The Effect of Pregnancy on Dermatological Disorders: A Systematic Review
Abstract
:1. Introduction
2. Materials and Methods
2.1. Search Strategy
2.2. Study Selection
2.2.1. Inclusion Criteria
2.2.2. Exclusion Criteria
2.2.3. Screening and Data Extraction
2.2.4. Quality Assessment and Bias Evaluation
2.3. Data Synthesis
3. Results
3.1. Study Selection and Characteristics
3.2. Dermatological Disorders in Pregnancy
3.2.1. Polymorphic Eruption of Pregnancy
3.2.2. Atopic Dermatitis and Biologic Therapy in Pregnancy
3.2.3. Lupus Erythematosus and Pregnancy
3.3. Maternal and Fetal Complications
3.4. Treatment Approaches and Variability in Effectiveness
4. Discussion
Limitations
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
Abbreviations
AEP | Atopic eruption of pregnancy |
BP180 | Bullous Pemphigoid 180 |
GRADE | Grading or Recommendations Assessment, Development, and Evaluation |
ICP | Intrahepatic cholestasis of pregnancy |
MeSH | Medical Subject Headings |
PEP | Polymorphic eruption of pregnancy |
PG | Pemphigoid gestationis |
PPP | Pustular psoriasis of pregnancy |
PRISMA | Preferred Reporting Items for Systematic Reviews and Meta-Analyses |
PUPPP | Pruritic urticarial papules and plaques of pregnancy |
RCT | Randomized controlled trials |
SLE | Systemic lupus erythematosus |
AD | Atopic dermatitis |
MOOSE | Meta-analysis of observational studies in epidemiology |
LE | Lupus erythematosus |
UDCA | Ursodeoxycholic acid |
Appendix A
Title of the Systematic Review | The Effect of Pregnancy on Dermatological Disorders; A Systematic Review |
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Pregnancy is a physiological state characterized by distinct immunological, hormonal, and vascular alterations that might affect dermatological health [1]. Up to 90% of pregnant women experience changes in their skin, ranging from benign physiological changes to exacerbations of pre-existing dermatological conditions and the appearance of pregnancy dermatoses [2]. The dermatological alterations are associated with fluctuations in estrogen, progesterone, and other hormones pertinent to pregnancy, as well as immune system modifications that promote fetal development [3]. Pregnancy dermatoses can be categorized into three primary groups. The first is normal physiological skin alterations; the second is the worsening of pre-existing skin conditions due to pregnancy; and the third is pregnancy-specific dermatoses [4]. Common physiological changes, typically returning postpartum, encompass hyperpigmentation (melasma and linea nigra), striae gravidarum, and vascular adaptations [5]. Pre-existing dermatological problems, including atopic dermatitis, psoriasis, and autoimmune bullous illnesses, might be dramatically impacted. Pregnancy-specific dermatoses, including pemphigoid gestationis (PG), polymorphic eruption of pregnancy (PEP), atopic eruption of pregnancy (AEP) and intrahepatic cholestasis of pregnancy (ICP), exhibit distinct di-agnostic and treatment challenges and may lead to detrimental maternal and fetal consequences [6]. The timing of start, intensity, and progression of dermatological illnesses during pregnancy are influenced by various factors, including maternal age, parity, genetic susceptibility, and immunological tolerance mechanisms. Some conditions resolve spontaneously after delivery, while others necessitate tailored intervention to avert unnecessary problems [7]. The clinical management of dermatological diseases in pregnant individuals must be cautious, prioritizing optimal results for both the mother and fetus, particularly in the selection of treatment choices to minimize teratogenic risk [8]. | |
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This systematic review investigates pregnancy-associated alterations that affect the course of cutaneous diseases and their treatment and then discusses these changes in terms of the safety of both the mother and the fetus. We aim to guide the clinician with evidence-based recommendations on the best diagnosis and management of skin diseases in pregnancy, to optimize maternal health, reduce morbidity, and provide the best quality of life for patients. | |
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Population, or participants and condition of interest | This review will examine pregnant patients with dermatological diseases in various healthcare settings and in patients of various ages and backgrounds. The condition of interest for this systematic review is the impact of pregnancy on multiple disease states and their management as well as the influence of physiologic changes of pregnancy and disease therapy on maternal-fetal outcomes. |
Interventions or exposures |
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Comparisons or control groups | The stanard care group consists of pregnant individuals having standard care for managing dermatological conditions during pregnancy. This may include observation, symptomatic management, or conservative treatment approaches considered safe during pregnancy. The outcomes of this group will be compared to those receiving targeted interventions or treatment adjustments based on pregnancy-related changes, allowing for an evaluation of disease progression, maternal symptom relief, and fetal outcomes. |
Outcomes of interest | Symptom improvement rates, complication rates associated with pregnancy-related physiological changes, effectiveness and safety of treatments during pregnancy, disease progression or remission patterns, maternal quality of life, and fetal outcomes (e.g., birth weight, gestational age at delivery) in patients with dermatological conditions during pregnancy. |
Setting |
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Inclusion criteria |
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Exclusion criteria |
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Electronic databases |
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Keywords | (Dermatological disorders OR Pregnancy-related skin conditions OR Maternal dermatology OR Pregnancy outcomes OR Hormonal changes OR Autoimmune skin diseases OR Treatment safety during pregnancy) |
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Quality assessment tools or checklists used with references or URLs | In addition to using the STROBE tool to find pertinent material and methodology in each of the papers to be examined, the protocol will specify the approach taken in the literature critique/appraisal. |
Narrative synthesis details of what and how synthesis will be performed | Alongside any meta-analysis, narrative synthesis will be conducted using a framework that comprises four components: producing a preliminary synthesis of the findings of included studies, investigating relationships within and between studies, evaluating the robustness of the synthesis, and developing a theory of how the intervention works, why, and for whom. |
