Continuing Education Activity
Pruritus during pregnancy represents a common but clinically important symptom that may arise from physiologic changes, exacerbation of preexisting dermatologic disorders, or pregnancy-specific conditions. Hormonal fluctuations, increased skin stretching, and alterations in immune and hepatic function contribute to itching in many pregnant individuals. Clinical presentation ranges from generalized pruritus without visible lesions to cases with primary dermatologic findings or secondary excoriation from persistent scratching. Several pregnancy-specific disorders, including intrahepatic cholestasis of pregnancy and dermatoses of gestation such as Polymorphic Eruption of Pregnancy, may manifest with pruritus and carry potential maternal or fetal risks. Careful evaluation remains essential because early recognition of underlying causes guides appropriate monitoring and treatment strategies.
This activity reviews the epidemiology, pathophysiology, clinical features, and differential diagnosis of pruritus in pregnancy. Participants learn evidence-based approaches for clinical assessment, including identification of warning signs that suggest pregnancy-specific dermatoses or systemic disease. The discussion also highlights diagnostic evaluation, symptom management strategies, and counseling to improve maternal comfort and safety. Emphasis is placed on coordinated care among clinicians, dermatology specialists, obstetric teams, nurses, and pharmacists. Interprofessional collaboration supports accurate diagnosis, timely treatment, and comprehensive monitoring, ultimately improving maternal well-being and fetal outcomes.
Objectives:
Identify the many etiologies of pruritus in pregnancy, including their risk factors, signs, and symptoms.
Assess the appropriate history, physical exam, and evaluation process for patients with pruritus in pregnancy.
Apply evidence-based pharmacological and non-pharmacological interventions to safely and effectively manage pruritus in pregnancy.
Collaborate with an interprofessional health care team to develop comprehensive care plans for pregnant patients with pruritus with the goal of improving maternal-fetal outcomes.
Access free multiple choice questions on this topic.
Introduction
Pruritus is a common symptom of skin barrier-related damage and dry skin. Damage to the skin barrier can result in water loss through the epidermis, activating nerve fibers and causing itching. Scratching can further damage the skin barrier, resulting in additional itching. Topical therapies are first-line treatments, and as the understanding of the etiology of itching improves, new antipruritic therapies are discovered.[1]
Pregnancy, a state of profound physiological and hormonal alterations, is associated with a spectrum of changes in the skin and appendages. More than 90% of pregnant women experience 1 or more forms of skin changes.[2] Among these, pruritus is extremely common. The complete mechanism underlying itching is not entirely understood.[3] Some skin disorders affect specific areas of the body. Vulvovaginal pruritus during pregnancy is one example. Because multiple pregnancy-related and non-pregnancy-related etiologies exist for pruritus in pregnancy, it is essential to distinguish between them. Itching in pregnancy may be the first sign of an underlying disorder that may have deleterious effects on pregnancy and fetal outcomes, including increased maternal and fetal morbidity and even mortality in some cases.
Etiology
Physiologic, mechanical, endocrine, and immunologic changes during pregnancy, increasing pressure from abdominal growth, and edema may all cause itching. Pruritus in pregnancy may also stem from a variety of other processes, including specific dermatoses of pregnancy, which are the afflictions of the skin that appear during pregnancy and resolve with parturition. This is a heterogeneous group of skin diseases. However, pruritus in pregnancy may also be associated with dermatoses that are not unique to pregnancy or ones associated with pre-pregnancy skin processes. During pregnancy, there is an increase in sex hormones, which affects the production of immunoglobulin E, mediator release, and mast cells, all of which contribute further to the problem of pruritus in pregnancy.[3]
Pruritus of Pregnancy that IS NOT Specific to Pregnancy
Etiologies that cause itching in pregnancy but are not specifically related to pregnancy include various diseases, such as renal, hepatic, and thyroid abnormalities, iron deficiency anemia, malignancy, rheumatic diseases, drug reactions, diabetes, infestations, neurologic disorders, primary psychiatric disorders, and systemic infection, such as hepatitis or HIV.[3] The most common cause of generalized itch is dry skin, which affects the entire body without apparent skin lesions.[4]
The following conditions are some of the common causes of pruritus during pregnancy, but are not specific to pregnancy:
Atopic dermatitis is a chronic inflammatory skin disease associated with impaired skin barrier function. Contact with irritants causes eczematous lesions and itching. Affected patients usually have a history of atopy.
