is one such skin condition that may develop during this period. It is characterized by itchy skin papules, often appearing on the limbs. Severe itching may disrupt sleep and cause persistent discomfort.The importance of this condition lies in recognizing its clinical features and distinguishing it from other pregnancy-related skin disorders, particularly those associated with potential complications affecting the mother or fetus, such as intrahepatic cholestasis of pregnancy. Accurate diagnosis and appropriate management are therefore essential to relieve symptoms and improve the pregnant woman's quality of life while prioritizing maternal and fetal safety.This article on Medical Guide aims to provide an overview of prurigo of pregnancy by exploring its definition, causes, and contributing factors; identifying its symptoms and clinical characteristics; explaining diagnostic approaches; and reviewing the available treatment options for managing the condition during pregnancy.

1. What Is Prurigo of Pregnancy?

   Prurigo of pregnancy is a skin condition that may develop during pregnancy and is characterized by small, intensely itchy skin papules. It most commonly appears during the second or third trimester and may cause significant discomfort and interfere with sleep. The condition usually improves after childbirth, although the time required for symptoms to resolve varies from one woman to another.

   Is Itching During Pregnancy Normal?

   Yes. Mild itching is common during pregnancy and is often associated with skin stretching or dryness caused by pregnancy-related changes. However, not all itching should be considered normal, particularly when it is severe or persistent, worsens at night, or primarily affects the palms of the hands and soles of the feet. These symptoms may indicate a condition requiring medical evaluation, such as intrahepatic cholestasis of pregnancy.

   When Does Itching Begin During Pregnancy?

   Itching can occur at any stage of pregnancy, and the timing varies depending on the underlying cause. Itching associated with skin stretching may develop as the pregnancy progresses and the abdomen grows. Intrahepatic cholestasis of pregnancy, on the other hand, most commonly develops during the second or third trimester, although it can occur earlier.

   Does Prurigo of Pregnancy Affect the Baby?

   The effect of itching on the baby depends on its underlying cause. Itching caused by dry or stretched skin does not usually pose a direct risk to the fetus. However, intrahepatic cholestasis of pregnancy may be associated with an increased risk of complications, including preterm birth and fetal distress. In severe cases, the risk of stillbirth may increase, particularly when bile acid levels in the blood are significantly elevated.

   It is important to distinguish prurigo of pregnancy from intrahepatic cholestasis of pregnancy, as these are different conditions. Accurate differentiation is essential for establishing the correct diagnosis and selecting appropriate treatment.

   How Is Prurigo of Pregnancy Diagnosed?

   The diagnosis of prurigo of pregnancy is based on clinical symptoms and a skin examination. Additional tests may be necessary to rule out other conditions that cause itching during pregnancy.

   Diagnostic steps may include:

   Pregnant women should inform their obstetrician about any previous history of severe itching or intrahepatic cholestasis of pregnancy. Early medical evaluation is particularly important if symptoms recur, helping ensure an accurate diagnosis and appropriate monitoring of both maternal and fetal health.

   What Are the Types of Pregnancy-Related Itching Disorders?

   Several skin conditions can cause itching during pregnancy. They differ in their timing of onset, rash characteristics, symptom severity, and potential effects on maternal and fetal health.

   The main conditions include the following:

   1. Atopic Eruption of Pregnancy (AEP)

   Atopic eruption of pregnancy is a relatively common pregnancy-related skin condition that often develops during the first or second trimester.

   2. Polymorphic Eruption of Pregnancy (PEP/PUPPP)

   Polymorphic eruption of pregnancy, also known as pruritic urticarial papules and plaques of pregnancy (PUPPP), is a benign skin condition that usually develops during the third trimester, particularly in first-time pregnancies.

   3. Pemphigoid Gestationis (PG)

   Pemphigoid gestationis is a rare autoimmune skin disease associated with pregnancy. It may begin during the second or third trimester, although it can develop at other stages.

   Treatment: Specialized medical assessment is required. Treatment may include topical or systemic corticosteroids, depending on the severity of the condition, along with appropriate pregnancy monitoring.

   4. Intrahepatic Cholestasis of Pregnancy (ICP)

   Intrahepatic cholestasis of pregnancy is a liver disorder that develops during pregnancy and is characterized by elevated bile acid levels in the blood. It most commonly occurs during the second or third trimester.

   • Clinical skin examination: To assess the characteristics of the rash, identify the papules and their distribution, and look for signs of other skin disorders.

   • Blood bile acid testing: To help detect intrahepatic cholestasis of pregnancy when suspected.

