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Accutane is given to patients for treating severe acne that do not respond to other medicines. Accutane is a retinoid. It works by reducing skin oil production, changing the characteristics of the skin oil, and preventing abnormal hardening of the skin.

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Serious immunological, endocrine, metabolic and vascular changes that develop during pregnancy can lead to changes in the skin. Some of them are physiological and in some cases can serve as proof of pregnancy. Such physiological changes of the skin include stretching lines (develop in 90% of pregnant women), associated with hormonal changes in melasma (developing in 75% of pregnant women), pigmentation of the midline of the abdomen (especially at the top of it) and generalized hyperpigmentation.

Vaginal swelling associated with edema of the pregnant, erythema of the palms, birthmarks in the form of spiders, varicose veins, marbling of the skin, swelling and reddening of the gums. Some women notice a change in hair and nails during pregnancy.

About 20% of pregnant women complain of itchy skin.

Itching of the pregnant - is an intense itching, developing in later terms and not associated with any rashes on the skin (except scratching) or jaundice. It is necessary to exclude other possible causes of itching: scabies, pediculosis, urticaria, atopic dermatitis, neurodermatitis, the effect of medications and, most importantly, obstetric cholestasis.

Obstetric cholestasis is manifested by intense itching, which can be combined with clinical jaundice. Primary rashes are absent, but typically the presence of excoriations, the number of which depends on the severity of the condition. At present, genetic predisposition (in 50% - family cases) to obstetric cholestasis and its relation to the level of estrogens has been proved. Usually, the disease manifests itself in the third trimester of pregnancy and is quickly resolved after childbirth. According to various authors from different countries, it is found in 0,02-2,4% of pregnant women. Specificity increases with multiple pregnancies.

Pathogenesis is not fully understood. Some authors suggest that the disease is associated with a decrease in hepatic blood flow and clearance of estrogens. As a result, the concentration of biliary cholesterol is increased and the ability of the liver to transport anions, such as bilirubin, decreases. It has also been shown that estrogens directly affect bile excretion.

The disease is typical for the third trimester of pregnancy, but it can be registered before 8 weeks of pregnancy. In subsequent pregnancies, relapses occur in 70% of cases, proceeding similarly. Provoke itching and cholestasis can also be oral contraceptives.

Clinically characterized by intense generalized itching, especially severe at night. Especially the localization on the palms and soles. The skin is usually not changed. There are only extensive excoriations. In 50% of cases, dark urine and light colored stools can be observed. Jaundice occurs only in 20% of cases, usually 2 to 4 weeks after the onset of itching.

In the biochemical study, the serum bile acids in the blood are increased. In addition, it is possible to increase the level of direct bilirubin, alkaline phosphatase, cholesterol and fats. The content of hepatic transaminases is usually increased slightly, liver tests are normal. The results of liver biopsy do not indicate the presence of a typical hepatic cholestasis. However, cholestasis of the central lobe and bile thrombi are revealed without dilating the tubules. Histological examination of the skin usually does not reveal pathological changes.

In hepatic cholestasis, a high level of stillbirth is recorded, as well as premature birth, prenatal hemorrhage, intracranial hemorrhage in the fetus due to reduced absorption of vitamin K. Changes in serum do not correlate with the risk for the fetus.

Intensive fetal monitoring and stimulation of labor in 38 weeks of pregnancy are recommended. These measures can improve the survival rate of newborns.

Treatment is more symptomatic - against itchy and emollients. Cholistiramine, phenobarbital, phototherapy (rays B) are also used, which reduces the severity of itching. In a number of cases, a low- and low-fat diet helps. With continued hepatic cholestasis, there is a need for intravenous vitamin K.

Specific dermatosis of pregnancy

In addition to the "physiological" skin changes occurring during pregnancy and usually well tolerated by pregnant women, there is a group of inflammatory dermatoses specifically related to pregnancy and / or the postpartum period. Almost always, these diseases are associated with skin itch and skin rashes of varying severity. Until now, terminological confusion has remained: the same clinical states are described under different names. However, in 1982 and 1983, Holmes and Black proposed a simplified clinical classification of pregnancy dermatoses. According to this classification, all pregnancy dermatoses are divided into 4 groups: 1) pemphigoid (herpes) of pregnant women; 2) polymorphic eruptions during pregnancy; 3) itching of the pregnant; 4) itching folliculitis of pregnant women. This classification is quite simple and convenient in practical work.