[5] Prurigo nodularis is another chronic inflammatory skin disease that results in intensely itchy nodular lesions, leading to constant pruritus and scratching. The pathophysiology of this skin disease is unknown.
[6]Psoriasis is a fairly common, long-lasting, inflammatory skin disease that produces pruritus and affects approximately 2% of people. This condition usually presents with plaques of thick, red, scaly skin.
[7] Historically, psoriasis was not known to cause significant itching, but this notion has been disproven over the past 10 years. Most patients with psoriasis experience some degree of pruritus, commonly affecting the legs, hands, body, back, and scalp.
[8]Notalgia paresthetica is chronic pruritus on the back, located lateral to the thoracic spine, in the interscapular and paravertebral area, and medial or inferior to the scapula. This condition affects women more than men. The pathogenesis is unclear.
Other causes of itching that are not specific to pregnancy include pigmented contact dermatitis, pityrosporum folliculitis, parapsoriasis, neurodermatitis, and primitive cutaneous amyloidosis.
[9]
Vulvovaginal itching is not usually specific to pregnancy and has multiple etiologies, including lichen planus, atopic and irritant contact dermatitis, lichen simplex chronicus, lichen sclerosis, and psoriasis. Vulvovaginal candidiasis is a prevalent cause of itching in this area. Typically, Candida albicans is the underlying pathogen responsible for this itching. Due to increased estrogen levels during pregnancy, vulvovaginal candidiasis is quite common. Parasitic vulvar infestations commonly include pediculosis pubis and scabies. These infestations are commonly sexually transmitted.[10]
Lichenoid vulvar diseases are additional dermatoses that affect the vulvar skin. Lichen sclerosis may involve the vaginal, perineal, and perianal skin. This is an inflammatory dermatosis that is rarely seen during pregnancy.
Lichen planus is an autoimmune disorder that causes pain and intense pruritus in only about 1% of the population. Lichen simplex chronicus is an eczematoid disorder that commonly affects the vulvar skin, resulting in a repetitive itch-scratch cycle.[10] A significant percentage (61%) of pregnant women experience itching that cannot be classified and is termed pruritus of unknown origin.[11]
Pruritus of Pregnancy that IS Specific to Pregnancy
There are 5 dermatoses that are specific to pregnancy. These include pemphigoid gestationis, intrahepatic cholestasis of pregnancy, polymorphic eruption of pregnancy, atopic eruption of pregnancy, and pustular psoriasis of pregnancy. In patients with pruritus in pregnancy, approximately 11.8% to 76.4% will have a dermatosis specific to pregnancy.[3]
Intrahepatic cholestasis of pregnancy
(ICP) is a cause of itching during pregnancy, affecting about 1% of pregnancies worldwide. Associated characteristics include elevated liver enzymes (transaminases) and serum bile acids (salts). The itching begins in the late second and early third trimesters. However, itching can onset as early as 8 weeks of gestation.[12] Other causes of liver abnormalities must be excluded to diagnose ICP. With ICP, pruritus occurs secondary to increased bile acid levels in the skin and serum.
Itching with ICP is usually intermittent at the outset and becomes constant. Pruritus begins first in the abdomen and spreads to involve the entire trunk, and very specifically occurs on the palms and soles. The itching ranges from mild to severe and is most bothersome at night.[13]
Itching is usually the main and only maternal complication of ICP. Icterus, if it does manifest, follows pruritus by at least 4 weeks in about 20% of cases.[14] If icterus is present, patients may develop steatorrhea, leading to fat malabsorption. Symptoms persist throughout pregnancy, resolve with childbirth, and may recur with subsequent gestations.[15] There are usually no long-term maternal consequences.[16]
Atopic eruption of pregnancy (AEP) is another cause of itching in pregnancy and is the most frequent dermatosis seen in pregnancy. AEP is diagnosed in 43% to 49% of women with a pruritic rash during pregnancy.[3] This condition may be associated with a history of atopy in the patient or the patient's family. AEP presents early in pregnancy, frequently as early as the first trimester.
