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Why does the skin itch during pregnancy?

Last updated date: 27-Jul-2022

CloudHospital

18 mins read

Why does the skin itch during pregnancy?

Itching during pregnancy is not very common. In most cases the skin begins to itch unbearably (as with mosquito bites) in the late evening, which may provoke insomnia and have a negative effect on a woman’s mood in general. The itching does not usually affect the baby and goes away by itself after the birth. It is however advisable to consult a gynecologist and dermatologist.

Pregnancy, a state of profound physiological and hormonal changes, is associated with a spectrum of changes in the skin and appendages. More than 90% of pregnant women experience one or more forms of skin changes. Up to 20% of women experience pruritus during their pregnancy. 

Specific dermatoses of pregnancy are the afflictions of the skin that appear during pregnancy and resolve with parturition. Pruritus gravidarum is a condition of the skin in gravid women represented by itching and only secondary lesions in the form of excoriations with or without evidence of cholestasis.

Pruritus gravidarum and intrahepatic cholestasis of pregnancy are terms used interchangeably in the medical literature with pruritus gravidarum characterizing the patients with pruritus in the absence of primary skin changes. 

To reiterate, there is no specific rash associated with pruritus gestationis, but many patients will have evidence of self-inflicted excoriations due to itching to attempt to relieve pruritus symptoms. Itching can range from mild to severe and most commonly affect the palms and soles. Symptoms may be worse at night. It is important for clinicians to recognize pruritus gestationis, as these patients must be evaluated for intrahepatic cholestasis of pregnancy. 

Most obstetric clinicians can expect to encounter intrahepatic cholestasis of pregnancy during their careers, as it is the most common liver disease specifically associated with pregnancy. If patients are diagnosed with intrahepatic cholestasis of pregnancy, this information can change the treatment plan, delivery timing, antenatal evaluation of the fetus, and care of future pregnancies. 

 

What causes it?

There has yet to be a definitive explanation for pruritus gravidarum. Hormonal and genetic variables are thought to have a significant influence in its development. 

However, itching during pregnancy is mostly caused by disorders in the function of the liver: production and excretion of bile, a general increase in the level of bilirubin in the blood. This happens as a result of a hormonal breakdown in the expectant mother’s body – a disorder in the synthesis of estrogen, and also because of pressure from the fetus on the bile ducts. 

A large amount of fatty acids that are produced are carried via the bloodstream to a woman’s skin and they irritate the nerve endings causing the unbearable itching. Similar conditions associated with the congestion of bile in the body may become apparent in the third trimester of pregnancy. Itching may also sometimes be accompanied by dangerous illnesses such as diabetes.

The condition usually starts in the third trimester, when hormone levels are at their highest, and ends with parturition. It might also return in consecutive pregnancies, indicating that the condition is caused by a hormonal imbalance.

Pruritus gravidarum is a condition that affects people differently depending on their ethnicity and location. This ethnic and geographic clustering of cases suggests that the disease has a hereditary foundation.

Heterozygous mutations in the MDR3 gene, also known as ABCB4, have been linked to disease etiology. The canalicular phosphatidylcholine translocase transport protein is encoded by the MDR3 gene.

A personal or familial history of intrahepatic cholestasis in a prior pregnancy, numerous gestations, chronic hepatitis C, and advanced maternal age are all risk factors for intrahepatic cholestasis during pregnancy. In pruritus gravidarum, skin biopsy results are frequently non-specific; epidermal ulceration is found as a result of excoriations.

 

Who is prone to the condition?

Itching during pregnancy is usually observed in women with chronic diseases of the biliary tracts and a high level of cholesterol in the blood. These expectant mothers should regularly (no less than once a month) undergo a biochemical analysis of the blood in order to exclude toxic effects on liver cells.

 

How can you control it?

A pregnant woman should talk to her gynecologist about the discomfort associated with the itching. In some cases, the itching may be a sign of the onset of a serious disease such as hepatitis. The doctor will conduct the necessary tests. 

If physical examination shows that the itch does not present any dangers, it is often possible to eliminate discomfort by following a diet aimed at reducing the level of cholesterol and limiting the consumption of fatty, spicy and salty foods, which interfere with the liver function of excreting bile and also by drinking plenty of fluids – this is needed to eliminate dry skin. If the diet does not help, the doctor may prescribe cholagogues (bile-expelling drugs) suitable for pregnant women.

It is important to find the cause of the irritating itch by excluding a whole group of skin diseases that may occur during pregnancy.

