Pregnancy induces a myriad of physiological changes, encompassing immunological, metabolic, endocrine, and vascular systems, which collectively influence the integumentary system. These alterations often manifest as cutaneous changes, broadly categorized into physiological skin modifications, exacerbation of pre-existing dermatological conditions, and specific dermatoses unique to pregnancy [1, 2]

Physiological skin changes are prevalent, with hyperpigmentation being the most common, observed in up to 90% of pregnancies. This includes conditions such as melasma and linea nigra. Striae gravidarum, commonly known as stretch marks, and vascular changes like spider angiomas and palmar erythema are also frequently reported [2-4]

Specific dermatoses of pregnancy (SDP) constitute a heterogeneous group of pruritic inflammatory skin disorders that occur exclusively during pregnancy or the immediate postpartum period. The major entities include atopic eruption of pregnancy (AEP), polymorphic eruption of pregnancy (PEP), pemphigoid gestationis (PG), and intrahepatic cholestasis of pregnancy (ICP). Among these, AEP is reported as the most prevalent, with studies indicating an incidence ranging from 4.8% to 9% among pregnant women. PEP, also known as pruritic urticarial papules and plaques of pregnancy (PUPPP), is another common condition, with incidence rates varying between 1% and 14.7%. Although less frequent, PG and ICP are associated with significant maternal and fetal risks, including preterm delivery and fetal distress [4-7]. ​

The prevalence and clinical spectrum of these dermatoses exhibit considerable variation across different populations and geographic regions. In the Indian context, studies have reported varying frequencies of pregnancy-specific dermatoses. For instance, a study from Northeast India documented a 13% prevalence of pregnancy-specific dermatoses, with AEP being the most common at 9%. Conversely, research from South India reported PEP as the predominant specific dermatosis. These discrepancies underscore the influence of genetic, environmental, and cultural factors on the manifestation of pregnancy-associated dermatoses [5-9].​  

Despite the recognition of these conditions, there remains a paucity of comprehensive data delineating the prevalence and clinical profiles of pregnancy-associated dermatoses among Indian women. Such information is crucial for early diagnosis, appropriate management, and counseling to mitigate potential adverse maternal and fetal outcomes. This study aims to bridge this knowledge gap by evaluating the prevalence and clinical characteristics of pregnancy-associated dermatoses in a cohort of Indian women, thereby contributing to the existing body of literature and informing clinical practice.

Study Design and Setting

This was a hospital-based, cross-sectional observational study conducted over a period of one year, from March 2019 to Feb 2020, at the Department of Dermatology in collaboration with the Department of Obstetrics and Gynaecology, at a tertiary care teaching hospital in South India.

Study Population and Sampling

A total of 412 pregnant women attending the antenatal outpatient department or admitted to the obstetric wards during the study period were enrolled. Consecutive sampling was used to recruit participants who met the eligibility criteria. Each subject underwent a comprehensive dermatological evaluation and obstetric assessment.

Inclusion Criteria

All pregnant women, irrespective of age, parity, or gestational age, who presented with new-onset cutaneous changes or dermatoses during the course of pregnancy were eligible for inclusion in the study. Participation was voluntary, and only those who provided written informed consent after understanding the study’s purpose and procedures were enrolled.

Exclusion Criteria

Women were excluded from the study if they had any pre-existing diagnosed dermatological disorders prior to conception, such as psoriasis, eczema, vitiligo, or chronic urticaria. Additionally, those with systemic illnesses known to independently affect the skin, including diabetes mellitus, autoimmune diseases, or thyroid dysfunction, were also excluded. Furthermore, women who refused or were unable to provide informed consent were not included in the study.

Clinical Assessment

A detailed medical and obstetric history was obtained from each participant, including information on demographic profile, gestational age, gravida, parity, and any previous history of similar skin changes. A thorough dermatological examination was then conducted by a trained dermatologist to assess the morphology, distribution, and type of skin lesions. Based on clinical findings, the dermatoses were classified into three categories: physiological skin changes of pregnancy, specific dermatoses of pregnancy (such as PUPPP, prurigo, atopic eruption of pregnancy, pemphigoid gestationis, and intrahepatic cholestasis of pregnancy), and pre-existing dermatoses exacerbated by pregnancy. In cases where clinical diagnosis was inconclusive, relevant laboratory investigations—including liver function tests, serum bile acid levels, and histopathological examination through skin biopsy—were performed, particularly in suspected cases of intrahepatic cholestasis of pregnancy or pemphigoid gestationis.

