Physiological changes during orengnancy of skin
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Physiological skin changes during pregnancy
Pregnancy-related hormonal, vascular, and connective-tissue changes cause many normal skin findings. Most improve after delivery.
1. Pigmentary changes
- Generalised hyperpigmentation occurs in more than 90% of pregnant women.
- Darkening is especially noticeable in the:
- Areolae and nipples
- External genitalia
- Axillae and neck
- Old scars, freckles, and moles
- Linea nigra: brown-black line in the midline of the abdomen, resulting from pigmentation of the linea alba.
- Melasma (mask of pregnancy or chloasma): symmetrical, blotchy brown pigmentation over the forehead, cheeks, nose, and upper lip. Sun exposure can worsen it.
- Most pigmentation fades postpartum, although melasma can persist.
Creasy & Resnik's Maternal-Fetal Medicine, p. 1713.
2. Connective-tissue changes
- Striae gravidarum (stretch marks): initially red, pink, or purple linear streaks, later becoming pale, atrophic, and silvery.
- Common sites: abdomen, breasts, thighs, buttocks, and hips.
- They result from stretching of skin with alteration and tearing of dermal connective tissue. They are very common in the second and third trimesters.
3. Vascular changes
Due to increased blood volume, vascularity, and estrogen:
- Spider angiomas (spider naevi), often on face, neck, upper chest, and arms.
- Palmar erythema.
- Telangiectasia.
- Varicose veins, particularly in the legs, vulva, and rectum (haemorrhoids).
- Dependent ankle/lower-leg edema may occur due to venous congestion.
- Gingival vascularity can cause swollen, bleeding gums. A benign gingival pyogenic granuloma, called epulis gravidarum, may develop.
Creasy & Resnik's Maternal-Fetal Medicine, pp. 1713-1714.
4. Hair changes
- During pregnancy, hair often appears fuller and less likely to shed, because more follicles remain in the growing (anagen) phase.
- Some women develop increased facial or body hair (mild hirsutism/hypertrichosis).
- After delivery, many follicles enter the resting phase together, causing postpartum telogen effluvium: diffuse hair shedding, usually beginning about 2-4 months after birth and generally resolving over subsequent months.
5. Nail changes
- Nails may grow faster.
- They can become brittle, soft, ridged, or show transverse grooves.
- Onycholysis, leukonychia, and ingrown toenails may occur.
- Uniform pigmentation of several nails can occur and usually fades postpartum. Irregular single-nail pigmentation, especially involving the cuticle, needs medical assessment.
6. Sweat and sebaceous gland changes
- Increased eccrine sweat gland activity can cause excessive sweating and heat rash (miliaria).
- Sebum production may increase, causing oily skin or acne. In some women acne improves instead.
- Montgomery tubercles become prominent: enlarged sebaceous glands on the areola that help lubricate the nipple for breastfeeding.
7. Other common changes
- Skin tags (acrochordons) may appear, especially on the neck, axillae, or groin.
- Existing benign moles may enlarge slightly as the skin stretches. However, a mole with asymmetry, irregular border, varied colour, enlargement, bleeding, or itching should not be assumed to be pregnancy-related and should be examined.
Normal hair, nail, vascular, and glandular changes usually resolve within months after delivery, whereas striae and some pigmentation may remain partially. DermNet's pregnancy skin overview also notes that stretch marks affect up to 90% of women, especially in later pregnancy.
What skin changes in pregnancy are abnormal or need referral?
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Most normal pigmentation, stretch marks, mild acne, skin tags, spider veins, and hair/nail changes do not need referral. Seek assessment for a new, persistent, intensely itchy, blistering, painful, infected-looking, or rapidly changing skin problem.
Same-day contact with maternity unit, obstetrician, or clinician
1. Itching without a primary rash, especially palms and soles
This can indicate intrahepatic cholestasis of pregnancy (ICP), particularly if itching is severe, worse at night, or begins in the second or third trimester. There may be only scratch marks, with no true rash.
- It needs prompt blood tests, including liver function tests and serum bile acids.
