How to manage atopic eruption of pregnancy

Atopic eruption of pregnancy is the most common dermatosis of pregnancy, and primary care doctors are often the first point of contact for affected patients. The GP's role is essential as timely management of atopic eruption of pregnancy is crucial for maternal comfort, quality of life, and to rule out more serious pregnancy-specific dermatoses.

Atopic eruption of pregnancy (AEP) affects five to 20 per cent of expectant mothers. AEP encompasses several conditions, including eczema in pregnancy, prurigo of pregnancy, and pruritic folliculitis of pregnancy.

What are the clinical features of AEP?

The typical presentation of AEP includes intensely pruritic papules, eczematous patches, or prurigo-like nodules. These characteristic features are usually distributed in flexural areas, trunk, and limbs, but the face and hands may also be affected. The periumbilical region is usually spared (unlike pemphigoid gestationis).

The first symptoms of AEP usually appear in the first or second trimester. The condition is benign, with no adverse maternal or fetal outcomes. However, it significantly affects quality of life.

How to diagnose AEP in primary care

Before diagnosing AEP, it is important to exclude other pregnancy dermatoses with higher maternal-fetal risk, such as:

• Pemphigoid gestationis – blistering rash, often starts periumbilically.
• Intrahepatic cholestasis of pregnancy (ICP) – generalised pruritus without rash, associated with abnormal liver function and raised bile acids.
• Polymorphic eruption of pregnancy (PEP) – urticarial papules/plaques, often starting in striae in the third trimester.

Investigations

AEP diagnosis is usually clinical. Primary care doctors may consider liver function tests and serum bile acids if pruritus is generalized or atypical. A skin biopsy or a dermatology referral may be necessary if blistering is present or there is diagnostic uncertainty.

General management principles

Education and reassurance are vital during a sensitive time, such as pregnancy. Make sure the patient understands AEP is benign and does not endanger the fetus.

Certain lifestyle modifications can facilitate the management of the condition:

• Use mild, fragrance-free emollients liberally
• Avoid overheating, irritants, and frequent hot showers
• Wear loose cotton clothing

Pharmacological treatment

First-line treatment includes the use of:

• Topical emollients (safe and effective)
• Mild to moderate topical corticosteroids (safe in pregnancy if used appropriately)

*Apply thinly, lowest potency effective, short duration. Avoid high-potency steroids over large areas or prolonged use.

Second-line treatment typically involves topical calcineurin inhibitors (e.g. tacrolimus, pimecrolimus). The safety data is limited. However, these may be considered for small, resistant areas after a specialist consultation.

For severe or refractory cases, systemic options include:

• Antihistamines: Chlorpheniramine, cetirizine, loratadine (generally regarded as safe in pregnancy) 

• Systemic corticosteroids (e.g. prednisolone) are reserved for severe, disabling cases unresponsive to topical therapy.

*Use short courses, lowest effective dose.

Monitoring and follow-up

Regular follow-up to assess response, adjust therapy, and monitor for secondary infection (excoriations, impetiginization).

Referral

Refer to dermatology or obstetrics if:

• Uncertainty about diagnosis.
• Severe, widespread, or refractory eruption.
• Suspicion of pemphigoid gestationis or intrahepatic cholestasis.

Atopic eruption of pregnancy is the most common pregnancy dermatosis and is benign. GPs, with adequate training, can differentiate AEP from conditions with fetal risk (e.g. cholestasis, pemphigoid gestationis). General management is symptomatic (emollients, safe topical steroids, antihistamines if needed), with close monitoring.

– Dr Rosmy De Barros

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References

• Maharajan, A., Aye, C., Ratnavel, R., & Burova, E. (2013). Skin eruptions specific to pregnancy: an overview. Obstetrician & Gynaecologist, 15(4).
• Massone, C., Cerroni, L., Heidrun, N., Brunasso, A. M., Nunzi, E., Gulia, A., & Ambros-Rudolph, C. M. (2014). Histopathological diagnosis of atopic eruption of pregnancy and polymorphic eruption of pregnancy: a study on 41 cases. The American Journal of Dermatopathology, 36(10), 812-821.
• Roth, M. M. (2011). Pregnancy dermatoses: diagnosis, management, and controversies. American journal of clinical dermatology, 12(1), 25-41.
• Balakirski, G., & Novak, N. (2022). Atopic dermatitis and pregnancy. Journal of Allergy and Clinical Immunology, 149(4), 1185-1194.
• Heilskov, S., Deleuran, M. S., & Vestergaard, C. (2020). Immunosuppressive and immunomodulating therapy for atopic dermatitis in pregnancy: an appraisal of the literature. Dermatology and Therapy, 10(6), 1215-1228.