This condition is characterized by discrete papulonodules on the extremities, specifically the extensor surfaces. Lesions are grouped, extremely pruritic, and may be located on the dorsal surfaces of feet and hands. No adverse fetal or maternal outcomes are associated with AEP. The condition may persist until delivery, but does not usually recur in the postpartum timeframe.[17]
Polymorphic eruption of pregnancy (PEP), also called pruritic urticarial papules and plaques of pregnancy, is a very common cause of itching in pregnancy. Almost 22% of patients with itching in pregnancy are diagnosed with PEP. An extremely intense, itchy rash usually begins in the third trimester or sometimes in the postpartum period and is confined to the abdominal striae, with occasional spread to the proximal thighs, buttocks, and chest.
Sparing of the periumbilical area, face, palms, and soles is usual. Urticarial papules with a pale halo surrounding each can be seen.[18] This condition is more common in primiparous individuals, with cesarean delivery, and with increased skin distention, as in multiple gestations.[19] PEP is a benign inflammatory disorder with no associated fetal or maternal risks.[3][20] The itching from PEP is likely due in part to skin stretching that damages collagen, triggering an allergic response.[11]
Pustular psoriasis of pregnancy is a very rare variant of pustular psoriasis that typically presents in the third trimester of pregnancy and often occurs in women with no prior history of psoriasis. The pustules occur on red patches of skin located in the groin, axillae, and inframammary folds. The pustules become large plaques that spread to the trunk and bilateral extremities, sparing the palms, head, and soles.
Mucous membranes, such as the oral and esophageal mucosa, may be involved, leading to painful erosions of the tongue or buccal mucosa. The associated itching is usually mild, but patients may have other symptoms, specifically fever, chills, joint pain, altered mental status, and diarrhea.[18] Lymphadenopathy and malaise may also be present. Elevated white blood cell count and sedimentation rate, and low calcium, phosphorus, and vitamin D levels, may be seen with hyperparathyroidism.[3]
Pemphigoid gestationis is a rare disorder of pregnancy that affects approximately 1 in 50,000 pregnancies. This autoimmune bullous disorder causes pruritus due to an underlying autoimmune process; it usually begins in the second or third trimester. Lesions most commonly involve the extremities but may affect the whole body, sparing the mucous membranes. Tense blisters may develop.
Diagnosis is made by direct immunofluorescence on a skin biopsy, which demonstrates linear C3 deposition along the dermo-epidermal junction.[18] Pemphigoid gestationis commonly improves as pregnancy progresses, but it may flare around the delivery time in 75% of affected patients. A small percentage of newborns will develop skin lesions, called neonatal pemphigoid gestationis, that resolve spontaneously within several days to weeks.
Pregnancy and fetal prognoses are generally unaffected, and the skin condition resolves postpartum. An increased risk of preterm birth and fetal growth restriction may be seen, and correlates with the severity of the skin disorder.[18] Pemphigoid gestationis may recur in future pregnancies.[3]
Epidemiology
Pruritus is reported by 23% to 38% of women during pregnancy, with 2% having severe itching. This burdensome symptom may be the first sign of a pregnancy-specific disease.[21] Approximately 11.8% to 76.4% will have a dermatosis specific to pregnancy as an etiology of their pruritus.[3][11]
On average, itching in pregnancy starts at or just after 27 weeks of gestation. The most common sites for pruritus during pregnancy, in decreasing order, are the abdomen, chest, hands, feet, and lower legs. Itching of the anogenital area is rarely reported in pregnancy, occurring most frequently in the evenings, with half of the affected patients reporting trouble sleeping. Sweat, heat, and dry air frequently exacerbate the itching. The true incidence of pruritus in pregnancy is unknown and is likely higher than previously reported.[11][3]
Pathophysiology
Water loss through the epidermis from skin barrier-related damage leads to a loss of flexibility of the stratum corneum and results in pruritus.[1] Itching is related to the underlying pathophysiology of each specific disease process, as noted above.
Histopathology
Pruritus in pregnancy is likely, to some extent, caused by skin stretching, which stimulates dermal nerve endings.[11] Polymorphic eruption of pregnancy is characterized by nonspecific skin changes. These changes range from mild spongiosis to perivascular lymphocytic infiltration mixed with neutrophils or eosinophils. Dermal edema is evident. Immunofluorescence, both direct and indirect, is negative.[20] The histopathology varies with the stage of the lesions, with nonspecific findings most common.