- Seek urgent assessment if there is jaundice, dark urine, pale stools, or reduced fetal movements.
- ICP can pose fetal risk and requires obstetric follow-up. Creasy & Resnik’s Maternal-Fetal Medicine, p. 1713. The RCOG ICP guideline classifies ICP by peak bile-acid concentration and guides maternal-fetal care.
2. Blisters or widespread peeling skin
Tense blisters, particularly itchy lesions beginning around the umbilicus and spreading over the trunk or limbs, may be pemphigoid gestationis, an autoimmune pregnancy dermatosis. This requires urgent obstetric and dermatology review. Diagnosis often needs a skin biopsy with direct immunofluorescence.
Creasy & Resnik’s Maternal-Fetal Medicine, p. 1714.
Creasy & Resnik’s Maternal-Fetal Medicine, p. 1714.
Also seek urgent care for blistering with fever, mouth/eye/genital sores, widespread skin pain, or skin peeling, as these features may reflect a serious drug reaction or infection.
3. Rash with fever or feeling unwell
Urgent medical assessment is needed for a rash accompanied by:
- Fever, severe headache, stiff neck, breathlessness, or marked malaise
- Rapidly spreading redness, warmth, swelling, pus, or severe tenderness, suggesting cellulitis
- Painful grouped blisters, especially near the eye or widespread, which may be herpes zoster or herpes simplex
- A non-blanching purple/red rash, bruising-like spots, or bleeding into the skin
These are not expected physiological pregnancy changes.
Prompt, non-emergency review
4. Severe or generalised itchy rash
A clinician should distinguish common, usually benign pregnancy eruptions from conditions requiring monitoring.
- PUPPP / polymorphic eruption of pregnancy: very itchy red papules or hive-like plaques, often beginning within abdominal stretch marks in late pregnancy and spreading to thighs/buttocks. It is generally not dangerous to the fetus, but needs assessment to exclude other causes.
- Atopic eruption/prurigo of pregnancy: itchy eczema-like areas or scratch papules, often earlier in pregnancy.
- A rash affecting the umbilicus, or progressing to blisters, makes pemphigoid gestationis more likely than PUPPP.
The ACOG overview identifies PUPPP, prurigo, pemphigoid gestationis, and ICP as important pregnancy-related skin conditions.
5. New or changing pigmented lesion
Refer for skin examination if a mole or pigmented spot shows:
- Asymmetry
- irregular Border
- varied Colour
- increasing Diameter or change over time
- bleeding, ulceration, persistent itching, or a non-healing sore
Pregnancy can darken skin and make existing moles appear larger as skin stretches, but it should not be used to dismiss suspicious lesions. Creasy & Resnik’s Maternal-Fetal Medicine, p. 1713.
6. Marked facial or hand swelling with other symptoms
Rapid swelling of the face or hands, especially with headache, visual disturbance, upper abdominal pain, nausea, or high blood pressure, needs urgent maternity assessment for possible pre-eclampsia. Mild ankle swelling alone is common, but sudden or severe swelling is not something to self-manage.
Emergency care now
Go to emergency care or contact emergency maternity services for rash/skin symptoms with:
- Difficulty breathing, lip/tongue swelling, faintness, or widespread hives
- Severe skin pain, extensive blistering/peeling, or mucosal involvement
- Fever and rapidly spreading red skin
- Jaundice with significant illness
- Reduced fetal movements, vaginal bleeding, or severe abdominal pain.
If you have itching or a rash now, the key details are: weeks of pregnancy, whether there are blisters, whether the palms/soles itch, and whether there is fever or reduced fetal movement.
Clinical significance of skin changes in pregnancy
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Clinical significance of skin changes in pregnancy
Skin changes in pregnancy are clinically important because they may be:
- Normal physiological effects of hormones and increased blood flow
- Markers of systemic disease or pregnancy complications
- Specific dermatoses of pregnancy, some of which carry fetal risk
- Alterations in pre-existing skin disease, requiring safe treatment choices
1. Reassurance and recognition of normal changes
Hyperpigmentation, linea nigra, melasma, striae, spider angiomas, palmar erythema, mild acne, skin tags, increased hair growth, and postpartum hair shedding are usually benign.