   • Liver function tests: To evaluate liver health and identify abnormalities that may be associated with itching.

   • Symptoms: Dry skin, eczema-like patches, or itchy skin papules.

   • Common locations: The face, neck, skin folds, and limbs.

   • Associated factors: A previous history of eczema or a predisposition to allergic conditions.

   • Effect on pregnancy: It is not usually associated with serious fetal complications.

   • Treatment: Includes skin moisturizers, avoiding irritants, and using pregnancy-appropriate topical treatments as recommended by a doctor.

   • Symptoms: Itchy red papules that typically begin within the stretch marks on the abdomen.

   • Distribution: The rash may spread to the thighs and buttocks, while the area around the navel usually remains unaffected.

   • Effect on pregnancy: It is not usually associated with an increased risk of fetal complications.

   • Treatment: Includes moisturizers and, when appropriate, topical corticosteroids or pregnancy-compatible antihistamines under medical supervision.

   • Prognosis: The condition usually improves after childbirth and gradually resolves.

   • Symptoms: The condition may initially cause severe itching and a rash around the navel, followed by the development of tense skin blisters.

   • Cause: It is associated with an autoimmune response targeting components at the junction between the skin layers.

   • Effect on pregnancy: It may be associated with an increased risk of preterm birth and low birth weight.

   • Diagnosis: Based on clinical examination and may require a skin biopsy and specialized immunological tests.

2. Symptoms: Intense itching, particularly on the palms of the hands and soles of the feet, often worsening at night.

3. Skin findings: There is usually no primary skin rash, although scratch marks and abrasions may develop due to repeated scratching.

4. Diagnosis: Based on blood bile acid measurements and liver function tests. Repeat testing may be necessary if symptoms persist.

5. Effect on pregnancy: It may increase the risk of preterm birth and fetal complications. The level of risk depends significantly on the concentration of bile acids.

6. Treatment and monitoring: Requires assessment by an obstetrician. Ursodeoxycholic acid may be used to relieve symptoms in some cases, alongside maternal and fetal monitoring and decisions about delivery timing based on the level of risk.

5. Generalized Pustular Psoriasis of Pregnancy (GPPP)

Historically known as impetigo herpetiformis, this is a rare but potentially serious skin condition that requires urgent medical assessment.

Symptoms: Small, sterile pustules, meaning they are not necessarily caused by a bacterial infection, appearing on red and inflamed skin.

Common locations: The rash often begins in skin folds and may spread across large areas of the body.

Associated symptoms: These may include fever, fatigue, electrolyte disturbances, and systemic complications in severe cases.

Effect on pregnancy: Severe or untreated disease may pose risks to both the mother and fetus.

Treatment: Requires urgent assessment by dermatology and obstetric specialists, with monitoring of the mother's general condition and laboratory results and selection of appropriate treatment.

If initial test results are normal but itching persists, the doctor may recommend repeating the investigations because itching can precede detectable abnormalities in bile acid levels and liver function tests.

Does Itching Disappear After Childbirth?

Whether itching resolves depends on its underlying cause. In many pregnancy-related skin disorders, symptoms gradually improve after delivery and may disappear completely.

In cases of intrahepatic cholestasis of pregnancy, itching usually improves after childbirth, and bile acid levels and liver enzymes gradually return to normal. This may take several weeks, so follow-up blood tests are recommended to confirm that the condition has resolved.

Can Prurigo of Pregnancy Recur in a Subsequent Pregnancy?

The likelihood of recurrent itching varies depending on the underlying condition. Some pregnancy-related skin disorders may recur, while intrahepatic cholestasis of pregnancy is known to have a relatively high recurrence risk in subsequent pregnancies.

Causes of Prurigo of Pregnancy

Several factors may contribute to the development of prurigo of pregnancy, including pregnancy-related immune and skin changes, a predisposition to atopic conditions, and skin dryness.

It is important to distinguish prurigo of pregnancy as a skin disorder from other conditions that cause itching during pregnancy, such as polymorphic eruption of pregnancy and intrahepatic cholestasis of pregnancy.

First: Causes and Contributing Factors

1. Immune and Skin Changes During Pregnancy

The immune system undergoes natural changes during pregnancy to accommodate the developing fetus. These changes may affect how the skin responds to irritants and inflammation.

They may contribute to the development of itchy papules or worsen certain skin conditions, particularly in women who are predisposed to atopic disorders.

2. Dry Skin and Loss of Moisture

Dry skin may increase itching, and the skin changes associated with pregnancy can make dryness more likely. Hot showers, fragranced soaps, and exposure to irritating substances may further aggravate symptoms.