Pemphigoid gestationis is characterized initially by dermal edema and perivascular infiltration of lymphocytes, histiocytes, and eosinophils. A subepidermal split and bullae follow. Linear deposits of complement 3 are visualized along the basement membrane of the skin adjacent to the lesions in all patients.[20]
Intrahepatic cholestasis of pregnancy is not typically associated with a rash or visible skin changes. Itching commonly occurs on the palms of the hands and the soles of the feet. The exact mechanism by which bile salts (or acids) induce pruritus is not well understood. Due to their detergent-like properties, bile salts can trigger the release of histamine and proteolytic enzymes by solubilizing cellular lipid membranes. The release of histamine and other enzymes can activate free nerve endings, leading to pruritus.[22] The levels of bile acids rise secondary to hormonal and genetic factors. As levels increase during pregnancy, hormones such as estrogen and progesterone exert a cholestatic effect, reducing hepatic excretory function.[13]
Psoriasis results from the production of proinflammatory cytokines following activation of T lymphocytes, leading to inflammation and proliferation of the skin [7]. Genital psoriasis may accompany psoriasis elsewhere on the skin, but 2% to 5% of cases are localized to the vulvar skin.[10] During pregnancy, psoriasis may improve in some patients and worsen in others.
The vulvar skin is very prone to pruritus because the skin's barrier function in this area is weaker than in other areas of the body. Transepidermal water loss is higher in this area, and the skin is more reactive to irritants. An underlying infectious, neoplastic, or inflammatory process may cause vulvovaginal itching.[10]
History and Physical
Itching is an irritating sensation that evokes the impulse to scratch. Evaluating pregnant individuals with itching involves a detailed history and physical examination, focusing on identifying primary skin lesions associated with the itching. The location, timing, and duration of pruritus and any remedies tried should be elicited to help diagnose the cause and provide efficacious treatment. Medication use, pruritus in other family members, and travel history should also be part of the detailed history.[3] Various methods for assessing itching are available. Following the European Guideline on Chronic Pruritus may help discern the etiology of itching. Laboratory evaluation may be beneficial depending on the differential diagnosis under consideration.[11]
Physical examination does not yield evidence of primary lesions in ICP. The diagnosis of ICP is rejected if any primary lesions are present.[23] Excoriations and scratch marks secondary to itching are the only typical findings on examination.
Vulvovaginal itching caused by a yeast infection is characterized by itching, burning, and sometimes dysuria and dyspareunia. Vaginal discharge, vulvar erythema, pustules, or erosions may be present on physical examination. Lichen simplex chronicus is described as varying degrees of erythema and scaling of the vulvar skin with lichenified plaques and excoriations. Burrows in the vulvar area may be seen with scabies, and adult lice and their eggs may be visible with pediculosis pubis.[10]
Evaluation
Pruritus in pregnancy may or may not be associated with primary skin lesions. The presence of primary skin lesions usually indicates a dermatologic disorder. Secondary lesions, including excoriations, lichenification, and hyperpigmentation, are reactive skin changes resulting from scratching and chronic rubbing. Determining the location of the itching and/or lesions is essential. The location may be generalized or localized. The timing of onset, aggravating factors, alleviating factors, and lesion morphology are important when evaluating pruritus in pregnancy.[3]
Initial testing may include liver function tests, complete blood count, basic metabolic panel, thyroid-stimulating hormone, and bile acids. Further workup should be directed by initial findings and may include protein electrophoresis, HIV testing, stool for ova and parasites, and hepatitis testing. Puritis without skin lesions may suggest cholestasis of pregnancy or psychogenic, systemic, or neurologic etiologies. Additional etiologies include nostalgia paresthetica, postherpetic neuralgia, cerebral infarct, vulvodynia, and brachioradialis pruritus.[3]
Treatment / Management
The goal of treatment should be to alleviate symptoms and prevent potential adverse outcomes in the fetus. Mild symptoms may be treated with reassurance, education, psychological strategies, antipruritic topical preparations, and weak steroidal ointments.[1][24] Patients should be advised to avoid anxiety and to wear non-irritating clothing.[25]
