The aim of this leaflet
This leaflet is designed to tell you more about Atopic Eruption of Pregnancy (AEP). It tells you what the condition is, what causes it, what can be done about it and where to find out more about it.

What is Atopic Eruption of Pregnancy?
Atopy is the term used for the tendency to develop eczema, asthma and/or hay fever.

Atopic eczema is an inflammation of the skin causing dry and itchy skin. It can affect any part of the skin, including the face, but the areas most commonly affected are the flexures of the elbows, knees, wrists and neck. It affects both sexes equally and usually starts in the first weeks or months of life. It is most common in children, affecting at least 10% of infants. It can carry on into adult life or, after a silent period, may recur in the teenage or early adult life. Many ‘environmental’ factors can make eczema worse. These include heat, dust, contact with irritants such as soap or detergents, stress, and infections. Also during pregnancy, eczema frequently gets worse (see below).

Atopic Eruption of Pregnancy includes women who already have eczema but experience an exacerbation of the disease (which accounts for approximately 20% of AEP patients) and women with their first manifestation of eczema during pregnancy (which accounts for the remaining 80% of cases). These patients present with atopic skin changes for the first time during pregnancy, but they often have a history of sensitive skin with a tendency to dryness and irritation (so called atopic diathesis) and often have first degree relatives with eczema, asthma, and/or hay fever.
Atopic eruption of pregnancy usually develops during the first half of pregnancy (75% before the third trimester). AEP was previously also known as “prurigo of pregnancy” but this name has been abandoned because it did not cover the whole variety of skin changes that may be seen.

What causes Atopic Eruption of Pregnancy?
This is still not fully understood. Atopy runs in families (see below) and is part of your genetic make-up. Atopic people have an overactive immune system and their skin easily becomes inflamed (red and sore). Their skin ‘barrier’ does not work well, so that their skin may become dry and prone to infections. During pregnancy, the immune system changes considerably, which may lead to worsening of pre-existing eczema or to a first development of atopic skin changes. These changes are usually reversible after delivery; however, a small number of women may continue to have eczema in following pregnancies.

Does Atopic Eruption of Pregnancy run in families?
Yes. Atopic eczema (as well as asthma and hay fever) tends to run in families. If one or both parents suffer from eczema, asthma, or hay fever, it is more likely that their children will get it too. Similarly, due to the genetic background, your sister or mother may also have experienced AEP during pregnancy. The probability is high that AEP will recur in successive pregnancies.

What are the symptoms of Atopic Eruption of Pregnancy and what does it look like?
The main feature is itch which can be bad enough to interfere with sleeping. The severity of the rash depends on the type of AEP. If you suffer from worsening of pre-existing eczema, it is likely that your skin will be red and dry. When the eczema is very active (during a ‘flare-up’) you may develop small water blisters on the hands and feet or your skin may become wet and weepy. In areas that are repeatedly scratched, the skin may thicken in response - a process known as lichenification. If you experience AEP for the first time during pregnancy, the rash is usually much milder. Two third of patients suffer from red scaly itchy patches (so called eczematous type or E-type AEP) in sites typically affected by atopic eczema such as the neck, breasts, and flexural parts of the limbs. The other third shows tiny red papules (1-2mm) or slightly larger nodules (5-10mm, at times with small open wounds (excoriations) due to scratching) on the abdomen, back, and limbs (so called prurigo type or P-type AEP).

How will Atopic Eruption of Pregnancy be diagnosed?
Worsening of already existing eczema is usually easy to diagnose by investigating your skin and taking your history. However, first manifestation of AEP may be more difficult to diagnose, it can be confused with other skin diseases such as scabies or a drug eruption, and other special skin diseases occurring in pregnancy. It is helpful to tell your doctor of a personal and/or family history of atopy and signs of the tendency to be atopic (so-called atopic diathesis, see above).

Will the baby be affected by Atopic Eruption of Pregnancy?
No, the mother’s rash causes no harm to the baby. However, due to the genetic background of AEP, the child may develop some kind of atopic disease (eczema, asthma and/or hay fever).

Can Atopic Eruption of Pregnancy be cured?
Not really; due to its genetic background, it cannot be cured as such. But there are many ways of controlling it. Especially the first development of AEP usually responds well to therapy and can easily be controlled.

