Abstract
We would like to thank Dr Kroumpouzos for his interest in our review article and for the opportunity to discuss the controversy surrounding nomenclature of the specific pruritic dermatoses of pregnancy. In their 2006 publication, Ambros-Rudolph et al. suggested a reclassification of the dermatoses of pregnancy, with addition of an umbrella term, “atopic eruption of pregnancy” (AEP), under which they included prurigo of pregnancy (PP), prurigo gestationis, early-onset prurigo of pregnancy, papular dermatitis of pregnancy, pruritic folliculitis of pregnancy (PFP), and eczema in pregnancy (EP). 1 This was based on clinical and histopathological overlap among women with EP, PP, and PFP. This recategorization has been accepted by some and critiqued by others. 2 , 3 In his current letter to the editor as well as previous publications, Kroumpouzos argues that AEP should not be used to describe pruritic, discrete papulonodules on the extensor surfaces of the extremities developed in the late second and third trimesters of pregnancy in women without atopic history – rather that the term PP should be maintained as a distinct label for these women.2,3
Kroumpouzos identifies the 1994 study by Roger and colleagues as the largest prospective study on dermatoses of pregnancy, which included a total of 42 cases of pregnancy dermatoses (7 cases of PP), and cites that this study failed to confirm an association of PP with atopy. 4 However, Roger and colleagues excluded women who had pruritic skin disease prior to pregnancy, thereby potentially excluding women with a history of atopic dermatitis (AD). 4 Additionally, while this was the largest prospective study, numbers were quite small. This is in contrast to the Ambros-Rudolph study in which 401 women with dermatoses of pregnancy were reviewed (251 cases of EP, 4 cases of PP, and 1 case of PFP; ultimately reported as 256 cases of AEP). 1
Kroumpouzos and others have called for prospective, large-scale studies to clarify the relationship between PP, PFP, and AEP. 3 Ravelli et al. have recently published a combined prospective and retrospective case series of 20 women with typical prurigo presentation and no personal or family history of atopic disease, with the aim of characterizing the clinical features of PP without atopic background. 5 In his letter, Kroumpouzos cites the key findings of this study: a later onset of PP without atopic history as compared to AEP, with median gestational onset of 27.5 weeks in this cohort of women with PP without atopic history. 5 However, in the 1994 study by Roger et al., average onset of PP was 22 (SD 9) weeks of gestation, suggesting onset prior to the third trimester in a significant proportion of women with PP. 4 Another main finding Kroumpouzos cites is comorbid psychiatric disease in 20% of the cohort (two women), with one case of anxiety and one case of obsessive compulsive disorder. 5 The incidence of anxiety in this series, however, is consistent with a recent study which reports 9.5% of women are affected by an anxiety or panic disorder at some point during gestation. 6
The clinical relevance of distinction between these two entities is somewhat limited by the fact that the two are not treated differently in pregnancy. However, Kroumpouzos’ main concern is the possibility for biased counseling about the nature of AEP, presumably risk of recurrence of dermatologic manifestations of AEP in the form of AD outside of pregnancy.
We appreciate the work that Kroumpouzos and his group are doing to better describe the specific dermatoses of pregnancy. We agree that more data is needed to add diagnostic clarity to the dermatoses of pregnancy which remain a heterogenous group of ill-defined pruritic skin diseases unique to pregnancy.
