Pregnancy is a state of heterogeneity characterised by substantial alterations in the vascular, immunological, hormonal and metabolic milieu. Almost ninety percent of the women experiences both physiological and pathological changes during pregnancy that reflects in the skin and its appendages [1]. These systemic changes are the physiological adaptations that support maternal and fetal well-being throughout pregnancy. The concernment of the patient ranges from cosmetic appearance to the chance of recurrence of the particular ailment during and in subsequent pregnancy, to its potential effects on fetus in terms of morbidity and mortality [2].

The dermatoses of pregnancy are broadly classified into three categories which includes physiological changes, specific dermatoses of pregnancy and dermatoses modified by pregnancy[3]. The present study was aimed to study and analyse the prevalence of physiological and pathological cutaneous changes based on various gravidas and trimesters during pregnancy.

Study design: A single centred, prospective study was conducted during the period of March 2023 to August 2024. Source of data: Pregnant women attending the OPD of Government Maternity Hospital, Kurnool were randomly selected irrespective of duration of pregnancy and gravida. Size of sample: 100 Method of collection of data Inclusion criteria Pregnant women who were willing to give informed consent irrespective of duration of pregnancy and gravidity. Exclusion criteria Pregnant women who do not give consent to participate in the study. Data collection procedure Informed consent was obtained before clinical examination. Detailed history that includes age, obstetric status, antenatal history, chief complaints related to skin, onset of skin changes and/or lesions in relation to duration of pregnancy, history of similar illness in previous pregnancies, family history of similar lesions, exacerbating factors and associated medical and skin diseases were elicited and recorded. Complete and thorough dermatological examination was conducted in all cases to study the physiological and pathological changes in skin and its appendages.In case of specific dermatoses of pregnancy, the distribution and morphology of the skin lesions along with the sites of involvement were noted. A relevant systemic examination was performed. Evidence of an aggravation or remission of any preexisting skin conditions was documented.Relevant investigations, whenever required were carried out to confirm the diagnosis. Bedside investigations like Gram’s stain, Tzanck smear and KOH mount were carried out if necessary. In a few instances, skin biopsies were performed. Statistical analysis Statistical analysis of the cutaneous manifestations was given by percentages between primi gravidas and multi gravidas and between various trimesters, analysed by Chi square test. P value <0.05 was considered statistically significant.

A total of 100 pregnant women were studied from March 2023 to August 2024. Of these 58 [58%] were multigravida and 42 [42%] were primigravida. Among the multigravida, 46 [46%] were second gravida, 10 [10%] were third gravida and 2 [2%] were fourth gravida. Cases seen in first trimester were 20 [20%], second trimester were 28 [28%] and third trimester were 52 [52%]. The distribution of the cases among various gravidas and trimesters was depicted in (Table 1).

In terms of age the youngest and oldest patients were 16 and 36 years old respectively. Majority of them belonged to the age group 21-25 years; n = 42 [42%].

Table 1: Distribution of the cases among various gravidas and trimesters

Table 2: Distribution of physiological changes in pregnant women according to various gravidas and trimesters [n=100]

Physiological skin changes were seen in 90% of the pregnant women [n=90] depicted in Table 2. Among them pigmentary changes were noted in 90 cases [90%]. Of the pigmentary changes, the most common was linea nigra seen in 89% of the cases [n=89]. Majority of them were second gravida [n=26;26%] in their third trimester [n=52;52%]. On statistical analysis, there was a statistically significant association noted between both the pigmentary changes and various gravidas (Table 3) and pigmentary changes and various trimesters (Table 4) with p values of 0.039 and <0.001 respectively. 

Table 3: Statistical analysis of the association between pigmentary changes and various gravidas [n=100]

Table 4: Statistical analysis of the association between pigmentary changes and various trimesters [n=100]

In 19% of the cases, vascular changes are seen [n=19], which constitutes the non-pitting type of pedal edema. It revealed a statistically significant association between pedal edema and various trimesters with p value of 0.005 (Table 5).

Table 5: Statistical analysis of the association between pedal edema and various trimesters [n=100]

Striae gravidarum was seen in 55% of the cases [n=55], majority of the cases were in their third trimester [n=39:39%]. There was a statistically significant association between striae gravidarum and various gravidas [p=0.0378] and striae gravidarum and various trimesters [p<0.001] in the study group as illustrated (Table 6 and Table 7).