How can Atopic Eruption of Pregnancy be treated?
The primary aim of treatment is to relieve the itch and to reduce inflammation / redness of the skin. It is also important to use treatments that are entirely safe for both mother and the unborn child. The treatments used most often are moisturisers and topical steroid creams or ointments.

Moisturisers (emollient creams and ointments) should be applied several times a day to prevent skin dryness. Many are available, and it is important that you choose one you like to use. Bath emollients and soap substitutes are also helpful in many cases. You should not take baths and showers too frequently; this will make your skin dry.

Topical steroid creams or ointments will settle severe redness and itching of your rash. They come in different strengths (potencies), and your doctor will advise you which type needs to be used at which site and for how long. In general it is advised to use low potency steroids for as short periods as possible. Topical steroids are usually applied once daily and should always be used in combination with moisturisers.
Most patients will respond quickly to mild or moderate steroid creams/ointments. However, if the rash can not be suppressed sufficiently, stronger topical steroids may be worth trying for short periods. Topically applied steroids are less likely to harm the mother and the unborn than steroids by mouth. It is difficult to know which are the best topical steroids to use, we know betamethasone and some other steroids cross the placenta easily so you should discuss with your doctor which preparation are best in your situation.
Steroid tablets are a last resort to control the condition, they should only be given in low doses and for short periods. Prednisolone is the steroid tablet of choice during pregnancy, it may be required for severe flares of eczema. Some patients may also benefit from additional ultraviolet light treatment (UVB), which is considered safe in pregnancy.
Antibiotics may be needed if your rash becomes wet and weepy, which may mean that it is infected by bacteria.

Topical immunosuppressants such as tacrolimus (Protopic®) and pimecrolimus (Elidel®) must be avoided as they are not licensed for the use in pregnancy.

In addition, oral antihistamines may help to relieve the itch. Antihistamines considered safe for the use in pregnancy are the non-sedating antihistamines loratadine and cetirizine; old, sedating antihistamines are usually considered safe, recommended are clemastine, dimethindene, (dex)chlorpheniramine (hydroxyzine should be avoided).

Is the treatment safe for the baby and mother? Is any special monitoring required?
Mild to moderately potent topical steroids are considered safe during pregnancy and your doctor will advise you in detail. Short courses (around 2 weeks) of prednisolone, the steroid tablet of choice in pregnancy, do not usually affect the unborn. However, high doses (above 10mg/day) of oral prednisolone administered during longer periods (more than 2 weeks) during the first 12 weeks of pregnancy seem to harbour an increased risk for the development of oral/palate clefts. Longer courses of steroid tablets (which are usually not necessary for the treatment of AEP) may also affect the baby’s development in general, in particular its growths. The pregnant women, like other patients taking steroid tablets, may for example develop diabetes (raised sugar levels), hypertension (raised blood pressure), and more striae. In such cases, careful observation of the blood pressure and urine checks are needed; ultrasound scans can monitor any changes regarding the baby’s development.

Is normal delivery possible?
Yes.

Can women with Atopic Eruption of Pregnancy still breastfeed?
Yes. Even while taking oral steroid tablets women should still be encouraged to breastfeed as only negligible amounts of steroids get into breast milk. However, these women are at risk of developing nipple eczema due to their sensitive skin, regular application of emollients is important. If topical steroids are applied to the nipple, they should be washed off prior to breast feeding to prevent oral ingestion by the infant.

Where can I get more information about Atopic Eruption of Pregnancy?
Web links to detailed leaflets:

www.bad.org.uk/public/leaflets/atopiceczema.asp

Books:
Black, Edwards, Lynch, Ambros-Rudolph. Obstetric and Gynecologic Dermatology. 3rd edition, 2008 (UK)
Schaefer, Spielmann, Vetter. Arzneiverordnung in Schwangerschaft und Stillzeit. 7th edition, 2006 (Germany)
Schaefer, Peters, Miller: Drugs during pregnancy and lactation. 2nd edition 2007 (English)
Briggs, Freeman, Yaffe. Drugs in pregnancy and lactation. 7th edition, 2005 (USA)

While every effort has been made to ensure that the information given in this leaflet is accurate, not every treatment will be suitable or effective for every person. Your own doctor will be able to advice in greater detail. The general information of this leaflet is adapted from the BAD patient information leaflet. February 2008

This leaflet has been prepared by the EADV task force “skin disease in pregnancy”, it does not necessarily reflect the official opinion of the EADV.