Title : Can pregnancy improve or exacerbate atopic dermatitis? Considerations for management of skin sequelae in the context of global health inequities
Abstract:
Globally, atopic dermatitis (AD) is the most common skin disorder in pregnancy and accounts for 36-59% of obstetric skin disease. The pathogenesis of AD in pregnancy is unclear. The prevailing theory suggests the immunity shift from Th-1 to Th-2 during pregnancy leads to AD exacerbations in gravid patients. Surprisingly, AD improves during pregnancy for some. The impact of AD must also be contextualized by a health equity lens, given its increased prevalence and severity in Black and Latinx populations. While clinical understanding of AD during pregnancy is unclear, current understanding of its disproportionate impact on gravid patients of color remains obscure. A systematic review of Pubmed and Web of Science was conducted. Keywords included atopic dermatitis, eczema, pregnancy, and persons of color. Approximately 100 studies were reviewed and 22 studies were selected based on relevance after review of titles and abstracts. In total, 11 manuscripts met inclusion criteria which included the following: (1) published in English and (2) discussed the AD course in pregnancy, (3) treatment for AD in pregnancy, or (4) AD in melanin-rich skin. Results suggested that 30-50% of gravid patients with pre-existing AD experienced an exacerbation of symptoms while 20% experienced improvement. Literature on the pathogenesis maintained that the progression of AD during pregnancy is due to a transition from cell-mediated to humoral immunity. Few studies explored treatment modalities for gravid populations. There was minimal data on the unique sequelae of AD in melanin-rich patients. Current literature indicates the shift from a Th1 to Th2 immune response, fueled by the increase in estrogen and progesterone, can exacerbate pre-existing AD and cause de novo AD in gravid patients. Clinical understanding regarding the associated predisposing factors is even less clear, complicating providers’ ability to identify at-risk individuals. Maternal AD is positively associated with premature rupture of membranes, staphylococcal neonatal septicemia, staphylococcal infections in the gravid patient. Untreated and poorly controlled AD leads to increased maternal stress which elevates risk of fetal AD development. Treating AD is well-established for the non-gravid patient. Data on treatment modalities for AD in pregnancy is sparse, likely due to difficulties in researching gravid populations for maternal and fetal safety concerns. Options for preferred treatment strategies are biased as some clinicians are conservative with AD management in gravid patients. Some patients report hesitancy in continuing their prepartum dermatological medications during pregnancy for fear of harming the fetus. This underscores the need for providers to counsel patients prepartum about progression, safe treatments, and for this counseling to become a fixture in prepartum protocol. There remains many questions regarding why 1 in 5 pregnant patients with AD experience an improvement of symptoms suggesting an avenue of exploration for improved treatment options and disease management. AD poses a disproportionate burden of disease among communities of color. However, the paucity of data on the disease progression and impact on gravid patients of color leaves uncertainty about this widening health inequity. Ongoing assessment with a global health equity lens will enable personalized prepartum AD guidance and management for all patients.
Audience Take Away Notes:
- Understand how pregnancy can exacerbate or improve atopic dermatitis and the underlying pathophysiology of its diverse disease courses in the gravid patient
- Explore the maternal and fetal complications linked to prepartum atopic dermatitis
- Discuss available treatment options for atopic dermatitis during pregnancy and their respective safety profiles
- Feel empowered to offer accurate and comprehensive prenatal guidance on atopic dermatitis to patients post-presentation
- Understand the global health inequities associated with atopic dermatitis and its impacts on communities of color