Skin barrier-related itching is treated initially with topical therapies, including emollients (water and lipids), corticosteroid creams and ointments, immunomodulators, capsaicin, local anesthetics, and oral and topical antihistamines. Topical therapies, in the form of creams, lotions, or ointments, target areas of the skin near the stratum corneum. A combination of topical and systemic therapies may be needed to stop the itch-scratch cycle. Therapy must then be tailored to the individual patient and underlying cause. A high frequency of recommended use for topical agents and unpleasant side effects are common reasons for noncompliance with use, resulting in the failure of a specific treatment regimen.[1]
Topical steroids are generally considered safe in pregnancy, but high-potency steroids may cause fetal growth restriction, skin thinning, and increased striae. Therefore, mild-to-moderate-potency steroids are recommended topically as initial treatment. If high-potency steroids are needed to control pruritus, limiting the duration of use and avoiding areas of thin skin (specifically the eyelids, axillae, genitals, and skin flexures) is advised.[3]
Topical azoles are minimally absorbed and may safely treat vaginal or topical yeast and fungal infections during pregnancy. Results from studies have shown no association between these topical and vaginal antifungal creams, such as clotrimazole and miconazole, and fetal malformations or increased rates of abortion. The safest oral antifungal agent to use in pregnancy is terbinafine, but low-dose fluconazole (150 mg or less) may also be safely used. Oral azoles, like ketoconazole and griseofulvin, have been linked to potential complications such as spontaneous abortion, fetal eye defects, congenital heart anomalies, and musculoskeletal malformations. Therefore, topical antifungal agents are the preferred treatment in pregnancy.[21]
The data on the safety of medications used to treat pruritus in pregnancy are somewhat limited. First-generation antihistamines such as diphenhydramine, chlorpheniramine, pheniramine, and tripelennamine are generally considered safe during pregnancy and may be used to treat pruritus.[25] Other drugs that may be used, especially for refractory pruritus, include cholestyramine, S-adenosyl-D-methionine, oral corticosteroids, nonerythemogenic ultraviolet B radiation, and phenobarbital. These drugs are used more in the treatment of ICP.
Medications
Polymorphic eruption of pregnancy
Itching from PEP may be treated with low- to mid-potency steroids applied topically. Hydrocortisone 2.5% and desonide 0.05% are examples of low-potency topical steroids, while triamcinolone 0.1%, mometasone 0.1%, or fluocinolone 0.025% are examples of mid-potency steroids that may be used. Emollients and antihistamines, such as chlorpheniramine, loratadine, and cetirizine, may also be used.[19] A short course of systemic corticosteroids or ultraviolet phototherapy may be used to treat intractable itching.[3]
Atopic eruption of pregnancy
Itching from AEP may be treated with antihistamines, mild soaps, emollients, and low- to mid-potency topical steroids. If these therapies do not relieve the xerosis and itching, phototherapy or oral corticosteroids may be necessary.[3][20]
Pemphigoid gestationis
Treatment for itching from pemphigoid gestationis begins with upper- to middle-strength topical steroids. High-potency topical corticosteroids may be used initially to suppress blister formation. If this initial therapy is inadequate, systemic corticosteroids may be recommended, starting at 0.5 mg/kg daily and tapering to a lower daily dose. However, severe itching may require 1 mg/kg to 2 mg/kg per day. Tapering steroids should only start after new blister formation has stopped for at least 2 weeks. Oral antihistamines may be added. Case reports have also used rituximab (only in postpartum women), intravenous immunoglobulin, azathioprine, dapsone, and cyclosporine.[3][20]
Intrahepatic cholestasis of pregnancy
Itching from ICP is initially treated with oral ursodeoxycholic acid 10 mg/kg to 15 mg/kg daily. This treatment not only alleviates pruritus but also lowers serum liver transaminase levels. Ursodeoxycholic acid works by increasing hepatobiliary secretion. Doses up to 20 mg/kg per day are safe in pregnancy. In addition, ursodeoxycholic acid treatment has been shown to reduce stillbirth and preterm birth rates, an additional clinical benefit of treatment. More recently, rifampicin 150 mg to 600 mg daily has been used safely and effectively in the third trimester as a treatment for ICP.[26]
There are increased risks of adverse fetal and neonatal outcomes with ICP, including increased risk of preterm birth, meconium-stained amniotic fluid, neonatal depression, respiratory distress syndrome, and stillbirth.[27] In contrast, maternal risks are small.[28] To reduce the risk of adverse events, the American College of Obstetricians and Gynecologists (ACOG) recommends antenatal surveillance with fetal non-stress tests after viability is reached, beginning at the time of diagnosis of cholestasis and continuing once or twice weekly until delivery [29].