 

Itching on the abdomen and chest

This kind of itching should be considered separately. The skin on the abdomen or chest itches during the second and third trimesters due to stretching, as it is these parts of the body that increase in size during pregnancy. In this case it is very important to not to scratch the skin.

This will cause stretch marks, which, unlike the itching, will not go away after the birth. You should regularly use moisturising creams and special formulas against stretch marks, massage the chest and stomach lightly with circular motions of the fingers and you should not take hot showers.

 

Epidemiology

The prevalence of pruritus gravidarum varies across the world. There have been reports of incidence rates ranging from 1% to 27.6%. In Chilean women of Araucanian Indian descent, the incidence rate was 22.1 percent, with the prevalence increasing in direct proportion to the degree of 'ethnic purity.' In European countries, incidence rates ranged from 0.5 percent to 1.5 percent, with Scandanavian women contributing the highest rates.

In the United States, the Hispanic population in Los Angeles had the highest incidence rate of 5.6 percent, while Connecticut had a 0.32 percent rate. The frequency was 1.2 percent to 1.5 percent in Indian-Asian and Pakistani-Asian women. During the winter, there was a greater occurrence.

Although dry skin is the most prevalent reason, it might also signal a pregnancy-specific underlying problem. pruritic urticarial papules and plaques of pregnancy (PUPPP), intrahepatic cholestasis of pregnancy (ICP), pemphigoid gestationis (PG), and atopic eruption of pregnancy are among the dermatoses of pregnancy.

 

Pathophysiology

Pruritus develops as a result of elevated bile acid levels in the skin and serum. The precise process through which bile acids cause pruritus is unknown. The solubilization of lipid cellular membranes by bile salts might result in the release of histamine and proteolytic enzymes due to their detergent characteristics. Pruritus can be caused by the release of histamine and other enzymes, which activates free nerve endings. 

Bile acid levels grow as a result of hormonal and hereditary causes. Hormones such as estrogen and progesterone, whose levels rise during pregnancy, have a cholestatic impact and lower hepatic excretory function. Mutations in the MDR3 gene can potentially result in cholestasis.

 

Signs and symptoms 

Signs and symptoms

The most common symptom of pruritus gravidarum is itching, which is an uncomfortable sensation that makes you want to scratch. Itching usually starts in the late second to early third trimester, however itching has been reported as early as eight weeks of pregnancy. In at least half of the women, the beginning of symptoms coincided with the commencement of a urinary tract infection, according to a research.

Itching is often episodic at first, then becomes continuous. Pruritus starts in the belly and then extends to the entire trunk, palms, and soles. Itching can range from minor to severe, and people experience the most discomfort at night.

Only approximately 20% of the time, icterus appears after pruritus has been present for at least four weeks. Patients with icterus may develop steatorrhea, which leads to fat malabsorption. Symptoms last throughout pregnancy, disappear after childbirth, and reappear in successive pregnancies. 

In pruritus gravidarum, the examination reveals no primary lesions. In fact, if any primary lesions are present, the diagnosis of pruritus gravidarum is ruled out. The most common inspection findings are excoriations and scratch marks caused by itchiness.

 

Diagnosis

Because pruritus without primary skin lesions is a key hallmark of pruritus gravidarum, a comprehensive history and physical examination are essential. 

An increase in the concentration of serum bile acids is a crucial laboratory finding in pruritus gravidarum. It's usually the initial and only aberrant test finding. Pruritus causes an increase in serum bile acid levels. The cholic/chenodeoxycholic ratio is skewed because cholic acid levels rise faster than chenodeoxycholic acid levels. In women with pruritus gravidarum, the cholic/chenodeoxycholic ratio was 3.4, compared to 1.1 in pregnant women without the disease.

This illness is distinguished from viral hepatitis by a rise in serum aminotransferases that does not surpass 1000 units/L. Due to the synthesis of the placental isoenzyme, alkaline phosphate levels, while high, are not specific for pruritus gravidarum. The presence of hyperbilirubinemia suggests the presence of pregnancy-related intrahepatic cholestasis.

There are no abnormalities on ultrasonography of the liver. Cholestasis without inflammation may be shown on histopathology, but a liver biopsy is not required for diagnosis.

 

Management

The goal of therapy should be to alleviate symptoms while also preventing negative effects in the fetus. Reassurance, antipruritic treatments like calamine lotion, calming oatmeal baths, menthol in aqueous cream, and weak steroidal ointments can be used to treat mild symptomatic instances. Patients should be comforted and told to stay away from stressful situations and unpleasant apparel. Rest and a low-fat diet should both be promoted.

