Skin diseases in pregnancy
Pregnancy-specific dermatoses demand careful diagnosis and tailored therapy. Multidisciplinary care and practical algorithms are essential to support both mothers and infants.
Polymorphic eruption of pregnancy
Prof. Dr. Robert Muellegger (Wiener Neustadt, Austria) opened the session by revisiting polymorphic eruption of pregnancy (PEP), one of the four dermatoses specific to gestation. Although benign and self-limiting, PEP significantly impairs maternal quality of life due to severe pruritus. It typically arises in the third trimester or early postpartum, more often in women with multiple pregnancies, excessive weight gain, IVF conception or male fetuses.
Clinically, PEP presents with urticarial papules and plaques starting in the striae, sparing the periumbilical region (an important distinction from pemphigoid gestationis). No fetal risk is associated, but maternal discomfort is high. Pathogenesis remains debated. Hormonal shifts and mechanical stretching of abdominal skin seem to contribute, as does the immune modulation typical of late pregnancy.
Therapy focuses on symptom control: topical corticosteroids of low-to-medium potency, second-generation antihistamines such as loratadine or cetirizine, and liberal use of emollients. Systemic corticosteroids are reserved for severe cases. Muellegger stressed that appropriate reassurance is key, as the condition invariably resolves postpartum.
Pustular psoriasis of pregnancy
Dr. MD Brigitte Stephan (Hamburg, Germany) addressed pustular psoriasis of pregnancy (PPP), a rare but potentially life-threatening entity. PPP is associated with systemic inflammation, metabolic disturbances and maternal complications including sepsis, heart failure and acute respiratory distress syndrome. Fetal risks include intrauterine growth restriction, prematurity and stillbirth.
Diagnosis requires careful differentiation from infectious pustuloses or drug eruptions. PPP shares features with generalised pustular psoriasis (GPP) but often remits postpartum, suggesting a pregnancy-specific trigger, possibly linked to IL-36 pathway dysregulation.
Treatment must be urgent and multidisciplinary. Systemic corticosteroids (prednisolone) remain first-line. Cyclosporine is a validated alternative, with substantial safety data in pregnancy. Novel agents such as the IL-36 receptor antagonist spesolimab, approved for GPP, may hold promise but remain experimental in pregnancy.
Dr. Stephan emphasised that outcomes for neonates can be unpredictable, and follow-up by neonatologists is crucial when intrauterine exposure to severe inflammation or systemic therapy has occurred.
Biologics in pregnancy
MD Jenny Murase (San Francisco, US) reviewed the evidence on systemic immunomodulators in pregnancy. The key principle is that placental transfer of biologics increases after the second trimester, peaking in the third, which has implications for neonatal exposure.
- TNF inhibitors: overall reassuring safety profiles. Certolizumab, lacking an Fc portion, does not cross the placenta and is preferred when biologics are essential.
- IL-12/23 and IL-17 inhibitors: growing safety data, though experience remains limited.
- Dupilumab: registry data (>50 pregnancies) are encouraging, without safety signals so far.
- JAK inhibitors and apremilast: associated with teratogenicity or miscarriage in preclinical studies, contraindicated.
- Cyclosporine: decades of experience show no increase in malformations; low birth weight may occur.
- Pemphigus therapy: maternal antibodies can affect the neonate; IVIG is a safe option.
Dr. Murase stressed that timing matters: discontinuing biologics before the third trimester can reduce neonatal exposure, but continuing may be justified in women with severe disease where maternal health is at risk.
She also highlighted the importance of vaccination planning: infants exposed in utero to biologics should not receive live vaccines (e.g. BCG) during the first six months of life.
Managing pruritus in pregnancy: common, but not always benign
Dr. Sara Pruneddu (London, UK) concluded with the management of pruritus in pregnancy, a frequent symptom with diverse aetiologies. Structured evaluation is essential: timing of onset, distribution, associated findings and laboratory screening guide the differential.
Key considerations include distinguishing PEP from pemphigoid gestationis, recognising cholestasis of pregnancy, and identifying exacerbations of pre-existing dermatoses such as eczema. Case discussions illustrated successful management of severe eczema flares with cyclosporine and the importance of differentiating pruritic eruptions from infections like varicella.
Dr. Pruneddu also highlighted iron deficiency as an under-recognised contributor to pruritus, with significant improvement after supplementation.
She closed by stressing that managing pruritus often requires close collaboration between dermatologists, obstetricians and hepatologists, ensuring safe outcomes for both mother and child.
Pregnancy and skin diseases: lessons from EADV 2025
The session underscored how pregnancy-specific dermatoses range from benign yet distressing (PEP) to potentially fatal (PPP). The therapeutic landscape for systemic agents is expanding, but robust safety data remain limited. Clinicians must balance effective maternal care with fetal safety, individualise treatment and counsel patients realistically.
Multidisciplinary collaboration (dermatology, obstetrics, rheumatology and neonatology) is essential. As the speakers stressed, pregnancy is not a contraindication to effective therapy, but a call for tailored, evidence-based management.
- Muellegger R. Polymorphic eruption of pregnancy. Session “Pregnancy and skin disease” (Session ID D1T05.2A), EADV Congress 2025, Paris/Virtual, 17 Sept 2025, 16:00–16:20 CEST.
- Stephan B. Pustular eruptions in pregnancy. Session “Pregnancy and skin disease” (Session ID D1T05.2B), EADV Congress 2025, Paris/Virtual, 17 Sept 2025, 16:20–16:40 CEST.
- Murase J. Biologics in pregnancy. Session “Pregnancy and skin disease” (Session ID D1T05.2C), EADV Congress 2025, Paris/Virtual, 17 Sept 2025, 16:40–17:00 CEST.
- Pruneddu S. Management of pruritus in pregnancy. Session “Pregnancy and skin disease” (Session ID D1T05.2D), EADV Congress 2025, Paris/Virtual, 17 Sept 2025, 17:00–17:20 CEST.