3. Genetic Predisposition and a History of Allergies

A predisposition to atopic itching or certain pregnancy-related skin conditions may be associated with a personal history of eczema, asthma, or allergic rhinitis.

However, the absence of such a history does not rule out prurigo of pregnancy.

4. Hormonal Changes

Estrogen and progesterone levels rise during pregnancy, and these hormonal changes may affect skin function and immune responses.

However, the direct relationship between these hormones and the development of prurigo of pregnancy has not been firmly established scientifically. Elevated hormone levels should not be considered a confirmed cause of the condition.

5. Skin Stretching and Mechanical Changes

As the uterus grows and the abdomen and breasts increase in size, the skin stretches, potentially causing dryness and itching.

Skin stretching is also believed to contribute to polymorphic eruption of pregnancy, commonly known as PUPPP, although the precise mechanism underlying this condition remains unclear.

6. Liver and Bile Duct Disorders

Intrahepatic cholestasis of pregnancy is an important cause of itching during pregnancy, but it is not a direct cause of cutaneous prurigo of pregnancy. It is a separate medical condition.

Pregnancy-related cholestasis develops through the interaction of hormonal and genetic factors that affect bile acid transport and secretion. This leads to elevated bile acid levels in the blood and the development of itching.

The itching often occurs without a primary skin rash, may be concentrated on the palms and soles, and frequently worsens at night.

Second: The Pathophysiology of Prurigo of Pregnancy

Although the exact cause of prurigo of pregnancy is not fully understood, several mechanisms may contribute to its development and persistence.

Skin barrier dysfunction: Impaired skin barrier function may increase water loss and dryness, making the skin more susceptible to irritation.

Inflammatory responses: Immune changes may contribute to skin inflammation and the development of itchy papules.

Increased sensitivity of nerve endings: Certain skin and inflammatory changes may heighten the sensation of itching.

The itch-scratch cycle: Repeated scratching damages the skin and increases inflammation, potentially worsening itching and causing crusting and scratch marks.

2. Small, Itchy Skin Papules

Small red or skin-colored bumps may appear individually or in clusters. They commonly affect the arms and legs, particularly the extensor surfaces of the limbs, although other areas of the body may also be affected.

3. Scratch Marks and Skin Crusting

Repeated scratching may lead to several skin changes, including:

Superficial scratches caused by persistent itching.

Small crusts over the skin papules.

Dark spots or temporary changes in skin pigmentation.

Skin inflammation or secondary skin infections when the skin becomes severely damaged.

Second: When Do Symptoms of Prurigo of Pregnancy Begin?

Symptoms may begin during the second trimester, although they can also develop during the first or third trimester.

Itching and skin lesions may persist for several weeks, with symptoms potentially increasing in severity or recurring throughout pregnancy.

The condition usually improves after childbirth, although complete resolution may take some time.

Medical note: Symptoms of prurigo of pregnancy can resemble those of other pregnancy-related skin disorders. Pregnant women should consult a doctor to confirm the diagnosis, particularly if itching becomes severe or affects the palms of the hands or soles of the feet without an obvious skin rash.

Medical Treatment of Pruritus in Pregnancy

The treatment of pruritus in pregnancy depends on the underlying dermatological or hepatobiliary disorder, the severity of itching, and the stage of pregnancy. The main goals are to relieve itching and inflammation, reduce skin irritation, and ensure the safety of both the mother and the fetus.

First: Pharmacological Treatment According to the Underlying Condition

1. Atopic Eruption of Pregnancy (AEP) and Prurigo of Pregnancy

Treatment aims to relieve inflammation and itching and improve the condition of the skin. It includes the following:

Medical moisturizers: Such as petroleum jelly and fragrance-free creams, used regularly to maintain skin hydration and reduce dryness.

Topical corticosteroids: Such as hydrocortisone at an appropriate concentration. Stronger topical preparations may be required in selected cases, depending on medical assessment. The lowest effective potency should be used for the shortest possible duration.

Oral antihistamines: Such as cetirizine or loratadine, which may be recommended by a physician after assessing the patient's condition and suitability during pregnancy.

Additional treatments: In severe cases or those that do not respond to initial treatment, a dermatologist may prescribe other therapies under specialist supervision.

2. Polymorphic Eruption of Pregnancy (PUPPP)

Treatment is intended to relieve itching, redness, and inflammation. Common options include:

Medical moisturizers and soothing antipruritic preparations, such as products containing menthol at an appropriate concentration.

