Atopic dermatitis (AD) or eczema is one of the commonest skin diseases
worldwide. It is more prevalent among women. Moreover, it is the most
common skin condition during pregnancy, registering approximately between
a third and a half of the total number of AD cases seen in dermatology
clinics. With this backdrop, ways to cope with this condition during
pregnancy is vital for patients, their families and practitioners.
Prevalence of atopic dermatitis in women
It has been estimated that 16% women in the United Kingdom suffer from
this skin problem and the frequency of this disease is probably similar
in the USA and elsewhere. There is a lifetime prevalence of 8-17% in adults
below 60 years of age. Sixteen to 24 years is the most vulnerable age
so far as this disease is concerned but it is on the rise among children.
Cure and control of moderate to acute cases is quite complex, which becomes
all the more difficult in women who plan to conceive or who are pregnant.
In fact, most women report the disease for the first time after they
conceive. Barely 20-40% of women affected by eczema are estimated to have
eczema before pregnancy. So that means 60-80% of all cases of eczema in
women first occur during pregnancy. Moreover, three quarters of these
women report indications within the first two trimesters of their pregnancy.
More than 50% of patients experience a deterioration of the syndrome
during pregnancy (generally more during the second trimester), while only
(approximately) 25% show improvement. Around 10 % of cases worsen in the
postpartum period.
Pregnancy-related complications
Studies have been conducted to examine whether having eczema is associated
with reduced fertility. However, despite speculation on a link between
eczema and fertility, there is no data indicating that atopic dermatitis
has an adverse action on fertility, causes miscarriage, birth defects
or preterm delivery.
However, here are a few cases where one needs to be cautious:
- In patients with secondary skin infections like eczema herpeticum caused
by the herpes simplex virus, there may be certain risks. Though there
is no definite evidence of eczema herpeticum causing intrauterine infection,
the presence of herpes simplex virus is linked with premature delivery,
intrauterine growth retardation, and miscarriage. Hence, it warrants immediate
treatment with Aciclovir, which is safe in pregnancy. The infection can
be detected with a viral swab test.
- Genetic and environmental triggers have a major role to play in the
development of childhood eczema. Some reports infer greater chances of
congenital eczema maternally rather than paternally. This can be traced
to maternal gene imprinting or transplacental fetal contact with allergens.
There have also been studies to find out whether a pregnant woman avoiding
cows’ milk or eggs has any effect on the child genetically contracting
eczema.
Therapy for atopic dermatitis during pregnancy
Though there are a variety of treatments available, pregnant women need
to follow certain guidelines to prevent complications. The various forms
of treatment and the associated course of action are as follows:
Treatment with topical corticosteroids
The mainstay of eczema treatment is the use of topical steroids combined
with moisturizer-based emollients. The process involves taking tepid baths,
applying the emollients and avoiding soap. However, one may need to seek
a second line of treatment in case of severe eczema. This approach is
also applicable in case of pregnant women but there are a few guidelines
about their usage.
Mild or moderate topical corticosteroids combined with moisturizer-based
emollients are the first line of treatment for mild to moderate eczema
during pregnancy. Potent topical steroid creams are generally avoided
for fear of systemic absorption into the blood and passage to the embryo.
Treatment with systemic corticosteroids
Systemic steroids are generally avoided since they can cause recurrence
of flares when discontinued and may have side effects on early embryo
development. Oral steroids are relatively safe during the third trimester.
Though they might interfere with fetal growth, (mostly seen in asthma
patients), there is no definite evidence whether it is caused by maternal
disease or the oral steroids. However, for safety, most dermatologists
will not use oral systemic steroids to treat eczema at any stage of pregnancy.
Systemic treatment is also not generally regarded as safe for lactating
mothers as the corticosteroids will be present in the milk.
Narrowband Ultraviolet B
Narrowband ultraviolet B is the safest second line treatment during pregnancy,
when topical steroids fail to manage the condition. It has been found
to control acute episodes of the disease by over 30%. Ultraviolet B is
also safe while breast-feeding.
Calcineurin inhibitors
It is comparatively safe to use topical calcineurin inhibitors (tacrolimus
and pimecrolimus), but strictly in small amounts. It is used as a secondary
therapy, but only if emollients and UV therapy has been ineffective. There
is however a risk of intrauterine growth retardation. The application
of the drugs is also limited to localised areas.
Other systemic treatments
If absolutely required, then the choices in systemic treatment begin
with the use of immunosuppressive agents such as cyclosporin or azathioprine,
but the condition of the patient and embryo must be closely monitored.
Use of Azathioprine involves the risk of miscarriage, premature delivery
and more rarely neonatal leucopenia, pancytopenia or inhibition of neonatal
haematopoiesis.
Those undergoing systemic therapy must also keep a minimum time interval
between discontinuing treatment to ensure a safe pregnancy and no harm
to the newborn. Fetal growth retardation (though it may actually be caused
by maternal diseases) is a risk factor in this group.
Methotrexate (another immunosuppressive agent) and psoralens plus ultraviolet
A (PUVA) are best avoided during pregnancy and are unsuitable for lactating
mothers.