Patients should also be informed about the disease's transitory nature and the rapid remission of their symptoms following birth. Antihistamines from the first generation, such as diphenhydramine, chlorpheniramine, pheniramine, or tripelennamine, are safe to use during pregnancy and can be taken as a supplement. 

Ursodeoxycholic acid can be used to treat severe or intractable pruritus that is accompanied by biochemical abnormalities (UDCA). By substituting other hydrophobic ions in enterohepatic circulation, UDCA, a hydrophilic bile acid, eliminates them. At a dosage of 15mg/kg/day, UDCA helps decrease pruritus while also correcting metabolic imbalances.

UDCA has no teratogenic effects and is more effective than other current medicines. It's vital to keep in mind that while UDCA medication can help with maternal symptoms, it doesn't reduce the hazards to the fetus.

Cholestyramine, S-adenosyl-D-methionine, oral corticosteroids, nonerythemogenic UVB radiation, and phenobarbital are some of the other medications that may be employed. Although these medicines are more commonly associated with the treatment of intrahepatic cholestasis of pregnancy, they are worth noting here since pruritus gravidarum and intrahepatic cholestasis of pregnancy have many similarities.

In the setting of intrahepatic cholestasis during pregnancy, there is an increased risk of preterm delivery, meconium-stained amniotic fluid, newborn depression, respiratory distress syndrome, and stillbirth, among other things. 

The American College of Obstetricians and Gynecologists (ACOG) advises prenatal surveillance with fetal non-stress tests after viability beginning at the time of cholestasis diagnosis and continuing once or twice weekly until birth to reduce the risk of adverse outcomes.

The total bile acid levels in the serum influence the optimum delivery time, according to ACOG. If the total bile acid level is less than 100 micromol/L, delivery should take place between 36 and 39 weeks of pregnancy. Delivery at 36 0/7 is indicated for total bile acid levels of 100 micromol/L or greater. If the patient is diagnosed with cholestasis after the optimum gestational age for delivery, delivery is advised at the time of diagnosis.

 

Differential Diagnosis

Because pruritus is such a prevalent symptom of pregnancy, it's crucial to rule out other possible reasons, including but not limited to: 

  • Specific dermatoses of pregnancy
  • Atopic dermatitis
  • pemphigoid gestationis 
  • Erythema multiforme 
  • Polymorphic eruption of pregnancy
  • Atopic eruption of pregnancy 
  • Pustular psoriasis of pregnancy
  • Scabies 
  • Pediculosis  
  • Neurodermatitis
  • Contact dermatitis and 
  • Drug eruptions. 

Other causes of liver dysfunction should be ruled out if the patient has simultaneous liver function abnormalities: viral hepatitis, acute fatty liver of pregnancy, HELLP (hemolysis, increased liver enzyme levels, and low platelet count) syndrome, and drug-induced liver damage.

 

Intrahepatic cholestasis of pregnancy

Despite the fact that ICP is a pruritic disorder in pregnancy that mainly includes secondary skin alterations, it is classified as a dermatosis of pregnancy since early detection is critical to reducing the risk of unfavorable fetal outcomes.

Idiopathic jaundice of pregnancy, obstetric cholestasis, and pruritus gravidarum are all terms for intrahepatic cholestasis in pregnancy. Hepatic bile flow is disrupted during pregnancy, which causes it. ICP is frequent in North America, affecting 0.5 percent to 1% of the population, but it is more prevalent in Scandinavia and South America, with the greatest incidence in Chile (15 percent to 28 percent). It tends to run in families and reoccur in subsequent pregnancies. 

 

Clinical presentation

Pregnancy-related intrahepatic cholestasis manifests itself in the second or third trimester as a rapid onset of severe pruritus that begins on the palms and soles and soon spreads throughout the body. The pruritus lasts the entire pregnancy and is most severe at night.

Scratching causes secondary lesions, which include linear excoriations and excoriated papules. Concomitant extrahepatic cholestasis causes jaundice in around 10% of patients, which is commonly accompanied by dark urine and clay-colored feces. With malabsorption of fat-soluble vitamins, particularly vitamin K, these individuals are at risk of developing steatorrhea, which can lead to bleeding problems and cholelithiasis.

