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ATOPIC DERMATITS (ECZEMA) IN PREGNANCY

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.