The serum's total bile acid levels determine the recommended delivery timing. For a total bile acid level less than 100 micromol/L, delivery is recommended between 36 0/7 to 39 0/7 weeks of gestation. For a total bile acid level of 100 micromol/L or greater, delivery is recommended at 36 0/7. If the patient is diagnosed with cholestasis at a gestational age later than the recommended gestation for delivery, delivery is recommended at the time of diagnosis.[28][30]
Differential Diagnosis
Primary Skin Lesions Present
Primary Skin Lesions Not Present
Psychogenic disorders
Systemic diseases
Neurologic conditions
Renal abnormalities
Liver abnormalities
Endocrine disorders (thyroid and diabetes)
Iron deficiency anemia
Malignancies
Rheumatic disease
Drug reactions
Systemic infections, such as HIV
Dry skin or xerosis
Intrahepatic cholestasis of pregnancy
Prognosis
Patients should be counseled regarding the temporary nature of the disease and the expected, usually prompt, resolution of their symptoms following delivery, particularly in cases of itching from pregnancy-specific dermatoses. In dermatoses not specific to pregnancy, the prognosis varies based on the etiology of the pruritus. With ICP, the maternal and fetal prognosis is excellent, with increased fetal surveillance, treatment with medications to reduce bile acids, and early delivery per the above recommendations.
Complications
Complications of pruritus in pregnancy vary for the mother and the fetus, depending upon etiology. With ICP, complications to the mother may include malabsorption and/or postpartum bleeding caused by reduced vitamin K levels due to liver abnormalities.[12] A study's results found an increased incidence of gallbladder disease, including cholelithiasis, among those affected.[31]
With ICP, complications to the fetus include premature birth, intrauterine asphyxia, meconium-stained amniotic fluid, and low birth weight.[32] Bile acid levels 40 µmol/L or greater, and particularly more than 100 µmol/L, are statistically significant for increased adverse events in the fetus.[33] Fetal complications are believed to arise from placental anoxia and the possible deleterious effects of high bile acid levels on the fetal heart. However, there remains a limited overall understanding of the pathophysiology and mechanisms underlying the adverse outcomes associated with ICP.[34]
Deterrence and Patient Education
Patients should refrain from scratching as much as possible to avoid secondary lesions and excoriations. Affected individuals are asked to follow up with their clinicians when symptoms are uncontrollable and bothersome. Adherence to treatment regimens is strongly recommended, and patients should be reassured regarding the prognosis.
Enhancing Healthcare Team Outcomes
The care of a patient with pruritus in pregnancy requires an interprofessional team. Healthcare professionals, including obstetricians, maternal-fetal medicine specialists, dermatologists, advanced practice providers, nurses, and pharmacists, must develop clinical skills to effectively manage pruritus during pregnancy. These skills include accurately diagnosing the underlying causes of pruritus, differentiating between pregnancy-related and nonpregnancy-related factors, and applying evidence-based treatments tailored to the patient's condition.
When the etiology of the itching is unclear, a dermatology consultation for possible skin biopsy, followed by recommended treatment regimens, is very helpful to the obstetrician caring for the patient. A hepatologist may also be helpful in some cases. The management team must make the patient as comfortable as possible while monitoring the fetus for potential complications.
The patient should be appropriately counseled regarding complications specific to the disease process underlying the itching. By integrating skills, strategies, responsibilities, interprofessional communication, and care coordination, clinicians can enhance patient-centered care for pruritus in pregnancy. This collaborative approach leads to improved patient outcomes, increased patient safety, and enhanced team performance, ultimately ensuring the well-being of both mother and fetus during pregnancy.
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Disclosure: Karen Carlson declares no relevant financial relationships with ineligible companies.
Disclosure: Moien AB Khan declares no relevant financial relationships with ineligible companies.