 

Pathophysiology

Pregnancy-related intrahepatic cholestasis is a hormonally induced cholestasis. It manifests in late-pregnancy genetically predisposed women who have a deficiency in bile acid excretion, leading in increased bile acid levels in the blood.

This causes severe pruritus in the mother, and because toxic bile acids can enter the fetal circulation, the fetus may suffer harm as a result of abrupt placental anoxia and cardiac depression. In half of instances, there is a family history of the condition, and those with a familial component are more severe.

 

Diagnosis

The typical symptom of pruritus originating from the palms and soles that is not accompanied by a rash is usually used to make a diagnosis. An increase in total serum bile acid levels can be used to confirm the diagnosis. Total blood bile acid levels of up to 11.0 mol/L in the third trimester are considered normal in healthy pregnancies.

The presence of total blood bile acid levels more than 40.0 mol/L in women with ICP is linked to a higher risk of unfavorable fetal outcomes. A slight rise in liver transaminase values, such as aspartate aminotransferase and alanine aminotransferase, may also occur; this increase may manifest weeks after the beginning of pruritus. 

Steatorrhea with vitamin K insufficiency may also be observed. Prothrombin time may need to be monitored closely. To rule out other illnesses such cholelithiasis and viral hepatitis, a liver ultrasound and serologic testing may be required.

 

Treatment

The goal of therapy is to lower bile acid levels in the blood. Ursodeoxycholic acid is the preferred therapy because it reduces maternal pruritus, lowers hepatic transaminase and bile acids, and may reduce the risk of bad fetal outcomes, however this last benefit is controversial. Until the baby is born, a daily dosage of 15 mg/kg or 1 g is given.

Cholestyramine was used to treat ICP before ursodeoxycholic acid therapy. This medicine, on the other hand, can create vitamin K insufficiency, which may already be present in this condition. Antihistamines may help with maternal symptoms as well.

Stillbirths tend to cluster around weeks 37 to 39, hence elective delivery around weeks 36 to 38 has been advocated. According to some publications, inducing labor at 37 weeks is only recommended in situations of severe ICP (defined as total serum bile acid levels of greater than 40 mol/L).

 

Prognosis 

The mother's prognosis is typically favorable. Pruritus usually goes away on its own within a few days to weeks following birth, but it might come again with subsequent pregnancies or when on hormonal contraception. There is a higher risk of intrapartum and postpartum hemorrhage if you have jaundice and vitamin K insufficiency.

This syndrome has been linked to fetal complications such as preterm labor, meconium in the amniotic fluid, fetal discomfort, and fetal death. Importantly, some have documented that fetal demise in ICP occurs as a result of a rapid occurrence, even if the fetal heart rate tracing was previously normal.

Indeed, there is little evidence that intensive prenatal monitoring can prevent fetal mortality in situations with ICP. As a result, it is suggested that labor be induced between 36 and 38 weeks. The need of early diagnosis, precise treatment, and thorough obstetric monitoring cannot be overstated. In ambiguous or severe situations, a gastroenterologist should be consulted.

 

Pemphigoid gestationis

Pemphigoid gestationis is a self-limiting autoimmune bullous illness that appears after the 20th week of pregnancy and may only arise after delivery.

Herpes gestationis was the name given to PG in the past due of the distinctive "creeping" blister development. Milton created the phrase in 1872. This phrase, however, may be misleading because the disorder has nothing to do with the herpes virus and is now known as pemphigoid gestationis. It's a rather uncommon illness, with an estimated 1 in 10,000 pregnancies affected.

 

Clinical presentation 

The skin lesions in pemphigoid gestationis might be preceded by acute itching. The pruritic, urticarial, erythematous papules and plaques around the umbilicus and extremities are the first signs of the rash. The sores become stiff blisters as the illness develops.

Mucous membrane involvement occurs around 20% of the time, while the face, palms, and soles are spared. PG often flares around the time of delivery, but then subsides on its own.

 

Diagnosis

To make the diagnosis, a skin biopsy is required. In the diagnosis of PG, direct immunofluorescence of perilesional skin is the gold standard. It demonstrates linear complement C3 deposition along the dermoepidermal junction, and biopsy findings in other pregnant dermatoses are often negative for this.

PUPPP (pruritic urticarial papules and plaques of pregnancy) is the most common differential diagnosis, especially early in the condition before the tight blisters appear. In suspected cases of PUPPP with an uncommon and severe appearance that does not respond to standard therapy, a skin biopsy is recommended.