Table 6: Statistical analysis of the association between striae gravidarum and various gravidas [n=100]

Table 7: Statistical analysis of the association between striae gravidarum and various trimesters [n=100]

Specific dermatoses observed in various gravidas and trimesters during pregnancy

The specific dermatoses of pregnancy were observed in 12 cases [12%]. The distribution of the specific dermatoses observed in pregnant women among various gravidas and trimesters was illustrated (Table 8). The most common one was pruritic urticarial papules and plaques of pregnancy [PUPPP] seen in 7% of the cases [n=7], followed by prurigo of pregnancy [n=4;4%] and pruritic folliculitis of pregnancy [n=1;1%].

Table 8: Distribution of the specific dermatoses observed during pregnancy [n=100]

The distribution of infections among pregnant women in various gravidas and trimesters was depicted (Table 9).

Table 9: Distribution of the infections observed during pregnancy [n=100]

The distribution of miscellaneous dermatoses among pregnant women in various gravidas and trimesters was depicted (Table 10).

Table 10: Distribution of the miscellaneous dermatoses observed during pregnancy [n=100]

Pregnant women are vulnerable to a multitude of physiological and pathological skin changes that may be exclusive to pregnancy or may result in modification of pre-existing dermatoses due to intense immunological, endocrinological, metabolic and vascular changes. The concerns of the patient ranges from cosmetic disfigurement to the chance of recurrence of the particular ailment during and in subsequent pregnancy, to its potential effects on fetus in terms of morbidity and mortality[2].In the present study, the age range was 16 to 40 years, with a mean of 24.80 years and SD of 3.913 and majority were between 21 to 25 years of age which corroborates with the study conducted by Panicker et al[4], in which the age of study population ranged from 18 to 38 years with majority being in the 20-25 year age group. The study population in Kumari et al [5] study was between the age group of 18 and 36, with a mean age of 23, which is consistent with the results of this study. In a study conducted by Iffat Hassan et al6, the mean age was 24, similar to the present study. Among the women in the current study, 42% were primigravida and 58% were multigravida. It includes 42 primigravida, 46 cases were gravida two, 10 cases were gravida three and 2 were gravida four. Consequently, majority of them in our study were multigravida [58%]. It is similar to the study conducted by Kumari et al, in their study reported that most of the cases belonged to multigravida [51.1%] and 49.9% were primigravida which is similar to the present study. In the current study, most of the cases were seen in their third trimester [52%], which is line with the studies reported by Shiva kumar et al[7] (61.76%) and Kumari et al5(73.1%). Physiological skin changes were detected in 90% of the cases in the present study. Pigmentary alterations were noted in 90 cases [90%] and the most common one was linea nigra, seen in 89 cases [89%]. These results are in line with the studies reported by Panicker et al and Kumari et al in which the most common pigmentary change was linea nigra observed in 91.4% and 87.67% of patients respectively. Diffuse pigmentation was seen in 51% of the pregnant women in which areola is the site of pigmentation with highest frequency. Melasma was noted in 24% of the cases in our study, which is higher when compared to the studies conducted by Panicker et al [2.16%] and Kumari et al [2.5%]. This can be attributed to increased sun exposure in the labourers, who make up the majority of the study group. Among vascular changes pedal edema was noticed in 19% of the cases in our study. It is more when compared to study conducted by Kumari et al [9.8%] and Panicker et al [10.5%]. Striae gravidarum was observed in 55% of the pregnant women with an onset being more frequent during third trimester in the present study. The prevalence of striae gravidarum in third trimester can be explained by the hormonal factors[2] (adrenocortical hormones, oestrogen, relaxin) and physical factors[8](stretching), might explain the prevalence of striae in third trimester. Kumari et al reported that striae gravidarum was seen in 79.7% of the cases, most commonly in the second trimester.Hirsutism was seen in 2% of the cases in their third trimester. Telogen effluvium was observed in 1% of the cases which is similar to the study conducted by Kumari et al [1.8%].In the present study, we found that 12% of pregnant women had pregnancy specific dermatoses.The most common pregnancy specific dermatoses was PUPPP in the present study seen in 7 cases [7%]. Among them, majority were primigravida [4%]. 