Pregnancy is one of the greatest challenges for the human immune system. The development of a genetically and immunologically alien entity in the human body without being rejected by the mother’s immune system is an extremely complex and fascinating process. The cascade of immunological changes dictated by hormones makes the mother’s immune system bend over backwards. No wonder that pregnancy and the postpartum period very often lead to changes in the course (or the first occurrence) of immunological skin diseases. In some cases, the disease goes into remission, in others there is a significant worsening of symptoms and in some changes do not appear until the postpartum period.

Skin conditions are often exacerbated by stressful events. There is no doubt that pregnancy and the postpartum period can be associated with increased levels of stress. However, the emotional state is not everything – changes in skin symptoms are largely the result extremely complex physiological processes that occur during and after pregnancy.

What exactly happens with eczema and psoriasis during pregnancy and the postpartum period? What mechanisms are responsible for the changes in symptoms? Can we influence them? And finally, what role does nutrition play in all of this? This article provides answers to all these burning questions. If you feel overwhelmed, you can find a summary of the most important information and practical recommendations at the end of the article.

Hormones and the skin

Hormones can directly affect the condition of the skin. Estrogen receptors are found in the epidermis, dermis, blood vessels, hair follicles and sebaceous glands. For this reason, the skin is extremely sensitive to the activity of sex hormones, which can regulate the collagen content in the skin and the ability to bind water, as well as maintain proper hydration of the epidermis (1).

During the menstrual cycle, it is common for skin symptoms to flare up in the luteal phase (preceding menstruation) and then to ease during menstruation. What’s more, hormonal fluctuations also affect allergic reactions of the skin. Increased allergic reactivity occurs in the luteal phase (as a result of increased estrogen levels), while reduced sensitivity to allergens occurs in the follicular phase (1). Hormonal changes are of course a fundamentally important feature of pregnancy – no wonder that during pregnancy we observe changes in the course of eczema and psoriasis.

The course of eczema during pregnancy and postpartum

Atopic eczema is the most common skin disease observed in pregnancy. Interestingly, only 20% of patients suffering from eczema during pregnancy struggled with this disease before becoming pregnant. In as many as 80% of cases, the first skin symptoms appear only during pregnancy (2).

In the case of women with eczema diagnosed before pregnancy, the exacerbation occurs in about half of the patients (52-61%) (3,4). Worsening of symptoms may be more common in women with IgE-mediated allergies and other atopic diseases (3).

The course of eczema in pregnancy can be predicted in part by the history of skin symptoms during the menstrual cycle. In women experiencing cyclic exacerbation of symptoms in the second phase of the cycle, the risk of eczema worsening during pregnancy is increased (2).

How is it possible that eczema worsens during pregnancy? First of all, during pregnancy estrogen and progesterone levels shift the Th1/Th2 balance (types of immune cells) towards Th2 dominance (1). Acute inflammation in eczema results primarily from the pro-inflammatory activity of Th2 cells (5). Therefore, an additional increase in the Th2 immune response during pregnancy may lead to the development or worsening of eczema. Elevated levels of estrogen may also act on mast cells and lead to IgE-mediated degranulation, indicating a stimulating effect of estrogen on allergic reactions (1).

Data on the course of eczema after childbirth in women who develop skin symptoms for the first time during pregnancy are extremely limited. If pregnancy has caused the onset of eczema, the logical consequence should be the resolution of symptoms 2-3 months after delivery – unfortunately, this is not always the case.

The course of psoriasis during pregnancy and postpartum

Let’s start with the good news – psoriasis symptoms can improve in up to 40% of women during pregnancy. Only 20% of women experience worsening of symptoms, while the rest does not not experience any changes (6).

How it’s possible? It is worth remembering that despite similar symptoms, the physiology of psoriasis is very different from the physiology of eczema. First of all, the inflammatory response in psoriasis is characterized by Th1 cell activity (7). Increasing the activity of Th2 cells and reducing the activity of Th1 may therefore have a beneficial effect on the course of psoriasis (as opposed to eczema). The described immunological changes are primarily the result of elevated estrogen levels during pregnancy. We know it also because the use of hormonal contraception with higher estrogen content may have a similar positive effect on skin symptoms as pregnancy, at least in some patients with psoriasis (6).

In addition, pregnancy is also a period when the natural production of glucocorticoids in the mother’s body doubles compared to the period before conception, and then decreases again 2-3 months after delivery (6). Synthetic glucocorticosteroids, i.e. immunosuppressive drugs, are the basic therapy of inflammatory diseases. The role of endogenous glucocorticoids during pregnancy is to suppress some immune responses so that the mother’s body does not reject the fetus. As a result, some immune diseases (such as psoriasis, inflammatory bowel disease, rheumatoid arthritis, and multiple sclerosis) can improve significantly during pregnancy due to natural immunosuppression (8). Probably the same mechanism may lead to the alleviation of eczema symptoms in about 20% of patients. However, as I mentioned, eczema has a different inflammatory profile than psoriasis. Moreover, elevated estrogen levels can lead to an increase in allergic symptoms, which play a key role in eczema, but not in psoriasis. Therefore, pregnancy more often has a negative impact on the course of eczema than psoriasis – although of course not in every case.