Ethical Considerations

The study protocol was approved by the Institutional Ethics Committee. All participants were enrolled after providing written informed consent. Privacy and confidentiality were strictly maintained throughout the study. Participation was voluntary, and subjects were free to withdraw at any time without affecting their standard clinical care.

Statistical Analysis

Data were collected using a structured pretested proforma and entered into Microsoft Excel for initial processing. Descriptive statistics were used to summarise demographic variables and clinical findings. Categorical variables such as the type and frequency of dermatoses were expressed as numbers and percentages. Continuous variables such as age and gestational age were summarised as means and standard deviations. Data analysis was performed using SPSS software (V.25). Chi-square test and Fisher’s exact test were used to examine associations between dermatoses and obstetric parameters, with a p-value of <0.05 considered statistically significant.

A total of 412 pregnant women were enrolled in the study over a one-year period. Among them, 157 women (38.1%) were diagnosed with pregnancy-associated dermatoses (PADs). The majority of these cases were classified as specific dermatoses of pregnancy, while the remainder included physiological skin changes and exacerbation of pre-existing dermatoses.

Among the specific dermatoses (Table 1), PUPPP was the most prevalent condition, observed in 64 women (40.8%). This was followed by Prurigo of Pregnancy in 35 women (22.3%), Intrahepatic Cholestasis of Pregnancy (ICP) in 27 cases (17.2%), Atopic Eruption of Pregnancy (AEP) in 19 cases (12.1%), and Pemphigoid Gestationis in 6 women (3.8%).

Table 1: Specific Dermatoses of Pregnancy

The trimester-wise distribution showed that PADs were most commonly reported during the third trimester, accounting for 91 cases (57.9%). This was followed by 51 cases (32.5%) in the second trimester and 15 cases (9.6%) in the first trimester (Table 2)

Table 2: Trimester-wise Distribution of PADs

Obstetric complications were recorded predominantly in cases of ICP. Among the 27 women with ICP, preterm labour was observed in 6 cases (22.2%) and fetal growth restriction (FGR) in 4 cases (14.8%) (Table 3).

Table 3: Obstetric Complications in ICP Cases

Overall, the study demonstrated that specific dermatoses of pregnancy are common in Indian women, with PUPPP being the most frequent condition, particularly in the third trimester. While most PADs were benign, conditions like ICP were associated with significant maternal and fetal morbidity.

The present cross-sectional study explored the prevalence and clinical characteristics of PADs in a cohort of Indian women attending a tertiary care hospital over a one-year period. Our findings revealed that 38.1% of the pregnant women evaluated presented with dermatological manifestations directly or indirectly related to pregnancy. This prevalence is consistent with previously reported data from similar demographic settings, suggesting that nearly one-third to two-fifths of all pregnant women may experience skin-related alterations during gestation, particularly in the late second and third trimesters [10-13].

Among the spectrum of dermatoses documented, Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP) emerged as the most prevalent specific dermatosis, affecting 64 of 157 women (40.8%) diagnosed with PADs. This aligns with findings from multiple Indian and international studies where PUPPP, also known as polymorphic eruption of pregnancy (PEP), is frequently reported as the dominant gestational dermatosis. PUPPP typically presents in primigravidas during the third trimester, often associated with excessive abdominal wall stretching [13-17]. The pathophysiology is thought to involve dermal connective tissue damage and inflammation triggered by rapid distension, although hormonal and genetic factors may also contribute.