5 out of 7 cases presented in the third trimester. The relatively higher incidence of PUPPP in primigravida is supported by the theory that the rapid distension of the abdominal wall in primigravida may cause damage to the connective tissue by converting non antigenic molecule into antigenic ones, thereby inducing an inflammatory reaction [9,10,11].Panicker et al reported that the most common specific dermatoses of pregnancy in their study was PUPPP, seen in 1.3% [n=8] of the cases comparable to our study. In the study conducted by Iffat Hassan et al highest proportion of PUPPP was noticed in primigravida which is similar to the present study. Prurigo of pregnancy was present in 4%[n=4] of cases in the present study and all the 4 cases had the personal history of atopy. In a study conducted by Iffat Hassan et al, prurigo of pregnancy was the most common pregnancy specific dermatoses, observed in 50% of cases with history of atopy in 2/3rd of the patients. Panicker et al reported 3 cases of prurigo of pregnancy among 526 cases (0.5%) and all of them had a history of atopy. Both the studies concords with the present study in terms atopy history. In our study pruritic folliculitis was reported in one case [1%] in a primigravida in her third trimester which is consistent with study of Panicker et al with a single case of pruritic folliculitis [0.16%] with the onset in last trimester. The infections observed in this study was 50%, the most common being fungal infections [30%]. Dermatophyte infections were noted in highest percentage of cases accounting for 19% which is similar to the study conducted by Panicker et al [21.6%]. The second most common was pityriasis versicolor reported in 8% of the patients.Panicker et al reported candidiasis in 21% and Shivakumar in 21.78% of the cases. Candidal infection in the form of vulvovaginitis and intertrigo was observed in 3% of the cases in the present study. The increased prevalence of candidiasis in pregnancy can be due to estrogen mediated increased adhesion of candida to the vaginal epithelium during pregnancy and also to the increased glycogen content in the vaginal milieu[12].Furunculosis was the most common bacterial infection seen in 3% of the cases. One case [1%] of BT leprosy in type 1 reaction was reported with onset of the disease during pregnancy with worsening of the course as detailed in the literature[13].Viral infections noted in our study was 14%. Among them, herpes labialis and varicella were noted in each 5% of the pregnant women respectively. Herpes zoster was observed in 2 cases [2%], as pregnancy being an immunocompromised state can be considered as a risk factor for the occurrence of herpes zoster. Condyloma acuminatum and molluscum contagiosum was detected in each 1% of the cases respectively. Scabies was observed in 2% of the cases in this study.Acne vulgaris was seen in 7% of the cases in our study. Among them 4% [n=4] of the cases had onset of the acne during pregnancy and 3 out of 7 cases had exacerbation of previous lesions. The increased rate of sebum production, as reported in the literature, could be caused by a sebotrophic factor released by the pituitary gland during the final trimester[14]. A single case of insect bite reaction was noted. SLE was noted in one case [1%] with exacerbation of cutaneous manifestations and arthritis which is similar to the studies conducted by Panicker et al and Kumari et al. Complement activation is associated with disease flares during pregnancy[15]. Acanthosis nigricans was noted in 2 cases [2%] in our study. Two cases of neurofibromatosis [2%] with increase in size and number of the lesions was seen in the present study. This is consistent with the literature that suggests neurofibromas may develop de novo or enlarges during pregnancy[3]. Pityriasis rosea was observed in 2% of the cases in the present study. Psoriasis vulgaris was seen in 1% of the cases without any worsening during the course of pregnancy in accordance with the literature[16]. 3% of the cases presented with acute urticaria. Leukocytoclastic vasculitis was noted in a single case [1%] in her third trimester without any complications during the course of pregnancy and delivery. Drug induced maculopapular rash and lichen planus was reported in each 1% of the cases in the current study.

The present study was undertaken to find out the prevalence of cutaneous manifestations during pregnancy. Our study results reveals that the skin changes are very common in the pregnancy and the majority of them are physiological phenomenon, that does not require further management. However, the specific dermatoses of pregnancy are not uncommon that can cause consequential distress to the mother and fetus, that warrants prompt medical attention and therapeutic intervention. Dermatoses like infections can be prevented by maintaining proper personal and environmental hygiene. Maternal viral infections caused by HPV, HSV, Varicella and HIV need timely diagnosis and pertinent treatment to prevent the vertical transmission thereby decreasing the adverse pregnancy outcomes. Miscellaneous dermatoses like autoimmune conditions, connective tissue diseases and pustular psoriasis of pregnancy requires exclusive management and follow up to minimise the maternal and fetal complications.

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