Pregnancy is always associated with unending endocrinological, immunological, metabolic, and vascular changes that certainly affects organs and skin in unique ways. These are physiologic happenings inside the body that can never be stopped and can either be harmless or can cause risks to both mother and baby. Physiological changes are classified into pigmentary changes, hair and nail changes, vascular, and glandular changes. For the dermatologic changes, more than 90% of pregnant women have complex and specific skin changes that can sometimes greatly impact the pregnant mother most specifically psychologically because of its very visible manifestations on the physical aspect of the woman.
One dermatologic occurrence during pregnancy is chloasma gravidarum, or fondly known as the “mask of pregnancy”, a type of skin change is commonly seen among pregnant women and are usually seen on the cheeks, upper lip, chin and forehead. Patterns of this kind of melasma are centrofacial, malar and mandibular and have a clear brownish demarcation. Chloasma initially starts in areas that are already hyperpigmented such as on the nipples, areola, and genital area and is seen in 45-75% of pregnant females. Chloasma is more common in women with moderate-brown Mediterranean skin tone to black skin color (Fitzpatrick skin type 1 or 2).
How does this happen?
Physiologic alterations during pregnancy are brought about by certain proteins and steroid hormones from the fetal-placental unit and the resulting activities of these hormones are much more increased by the mother’s pituitary, thyroid, and adrenal glands. Just like any other conditions, the mechanism by how pregnancy affects the development of this increased pigmentation cannot be pinpointed but it is said that it might probably because of elevated levels of melanocyte-stimulating hormone (MSH) secreted by the pituitary gland, estrogen, and progesterone.
Estrogen is said to stimulate the increase output of melanin by the melanocytes, and this role of estrogen is further augmented by the presence of progesterone, and these hormones are usually elevated in the third trimester of pregnancy. Because of the spike in estrogen and progesteron in the maternal’s circulation, chloasma may not be the only hyperpigmentation that can take place on the skin when pregnant. Freckles, nevi and recent scars may become darker and can enlarge during the period. Another is the occurrence of this hyperpigmented line on the abdomen of the mother, the Linea Nigra. This is found vertically from the pubic bone to the belly button of the pregnant woman, and in some instances can even go all the way up to the chest.
Does this need interventions?
This hyperpigmentation will just gradually disappear after pregnancy. Although, in some cases, it can persist for months and even years and if the woman is taking oral contraceptives, these estrogen-containing pills may induce some hyperpigmentation. Understandably, this can be quite distressing for some women. If necessary interventions are needed topical bleaching creams, retinoids and steroids and other dermatologically supervised treatment may be needed but it has to be properly ordered, closely supervised, monitored, and followed-up as most of it, if not all, are contraindicated to pregnancy and lactation.
Avoidance of too much exposure to the sun can be helpful to prevent further development or exacerbation of the skin discoloration. Strict photoprotection is required. So, one should wear hats, use umbrellas, and apply sunscreens with wide coverage. Clinical effectiveness of sunscreen in one study was considered to be “excellent” by a group of postpartum mothers. In 6 months, an observable improvement was noted in 67% of the 12 volunteers who already had preexisting chloasma. The study used a colorimetric measurement and it showed that, after pregnancy, the woman’s skin was on average less pigmented, thus, resulting in a significantly lighter skin color compared to before.
What if there is already the presence of pre-existing causes of chloasma or any other skin related conditions?
It is very important that pregnant women have to pay their clinicians a visit so their doctors can determine whether skin conditions of any forms during pregnancy are due to pre-existing dermatologic conditions or triggered by pregnancy itself. Due to the overall changes in the maternal circulation during pregnancy there are other forms of skin lesions such as intrahepatic cholestasis of pregnancy, atopic eruption of pregnancy, pemphigoid gestations and some other conditions that can occur which can definitely put the developing infant at risk.
There are skin conditions which are related to pregnancy and there are those that have uncertain relationship association with pregnancy. Although skin conditions may resolve after pregnancy, a few of these can be risky to fetal survival and needs surveillance during and even before pregnancy. Most can be managed but a few needs significant intervention such as in extreme cases where termination of pregnancy is needed. Thorough history assessment and physical examination is very important and will allow us to determine appropriate intervention.
Author: Sarah Catina RN