The second most common condition, Prurigo of Pregnancy, was observed in 22.3% of the affected women. This condition tends to present earlier in pregnancy and is often associated with a personal or family history of atopic disorders. Prurigo may persist post-partum and tends to be more resistant to conventional symptomatic treatment compared to PUPPP. It is now considered under the broader category of Atopic Eruption of Pregnancy (AEP) in some modern classifications, which also includes eczematous and papular lesions in atopically predisposed individuals. In our cohort, AEP accounted for 12.1% of PADs, consistent with regional variability reported in Indian and Southeast Asian populations. AEP often begins in the first or second trimester and may recur in subsequent pregnancies.

Intrahepatic Cholestasis of Pregnancy (ICP) was identified in 17.2% of the affected women and was notable not only for its pruritic presentation but also for its association with adverse obstetric outcomes. In our study, preterm labour occurred in 22.2%, and fetal growth restriction in 14.8% of the ICP cases. These findings underscore the systemic implications of ICP, attributed to elevated bile acid levels affecting placental function and fetal well-being. As supported by current literature and clinical guidelines, early detection and regular monitoring of bile acid levels are crucial for reducing the risk of complications such as intrauterine fetal demise.

A small subset of women (3.8%) presented with Pemphigoid Gestationis, a rare autoimmune bullous dermatosis with significant implications for both mother and fetus. It typically appears in the late second or third trimester and may flare post-partum. The diagnosis in our study was established based on clinical features and supported by histopathological and immunofluorescence findings. Although uncommon, this condition carries a higher risk of preterm delivery and transient neonatal lesions due to passive transplacental transfer of maternal autoantibodies.

Analysis of the trimester-wise distribution revealed a clear predominance of PADs in the third trimester (57.9%), followed by the second (32.5%) and first (9.6%). This distribution is congruent with previous reports suggesting that the peak incidence of pregnancy dermatoses coincides with maximal hormonal fluctuations, immunological adaptations, and physical changes such as increased abdominal girth. This temporal pattern may aid clinicians in anticipating and proactively screening for skin changes during routine antenatal care, especially in high-risk pregnancies.

Notably, while most of the dermatoses were self-limiting and benign, a subset such as ICP and pemphigoid gestationis warranted multidisciplinary management due to their potential systemic and fetal implications. This highlights the importance of incorporating dermatological assessment into antenatal care protocols, particularly in resource-limited settings where such conditions may be underdiagnosed or misclassified.

From a broader perspective, this study contributes to the growing body of regional data on PADs, which remain underreported and often underestimated in India. While several studies from urban academic centres have explored pregnancy dermatoses, data from semi-urban or rural tertiary care institutions are sparse. The findings of our study emphasize the need for awareness, early recognition, and evidence-based management of PADs to mitigate maternal discomfort and prevent adverse neonatal outcomes.

Limitations

This study was conducted at a single tertiary care institution, which may limit the generalizability of findings to broader populations. In addition, the lack of long-term post-partum follow-up restricted the evaluation of recurrence and chronicity of dermatoses, particularly in conditions like AEP and PG. Future multicentric studies with longitudinal follow-up are recommended to capture the full spectrum of cutaneous changes across pregnancy and the postpartum period.

Pregnancy-associated dermatoses (PADs) are common and clinically significant conditions that affect a substantial proportion of pregnant women, as observed in our study where 38.1% of participants exhibited such manifestations. While many dermatoses, such as PUPPP and atopic eruption of pregnancy, are benign and self-limiting, others like intrahepatic cholestasis of pregnancy and pemphigoid gestationis require timely recognition and management due to their potential implications for maternal and fetal outcomes. The third trimester emerged as the period with the highest burden of specific dermatoses, underscoring the need for enhanced dermatological surveillance during this phase. Integrating routine dermatological evaluation into antenatal care protocols can facilitate early diagnosis, appropriate intervention, and improved obstetric outcomes.

Acknowledgements

The authors extend their sincere gratitude to the Department of Dermatology and the Department of Obstetrics and Gynaecology at the participating tertiary care hospital for their cooperation and clinical support. We are thankful to all the study participants for their willingness to contribute and for their trust throughout the study period. Special thanks to the data entry and nursing teams for their assistance in coordinating patient evaluations and follow-up.

Conflict of Interest

The authors declare that there are no conflicts of interest relevant to this study.

Funding Source

This study was conducted without any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The research was self-funded by the investigators.

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