Topical corticosteroids to reduce inflammation and itching, as recommended by a physician.

Oral antihistamines when necessary, particularly when severe itching interferes with sleep.

Oral corticosteroids: These may be considered in selected severe cases following specialist assessment.

This condition usually improves after delivery; however, the diagnosis should be confirmed before treatment is initiated.

3. Pemphigoid Gestationis

This rare autoimmune blistering disorder requires specialist medical follow-up, particularly when skin blisters develop. Treatment may include:

Topical corticosteroids: At a potency appropriate to the severity of inflammation, as determined by a physician.

Oral corticosteroids: Prednisolone may be prescribed in moderate-to-severe cases or when new blisters appear. The dosage must be determined by the treating physician.

Antihistamines: These may be used to relieve itching, depending on the patient's condition.

Treatment should be coordinated between a dermatologist and an obstetrician. Oral corticosteroids must not be used without medical supervision.

4. Intrahepatic Cholestasis of Pregnancy (ICP)

Intrahepatic cholestasis of pregnancy differs from primary skin disorders associated with pregnancy because itching may occur without an obvious primary skin rash. It commonly affects the palms of the hands and soles of the feet.

Diagnosis requires blood tests, including measurement of total serum bile acids, together with liver function tests and appropriate pregnancy monitoring.

Treatment options include:

Ursodeoxycholic acid (UDCA): A physician may prescribe this medication to relieve itching in some pregnant patients. The usual dosage is approximately 10–15 mg/kg/day, divided into doses, according to medical assessment.

Antihistamines: Some may help improve sleep, but their effectiveness in relieving cholestatic itching is limited or uncertain.

Moisturizers and menthol-containing preparations: These may provide temporary symptomatic relief.

Important note: Ursodeoxycholic acid does not replace monitoring of serum bile acid levels, assessment of pregnancy risks, or determination of the appropriate timing of delivery. It should not be assumed to prevent intrauterine fetal death.

5. Pustular Psoriasis of Pregnancy

This is a rare but potentially serious condition that requires urgent medical assessment. Treatment may involve corticosteroids or other medications selected according to disease severity, with careful monitoring of maternal and fetal health.

Self-treatment is not recommended.

Surgical Treatment and Procedures for Pruritus in Pregnancy

The need for surgical intervention in pregnant patients with itching depends on the underlying cause. Most pregnancy-associated skin disorders do not require surgery, whereas certain hepatobiliary conditions may require specific medical or surgical interventions.

First: Conditions That May Require Medical or Surgical Intervention

1. Intrahepatic Cholestasis of Pregnancy (ICP)

This disorder is characterized by severe itching, particularly on the palms of the hands and soles of the feet. It often occurs without a primary skin rash, although scratching may cause secondary skin lesions.

Diagnosis is based on serum bile acid measurements and liver function tests.

Does it require surgery?

Typical intrahepatic cholestasis of pregnancy does not require direct liver surgery. Management focuses on:

Relieving maternal symptoms.

Monitoring maternal and fetal health.

Assessing serum bile acid levels and other risk factors.

Determining the appropriate timing of delivery.

2. Pemphigoid Gestationis

Pemphigoid gestationis is a rare autoimmune skin disorder that may cause intense itching and a rash, sometimes progressing to blister formation. Lesions may initially appear around the umbilicus before spreading to the abdomen and extremities.

Treatment generally involves topical or oral corticosteroids, depending on disease severity, together with specialist follow-up.

Surgery is not a treatment for this condition.

3. Biliary Obstruction or Gallstones

Some diseases affecting the bile ducts may be associated with itching and other symptoms, such as:

Yellowing of the skin and eyes (jaundice).

Dark urine.

Pain in the upper abdomen.

If investigations confirm gallstones or biliary obstruction requiring treatment, endoscopic intervention or surgical removal of the gallbladder may be necessary, depending on the diagnosis and clinical condition.

These disorders are different from intrahepatic cholestasis of pregnancy and must be distinguished before treatment is selected.

Second: Obstetric Procedures in Intrahepatic Cholestasis of Pregnancy

1. Induction of Labor

Induction of labor is not a surgical operation. It is a medical procedure used to initiate labor when the healthcare team determines that delivery is the most appropriate option for the mother and fetus.

Steps of the procedure:

Assessment of the mother and fetus: Review gestational age, serum bile acid levels, liver function tests, and overall maternal and fetal status.

Cervical examination: Assess the degree of cervical readiness for labor.