Their recognition:
- Prevents unnecessary investigations and anxiety.
- Allows appropriate counselling that most fade after delivery.
- Identifies changes that may have cosmetic persistence, especially striae and melasma.
Hyperpigmentation is common, occurring in at least 90% of pregnancies; most pigmentary and vascular changes regress after delivery. Creasy & Resnik's Maternal-Fetal Medicine, p. 1713.
2. Detection of obstetric cholestasis
Severe generalised itching without a primary rash, particularly on the palms and soles and worse at night, is clinically significant because it may indicate intrahepatic cholestasis of pregnancy (ICP).
- The skin may show only scratch marks.
- It requires assessment of bile acids and liver function.
- ICP has important fetal implications, so it requires obstetric follow-up and monitoring.
- Jaundice, dark urine, pale stools, or reduced fetal movement make assessment more urgent.
Thus, pruritus in pregnancy should not automatically be labelled as a simple skin problem. Creasy & Resnik's Maternal-Fetal Medicine, p. 1713. The RCOG guidance on ICP defines and stratifies the disorder by serum bile-acid levels.
3. Identification of pregnancy-specific dermatoses
An itchy eruption may represent one of several pregnancy dermatoses:
| Condition | Clinical significance |
|---|---|
| Polymorphic eruption of pregnancy / PUPPP | Very itchy papules and plaques, often in abdominal striae late in pregnancy. Distressing but generally benign for mother and fetus. |
| Atopic eruption/prurigo of pregnancy | Common itchy eczema-like lesions or papules. Mainly affects maternal comfort; usually no major fetal risk. |
| Pemphigoid gestationis | Itchy periumbilical rash that may progress to tense blisters. Autoimmune condition requiring dermatology and obstetric assessment because of associations with adverse pregnancy outcomes and neonatal lesions. |
| Pustular psoriasis of pregnancy | Rare but potentially severe systemic illness with fever and pustules. Requires urgent specialist and obstetric care. |
Severe pruritus with lesions needs a careful clinical assessment because some pregnancy dermatoses have fetal implications. Dermatology, 2-Volume Set, 5e, section “Approach to the Pregnant Woman with Pruritus.”
4. Recognition of systemic disease
Some apparent skin changes are clues to illnesses unrelated to normal pregnancy:
- Jaundice or itch without rash: cholestasis, hepatitis, biliary obstruction, or other liver disease.
- Velvety darkening of neck/axillae: consider acanthosis nigricans and assess for diabetes or endocrine disease rather than assuming normal pigmentation.
- Marked edema with sudden facial/hand swelling, headache, visual symptoms, or upper abdominal pain: assess urgently for pre-eclampsia.
- Painful, hot, spreading redness, pus, fever: possible skin/soft-tissue infection.
- Changing pigmented lesion, non-healing ulcer, bleeding mole: investigate for melanoma or another skin cancer. Pregnancy should not delay evaluation.
5. Review of existing skin conditions and medications
Pregnancy may improve, worsen, or unpredictably alter diseases such as acne, atopic dermatitis, psoriasis, lupus, and autoimmune blistering disease. Most skin diseases do not directly affect fetal outcome, but treatment must be reviewed for fetal safety.
Creasy & Resnik's Maternal-Fetal Medicine, p. 1714.
Creasy & Resnik's Maternal-Fetal Medicine, p. 1714.
Practical summary
The main clinical value of examining skin in pregnancy is to distinguish benign physiological change from signs requiring action:
- Itch without rash: exclude ICP.
- Blisters: exclude pemphigoid gestationis.
- Pustules, fever, or systemic illness: urgent specialist assessment.
- Rapidly changing pigmented lesion: assess for malignancy.
- New severe edema with systemic symptoms: assess for pre-eclampsia.
The ACOG pregnancy skin guidance similarly distinguishes common hormonal changes from PUPPP, prurigo, pemphigoid gestationis, and ICP.
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