Pemphigoid Pregnant

Pemphigoid of pregnant women (GH) - strongly hardening, hormone-mediated autoimmune disease. The disease develops in association with pregnancy, bladder drift and even chorionepithelioma. Clinically, histopathologically and immunologically, the disease is very similar to the bullous pemphigoid. The disease occurs frequently, with an approximate frequency of 1: 60,000 pregnant women. More often it occurs in the white skin, although there are descriptions of it in other racial groups.

Pathogenesis. Pemphigoid pregnant women are referred to hormone-mediated autoimmune diseases. The primary immune response occurs within the placenta. Deviations from normal expression of genes of a large class II histocompatibility complex complex lead to a local allogeneic reaction against the fetoplacental complex. As a result, an autoimmune response is triggered against the placenta-uterine antigen. This autoantibody response results in the deposition of immune complexes and the activation of complement in the skin, which causes tissue damage.

The pemphigoid of pregnant women begins within II, rarely III trimesters of pregnancy. Rarely is the disease manifested in the first trimester or during the postpartum period (25% of cases). The disease can develop with any pregnancy, but once developed, it tends to return in all subsequent pregnancies. There are no methods of forecasting. Having developed, the disease proceeds undulating with periods of exacerbations and remissions. In the last few weeks of pregnancy, the illness usually abates, but in 75% of cases after the birth a new exacerbation develops. There are also described exacerbations before the monthly for 18 months after childbirth and when taking oral contraceptives. These facts allow us to conclude that hormonal contraceptives are not indicated for patients with pemphigidae in pregnant women. In most cases, spontaneous remission develops in the first weeks and months after delivery. It is noted that breastfeeding reduces the risk of postpartum continuation of the disease.

Clinical manifestations. The disease usually begins with severe itching. Soon there are urtic rashes on the background of normal or erythematous skin. From the appearance of itching to the eruption of intense blisters runs from several days to several weeks. In 50% of cases, the first manifestations of the disease are on the skin of the abdomen, however, rashes can also be on the limbs, including the feet and soles. The facial skin and visible mucous membranes are rarely involved in the pathological process.

Histopathology. The histological picture varies depending on the stage and severity of the disease, but in classical cases, typical: 1) subepidermal bladder; 2) edema of the papillary layer of the dermis; 3) spongiosis with exocytosis of eosinophils; 4) perivascular infiltration, consisting of lymphocytes, histiocytes and a significant number of eosinophils.

Immunopathology. With direct immunofluorescence surrounding the foci of the skin, almost all patients have a bright line of sedimentation along the basement membrane. In 25-30% of patients, IgG is also detected. With the usual direct immunofluorescence, antibodies against basal membrane antigens are detected in 20% of GH patients. At the same time, when using monoclonal antibodies IgG (predominantly IgGj) against basal membrane antigens are detected in the majority of patients. The titer of antibodies does not correlate with the severity of the disease. A low antibody titer can be detected within months against a background of clinical remission.

Risk for mother and fetus. In 10% of cases of pemphigoid pregnant women develop rapid skin days (days of the week), usually urticarious and vesicular. The incidence of these incidents increases with the duration of pregnancy: 16% to 36 weeks and 32% to 38 weeks, which implies a low level of placental insufficiency in patients with this disease. But сases of an increase in the incidence of spontaneous abortions and the level of child mortality are not described.

Treatment. In mild cases, you can limit the appointment of topical steroids with systemic antihistamines or without them. However, as a rule, it is necessary to prescribe systemic corticosteroids (20-40 mg of prednisolone per day). With a more severe course of the disease, daily doses of corticosteroids increase. In the last trimester of pregnancy, when the disease is usually relatively quiet, daily doses of corticosteroids decrease. However, after delivery, to prevent an imminent outbreak of disease, the daily dose of corticosteroids rises sharply. In the future, the dose of corticosteroids decreases again depending on the clinical manifestations of the disease.

In severe postpartum exacerbations of the pemphigoid pregnant women can be used drugs of other groups: cyclophosphamide, preparations of gold, dapsone, methotrexate. In extremely severe cases, plasmapheresis and intravenous administration of high doses of immunoglobulin in combination with cyclosporine can be used.