 

Prognosis

Exacerbations and remissions define the normal course of the disease throughout pregnancy, with frequent recovery in late pregnancy followed by a flare-up at birth. Lesions normally disappear within a few weeks or months. It tends to reoccur at an earlier gestational age and with increasing severity in consecutive pregnancies. It might also happen during menstruation or when using hormonal contraception. Other autoimmune conditions, including Graves' disease, are at an elevated risk.

Pregnancies afflicted by PG are deemed high-risk since there is a link between the condition and a higher likelihood of negative fetal outcomes such preterm delivery and low birth weight. About 10% of neonates may suffer modest skin lesions that heal spontaneously within days to weeks due to passive transmission of maternal autoantibodies to the fetus.

 

Treatment

The goal of treatment is to reduce pruritus and prevent blister development. Topical corticosteroids combined with oral antihistamines may be adequate in situations of mild pre-blistering. Systemic steroids, such as 20 to 60 mg of prednisone per day, are required in all other instances. To avoid a flare-up during delivery, the prednisone dose should be raised gradually.

 

Prognosis of pruritus gravidarum

The prognosis for pruritus gravidarum is excellent, with symptoms subsiding quickly after delivery. Pruritus and icterus usually go away within 24-48 hours of birth, however they might continue up to four weeks. Bile acid levels return to normal in 4-6 weeks. In 40 percent to 70 percent of women, pruritus gravidarum might reoccur in successive pregnancies. In certain cases, estrogen-containing medications might trigger recurrences.

 

Complications pruritus gravidarum

The mother's and fetus' complications differ. Malabsorption or postpartum hemorrhage may occur in the mother as a result of low vitamin K levels caused by liver problems. Gall bladder illness, including cholelithiasis, was shown to be more common in these patients, according to a research.

Premature delivery, intrauterine asphyxia, meconium-stained amniotic fluid, and low birth weight are all risks for the fetus. Bile acid levels of 40 micromol/L or above were shown to be statistically significant for increased adverse outcomes in the fetus in a research. Placental anoxia is thought to cause fetal problems.

 

Skin itching home remedies

Skin itching home remedies

  • Olive Oil 

Any type of rash can cause significant skin harm. Olive oil is an excellent choice for both healing and skin renewal after a rash. Irritant dermatitis diaper rashes and allergic contact dermatitis rashes benefit from olive oil's anti-inflammatory and antibacterial characteristics.

You may use olive oil to massage on a rash with honey or on its own. A pinch of turmeric powder can also be added. This is a potent antibacterial and anti-inflammatory agent. Mix it together with the olive oil and apply it on the rash several times a day.

  • Coconut Oil 

Coconut oil is a fantastic substitute for olive oil for hydrating and soothing a rash. Coconut oil protects the skin as well. Coconut oil, unlike olive oil, has a thick viscosity similar to that of most diaper rash creams. Virgin coconut oil is suggested because it retains unprocessed coconut oil's antibacterial and anti-inflammatory qualities.

  • Cold Compress 

A simple yet effective rash treatment is a cold compress. This helps to alleviate the annoying symptoms of a rash while also reducing its intensity. Heat-related rashes respond best to cold compresses, which minimize swelling and irritation.

  • Oatmeal Bath 

The oatmeal bath has even been certified by the US Food and Drug Administration as a means to protect the skin. Oatmeal contains anti-inflammatory qualities as well as skin-soothing benefits.

 

Conclusion 

When it comes to pruritus during pregnancy, a comprehensive medical history and physical examination are required. In order to identify the most likely diagnosis, laboratory tests such as liver transaminase levels, serum bile acid levels, and in certain situations, skin biopsies may be required. Pregnancy dermatoses should be included in the differential diagnosis of pruritus and treated as such.

Because several of these disorders are linked to an elevated risk of unfavorable fetal outcome, a correct diagnosis is required. The therapies for the disorders listed above are considered safe during pregnancy.

Patients should be instructed to minimize scratching in order to avoid subsequent lesions and hyperpigmentation. When patients' symptoms become unmanageable and troublesome, they should be requested to follow up with their doctors. Patients should be comforted about their prognosis and the hazards to the fetus. These individuals should also be encouraged to avoid or take estrogen-containing oral contraceptives in the smallest feasible doses.

Physicians must be conversant with these disorders in order to distinguish between those that may be treated symptomatically and those that need to be investigated further. A multidisciplinary team that includes an obstetrician or a maternal-fetal medicine expert, a family physician, a dermatologist, and occasionally a gastroenterologist should examine and manage some of these diseases.

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