Now, unfortunately, it’s time for more pessimistic data. Although psoriasis often improves during pregnancy, many women experience exacerbations in the postpartum period. In a study of 46 patients with psoriasis, 65% noticed worsening of symptoms within 6 weeks after giving birth (9). This phenomenon is the result of a sudden decrease in the levels of estrogen, progesterone and endogenous glucocorticoids, combined with stress and lack of sleep. Moreover, in a study involving patients suffering from psoriatic arthritis, a significant worsening of the symptoms was observed 6 months after childbirth compared to 6 weeks after childbirth (10). These data suggest that postpartum exacerbation of psoriasis does not necessarily occur within the first weeks of the postpartum period but may be significantly delayed.

Here we should ask an important question: is the exacerbation of symptoms after childbirth the result of a return of the pre-pregnancy symptoms, or do the symptoms become worse than before pregnancy? For now, we do not have a clear answer to this question. However, some researchers suggest that the exacerbation is simply a return to the course of the disease from before pregnancy (9).

The appearance of psoriasis symptoms during pregnancy for the first time is extremely rare. It is worth remembering that the first symptoms of psoriasis usually appear in women between 30 and 40 years of age. This period often coincides with the time of conception, so it is possible that skin symptoms will occur during pregnancy. However, pregnancy itself does not predispose you to developing psoriasis.

Gut health during pregnancy and postpartum

The immunological changes that occur during pregnancy also contribute to the transformation of the mother’s intestinal microbiome. Currently, the only consistent finding seems to be a reduced diversity of microbes in the mother’s gut and increased stability of the microflora (11). The greater the diversity of the microflora, the healthier the intestines – perhaps the natural immunosuppression during pregnancy also reduces the growth of microbes in the intestines. In inflammatory skin diseases, we often observe a lower diversity of intestinal microflora compared to healthy people (12,13). The severity of skin symptoms may therefore be related to changes in the gut microbiome (and probably also the skin) that occur during pregnancy. For now, this is only a hypothesis – perhaps it will be confirmed in future research.

What we do know is that women often experience intestinal disorders after giving birth. There is no doubt that hormonal changes affect gut function, perhaps in part through modulation of the microbiome, and in part through other processes. In turn, intestinal health has a huge impact on the course of psoriasis and eczema. It is possible that the exacerbation of symptoms in so many cases of psoriasis (and sometimes eczema) in the postpartum period is associated at least in part with intestinal disorders. Without a doubt, it is worth taking care of the intestines in the postpartum period and throughout pregnancy.

Nutritional deficiencies

During pregnancy and lactation, the demand for almost all nutrients increases. Therefore, the risk of nutritional deficiencies increases as well. What’s more, the mere presence of a chronic disease predisposes to the development of nutritional deficiencies – e.g. zinc deficiency in the case of eczema and psoriasis (14). In addition, intestinal disorders occurring in the postpartum period (especially diarrhea) can limit the absorption of nutrients in the intestines.

To make things worse, eczema is partly a genetic disease. Mothers with eczema who breastfeed often observe allergic skin reactions in infants. Elimination of food allergens then takes place through the use of an elimination diet by the mother. If the child reacts to several allergens, the diet may turn out to be extremely restrictive and deficient.

Thus, we observe: (1) increased demand as a result of pregnancy and lactation, (2) increased demand due to chronic inflammatory disease, (3) increased risk of intestinal malabsorption, (4) potentially deficient diet. As a result, the risk of developing nutritional deficiencies in women with eczema and psoriasis can become really high.

It is worth remembering that deficiencies of zinc, vitamin D, B12 and other micronutrients may lead to worsening of skin symptoms (14-17). In some cases, this may explain the exacerbation of skin symptoms in the postpartum period, as well as during pregnancy. In order to ensure proper nutrition of the mother and child, it is worth consulting a dietitian and considering the use of supplementation. If you wonder how should the diet look like during pregnancy, have a look at this article.

To sum up:

1. Eczema symptoms often exacerbate during pregnancy. Many women also develop eczema for the first time during pregnancy.
2. Psoriasis symptoms often improve significantly during pregnancy, but many women experience exacerbations in the postpartum period.
3. The worsening of the skin symptoms during pregnancy and postpartum is associated with hormonal and immunological changes, but perhaps also with microbiome transformations, digestive disorders and nutritional deficiencies.

The role of nutrition

Eczema exacerbation during pregnancy is most likely the result of increased sensitivity to allergens, including food allergens. Therefore, elimination of nutritional triggers can lead to an improvement in the symptoms of the disease. Of course, elimination must be designed to prevent nutritional deficiencies. For this reason, it is worth consulting a dietitian and not experimenting with elimination diets during pregnancy on your own.

In the case of psoriasis, exacerbation most often occurs after giving birth, as a result of the loss of natural immunosuppression provided by pregnancy and the dramatic decrease in estrogen and progesterone. In this case, it is worth focusing on a diet and supplementation aimed at reducing inflammation and restoring hormonal balance.

Gut health is also of great importance in both diseases and can be weakened as a result of pregnancy. In order to improve the condition of the intestines, it is worth including pre- and probiotic products in the diet and considering testing for certain disorders (e.g. SIBO, IMO). Depending on the type of symptoms, a low-FODMAP diet may be useful.

Moreover, during pregnancy and lactation, women with eczema and psoriasis may be at risk of developing nutritional deficiencies. We know that deficiencies can lead to exacerbation of skin symptoms, as well as many other negative health effects. It is worth making sure that the mother’s diet is rich in all the necessary nutrients and that their absorption is proper. If in doubt, it is worth consulting a dietitian and considering the introduction of appropriate supplementation.

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