Polymorphic rashes of pregnant women

Polymorphic eruptions of pregnant women (PVB) appear usually late in pregnancy and / or after childbirth. The variety of clinical manifestations has led to the terminological confusion that exists in the literature to date.

Epidemiology. PVBs are widely distributed in the world and are the most common of the specific dermatoses of pregnancy. The frequency is about 1 for 160 pregnancies. Usually this disease is primitive, but PVB can also develop in many-reared women, especially if there is a large fetus and with multiple pregnancies.

Pathogenesis. PVB has neither an autoimmune etiology, nor a connection with other autoimmune diseases, atopy or preeclampsia. There are three basic theories of pathogenesis.

1. Excessive distension of the abdomen leads to the destruction of elastic fibers. This is evidenced by the following facts: in most cases PVB are observed in late pregnancy with primary eruptions occurring on the stretch bands. In addition, the disease is more common in women with excessive weight gain during pregnancy, with large-fetal and multiple pregnancies.

2. Hormonal factor. Patients often have a low serum cortisol level.

3. Embryonic factors. PVB occurs in 2 times more often when pregnancy is a male fetus. In the maternal skin, fetal male DNA was found.

PVB usually begins in the last few weeks of pregnancy (usually between 36 and 39 weeks gestation). However, it is possible both earlier and later (within the first two weeks after delivery). The average duration of rashes is 6 weeks. Propensities to relapse in subsequent pregnancies PVB does not have, if there is no connection with pregnancy twins or triplets.

Clinical manifestations. Eruptions begin with itchy urticaria papules, usually in the area of ​​streaks. However, the morphology of the rashes can vary considerably. In 40% of cases, the urticaria papules or microvesicles are located along the bands. In 20% of cases there are rashes in the form of a target shape (as with multiforme exudative erythema), in 18% - ring-shaped or polycyclic bands. In 70% of cases, the rashes merge and, through wide distribution, become similar to toxic erythema. In a small percentage of cases, vesicles can merge into larger cavities. When solving the process, in most cases the rashes begin to peel off.

PVB usually begin on the skin of the abdomen with a characteristic bypass around the umbilical area (as opposed to the pemphigoid of pregnant women). In addition, usually affects the skin of the hips, buttocks, arms and legs. Lesion of mucous membranes is not described.

Histopathology. In most cases, nonspecific inflammatory changes; Mainly perivascular lymphohistiocyte infiltrate. In a small percentage of cases, acute folliculitis with perifollicular neutrophil infiltration, sometimes associated with gram (+) cocci or bacilli, is described.

The prognosis is favorable. The disease is self-passing. The prognosis is favorable for both the mother and the fetus. In women with PVB, boys predominate, the number of twins and triplets increases substantially.

Treatment is symptomatic. Usually enough short courses of topical steroids. In severe cases, it is possible to prescribe short courses (7-14 days) of systemic steroids (30 mg prednisone per day).

If the therapy is ineffective and the severity is cesarean, after which the patient's condition improves within a few hours.

Itching of pregnant women

Itching of pregnant women (ST) occurs at a frequency of 1: 300 pregnant women. ZB is more typical for women with atopic diseases in the anamnesis. Usually the disease begins at the time of 25-30 weeks of pregnancy and passes after childbirth. However, persistence in the postpartum period is also possible. Recurrences of the ST at subsequent pregnancies are rare.

Clinical manifestations. In addition to itching, the appearance of small (no more than 0.5 cm in size) red or the color of unchanged papules is characteristic. The primary location of the rash is the skin of the body and the extensor surfaces of the limbs.

The histopathological picture is not specific.

The prognosis is favorable. The disease does not affect either the course of the pregnancy or the condition of the fetus.

Treatment is symptomatic: external antipruritic drugs, including topical steroids.

Itching folliculitis of pregnant women

A rare disease, the pathogenesis of which is not known. A mechanism of development similar to the mechanism of development of steroid acne is suggested (acne eruptions when using systemic corticosteroids or progesterone).

The disease usually begins between 4 and 9 months of pregnancy, proceeds gently and passes within 2-3 weeks after childbirth. The tendency to relapse in subsequent pregnancies is not noted.

Clinical manifestations. Characteristic of severe itching and eruption of small follicular papules of red color predominantly on the upper part of the trunk.

Treatment is external. The agents containing benzoyl peroxide, possibly in combination with weak topical steroids, are indicated.

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