a minimum drug-free interval of 3 months before conception for both the mother and father, to avoid developmental risks.

Another effective therapy, psoralen plus ultraviolet light therapy (PUVA). is a combination of the medication psoralen with ultraviolet A light. It should be avoided during pregnancy and should be stopped before conception. A study reported congenital malformations and stillbirths after maternal exposure to PUVA therapy.15

Prevention

The most effective way to prevent eczema flareups during pregnancy is to avoid potential irritants and allergens. Continued application of moisturizers and mild to moderate topical steroids will minimize the disease. Any patient who is on systemic therapy for eczema should be made aware that time intervals between stopping the drug and attempting conception are necessary, especially methotrexate and PUVA.

Provide Safe and Effective Options

Studies have shown that physiologic changes such as immunologic shifts during pregnancy may cause eczema to worsen, but pregnant women do not have to suffer when it comes to eczema. Safe options for treatment include emollients, topical steroids (excluding potent forms) and ultraviolet B therapy. Relatively safe options to be prescribed with caution include small quantities of potent topical steroids, such as betamethasone dipropionate 0.05%, as well as oral steroids, topical calcineurin inhibitors and cyclosporine. Systemic therapies such as methotrexate and PUVA therapy must be discontinued at least 3 months prior to conception and should be avoided even during breastfeeding.16

Donna Mathis is a student in the physician assistant program at Georgia Regents University in Augusta. Sara Haddow Liebel is an associate professor in the program.  

References

1. Vaughan Jones SA, et al. A prospective study of 200 women with dermatoses of pregnancy correlating clinical findings with hormonal and immunopathological profiles. Br J Dermatol. 1999;141(1):71-81.

2. Kemmett D, Tidman MJ. The influence of the menstrual cycle and pregnancy on atopic dermatitis. Br J Dermatol. 1991;125(1):59-61.

3. Saito S, et al. Quantitative analysis of peripheral blood Th0, Th1, Th2 and the Th1:Th2 cell ratio during normal human pregnancy and preeclampsia. Clin Exp Immunol 1999;117(3):550-555.

4. Palmer CN, et al. Common loss-of-function variants of the epidermal barrier protein filaggrin are a major predisposing factor for atopic dermatitis. Nat Genet. 2006;38(4):441-446.

5. Agner T, et al. Menstrual cycle and skin reactivity. J Am Acad Dermatol. 1991;24(4):566-570.

6. Rudikoff D, Lebwohl M. Atopic dermatitis. Lancet. 1998;351(9117):1715-1721.

7. Spergel JM, Paller AS. Atopic dermatitis and the atopic march. J Allergy Clin Immunol. 2003;112(6):S118-S1127.

8. Czeizel AE, Rockenbauer M. Population-based case-control study of teratogenic potential of corticosteroids. Teratology. 1997;56(5):335-340.

9. Reynolds NJ, et al. Narrow-band ultraviolet B and broad-band ultraviolet A phototherapy in adult atopic eczema: a randomised controlled trial. Lancet. 2001;357(9273):2012-2016.

10. Gur C, et al. Pregnancy outcome after first trimester exposure to corticosteroids: a prospective controlled study. Reprod Toxicol. 2004;18(1):93-101.

11. Christopher V, et al. Pregnancy outcome after liver transplantation: a single-center experience of 71 pregnancies in 45 recipients. Liver Transpl. 2006;12(7):1138-1143.

12. Sowden JM, et al. Double-blind, controlled, crossover study of cyclosporin in adults with severe refractory atopic dermatitis. Lancet. 1991;338(8760):137-140.

13. Moretti, ME, et al. Which drugs are contraindicated during breastfeeding? Can Fam Physician. 2000;46(9):1753-1757.

14. Lloyd ME, et al. The effects of methotrexate on pregnancy, fertility and lactation. QJM. 1999;92(10):551-563.

15. Stern RS, Lange R. Outcomes of pregnancies among women and partners of men with a history of exposure to methoxsalen photochemotherapy (PUVA) for the treatment of psoriasis. Arch Dermatol 1991;127(3) 347-350.

16. Weatherhead S, et al. Eczema in pregnancy. BMJ. 2007;335(7611):152-154.




     

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