Cervical ripening: Use medications or a mechanical balloon catheter to help the cervix soften and dilate, if required.

Stimulation of uterine contractions: Administer medications to induce contractions or perform amniotomy (artificial rupture of membranes) when appropriate.

Monitoring during labor: Monitor uterine contractions and fetal heart rate.

Delivery: Proceed with vaginal delivery if appropriate and safe, or perform a cesarean section when medically indicated.

The decision depends on serum bile acid levels, gestational age, maternal and fetal health, and any additional risk factors. Recommendations may vary according to the applicable clinical guidelines and the individual patient's circumstances.

Total serum bile acid level	Possible management
19–39 µmol/L	Expectant management until the expected date of delivery may be considered in selected cases without additional risk factors.
40–99 µmol/L	Earlier delivery may be recommended, depending on gestational age and clinical assessment.
100 µmol/L or higher	The risk of fetal complications increases, and earlier delivery may be recommended according to established guidelines.

These thresholds should not be used in isolation to determine the timing of delivery. The obstetrician must consider the complete clinical picture.

2. Cesarean Section

A cesarean section is not a direct treatment for itching. It is a method of delivery that may be necessary for maternal or fetal indications or when vaginal delivery cannot be performed safely.

General steps of the procedure:

Preparation: Assess the mother's condition, review laboratory results, and prepare the operating room.

Anesthesia: Spinal or epidural anesthesia is commonly used; general anesthesia may be required when medically indicated.

Abdominal incision: A surgical incision is usually made in the lower abdomen.

Uterine incision: An incision is made in the uterus to access the fetus.

Delivery of the baby and placenta: The baby is delivered, followed by removal of the placenta and assessment of the uterus and bleeding.

Closure: The uterus and abdominal wall are closed in layers, after which the mother is transferred to the recovery area for monitoring.

Does every pregnant patient with intrahepatic cholestasis require a cesarean section?

No. Intrahepatic cholestasis of pregnancy alone does not automatically require cesarean delivery. Labor may be induced, and vaginal delivery may be appropriate if there are no contraindications. The delivery method depends on the overall obstetric and medical assessment.

3. Endoscopic Retrograde Cholangiopancreatography (ERCP)

ERCP is used to treat certain causes of biliary obstruction, such as a gallstone blocking the bile duct. It is not a treatment for uncomplicated intrahepatic cholestasis of pregnancy.

How is the procedure performed?

Assess the patient's condition and review laboratory and imaging results, in coordination with the gastroenterologist and obstetrician.

Administer appropriate sedation or anesthesia, with precautions for maternal and fetal monitoring.

Insert a flexible endoscope through the mouth, advancing it through the esophagus and stomach into the duodenum.

Identify the opening of the bile duct and use the necessary imaging techniques to locate the obstruction.

Remove the stone using specialized instruments, enlarge the duct opening if necessary, or insert a stent to facilitate bile drainage.

Monitor the patient after the procedure for potential complications, including pancreatitis, bleeding, and infection.

ERCP can be performed during pregnancy when there is a clear medical indication. Radiation exposure should be minimized, and appropriate precautions should be taken.

Cholecystectomy (surgical removal of the gallbladder) may be considered separately if clinically indicated.

Third: Non-Surgical Management of Intrahepatic Cholestasis of Pregnancy

When intrahepatic cholestasis of pregnancy is confirmed, management generally includes the following:

Laboratory investigations: Measure total serum bile acids and liver enzymes, repeating the tests as clinically indicated.

Drug treatment: Ursodeoxycholic acid (UDCA) may be prescribed to relieve maternal symptoms when appropriate.

Relief of itching: Use suitable moisturizers or menthol-containing preparations for temporary symptomatic relief.

Pregnancy monitoring: Assess maternal and fetal health and establish a delivery plan based on bile acid levels, gestational age, and additional risk factors.

Postpartum follow-up: Reassess symptoms and laboratory results after delivery to confirm resolution of the disorder.

Important: Improvement in itching after treatment does not necessarily indicate that fetal risks have resolved. Medical follow-up, assessment of bile acid levels, and appropriate timing of delivery remain essential components of management.

How is the timing of delivery determined?

Symptoms of Prurigo of Pregnancy

First: Main Symptoms of Prurigo of Pregnancy

1. Itching (Pruritus)

Itching is the primary symptom of prurigo of pregnancy, and its severity may range from mild to intense.

It may worsen at night or with exposure to heat and sweating. It can also interfere with sleep and daily comfort during pregnancy. Itching may develop before the skin lesions appear or at the same time.