Meta-analysis details of what and how analysis and testing will be performed. If no meta-analysis is to be conducted, please give reason. | Although there are plans for a meta-analysis, it will only be come clear after the systematic review what data will be extracted and put to public domain. We need to think about how we will study heterogeneity. |
Grading evidence system used, if any, such as GRADE | GRADE will be used for the evidence assessment. |
Appendix B
Section and Topic | Item # | Checklist Item | Location Where Item Is Reported |
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Title | |||
Title | 1 | Identify the report as a systematic review. | Page 1; lines 2 to 3 |
Abstract | |||
Abstract | 2 | See the PRISMA 2020 for the abstracts checklist. | Page 1; lines 14 to 35 |
Introduction | |||
Rationale | 3 | Describe the rationale for the review in the context of existing knowledge. | Page 2; lines 41 to 65 |
Objectives | 4 | Provide an explicit statement of the objective(s) or question(s) the review addresses. | Page 2; lines 66 to 77 |
Methods | |||
Eligibility criteria | 5 | Specify the inclusion and exclusion criteria for the review and how studies were grouped for the syntheses. | Page 3; lines 95 to 108 |
Information sources | 6 | Specify all databases, registers, websites, organizations, reference lists, and other sources searched or consulted to identify studies. Specify the date when each source was last searched or consulted. | Page 3; lines 81 to 92 |
Search strategy | 7 | Present the full search strategies for all databases, registers, and websites, including any filters and limits used. | Page 3; lines 81 to 92 |
Selection process | 8 | Specify the methods used to decide whether a study met the inclusion criteria of the review, including how many reviewers screened each record and each report retrieved, whether they worked independently, and, if applicable, details of automation tools used in the process. | Page 3; lines 95 to 102 |
Data collection process | 9 | Specify the methods used to collect data from reports, including how many reviewers collected data from each report, whether they worked independently, any processes for obtaining or confirming data from study investigators, and, if applicable, details of automation tools used in the process. | Page 3; lines 109 to 119 |
Data items | 10a | List and define all outcomes for which data were sought. Specify whether all results that were compatible with each outcome domain in each study were sought (e.g., for all measures, time points, analyses), and, if not, the methods used to decide which results to collect. | ND |
10b | List and define all other variables for which data were sought (e.g., participant and intervention characteristics, funding sources). Describe any assumptions made about any missing or unclear information. | ND | |
Study risk of bias assessment | 11 | Specify the methods used to assess the risk of bias in the included studies, including details of the tool(s) used, how many reviewers assessed each study, and whether they worked independently, and, if applicable, details of automation tools used in the process. | Page 3 and 4; lines 120 to 130 |
Effect measures | 12 | Specify for each outcome the effect measure(s) (e.g., risk ratio, mean difference) used in the synthesis or presentation of the results. | ND |
Synthesis methods | 13a | Describe the processes used to decide which studies were eligible for each synthesis (e.g., tabulating the study intervention characteristics and comparing them against the planned groups for each synthesis (item #5)). | Page 4; lines 132 to 142 |
13b | Describe any methods required to prepare the data for presentation or synthesis, such as handling of missing summary statistics, or data conversions. | Page 4; lines 132 to 142 | |
13c | Describe any methods used to tabulate or visually display results of individual studies and syntheses. | Page 4; lines 132 to 142 | |
13d | Describe any methods used to synthesize results and provide a rationale for the choice(s). If meta-analysis was performed, describe the model(s), the method(s) to identify the presence and extent of statistical heterogeneity, and software package(s) used. | ND | |
13e | Describe any methods used to explore possible causes of heterogeneity among study results (e.g., subgroup analysis, meta-regression). | ND | |
13f | Describe any sensitivity analyses conducted to assess robustness of the synthesized results. | ND | |
Reporting bias assessment | 14 | Describe any methods used to assess the risk of bias due to missing results in a synthesis (arising from reporting biases). | Page 3 and 4; lines 120 to 130 |
Certainty assessment | 15 | Describe any methods used to assess certainty (or confidence) in the body of evidence for an outcome. | ND |
Results | |||
Study selection | 16a | Describe the results of the search and selection process, from the number of records identified in the search to the number of studies included in the review, ideally using a flow diagram. | Page 4; lines 144 to 157 |
16b | Cite studies that might appear to meet the inclusion criteria, but which were excluded, and explain why they were excluded. | Page 4; lines 144 to 157 | |
Study characteristics | 17 | Cite each included study and present their characteristics. | Page 6 and 7; lines 163 to 165 |
Risk of bias in studies | 18 | Present assessments of the risk of bias for each included study. | Page 3 and 4; lines 120 to 130 |
Results of individual studies | 19 | For all outcomes, present, for each study (a) summary statistics for each group (where appropriate) and (b) an effect estimate and its precision (e.g., confidence/credible interval), ideally using structured tables or plots. | Page 6 and 7; lines 163 to 165 |
Results of syntheses | 20a | For each synthesis, briefly summarize the characteristics and risk of bias among contributing studies. | Page 8 till 10; lines 166 to 217 |
20b | Present results of all statistical syntheses conducted. If meta-analysis was performed, present each summary estimate and its precision (e.g., confidence/credible interval) and measures of statistical heterogeneity. If comparing groups, describe the direction of the effect. | ND | |
20c | Present results of all investigations of possible causes of heterogeneity among study results. | ND | |
20d | Present results of all sensitivity analyses conducted to assess the robustness of the synthesized results. | ND | |
Reporting biases | 21 | Present assessments of risk of bias due to missing results (arising from reporting biases) for each synthesis assessed. | ND |
Certainty of evidence | 22 | Present assessments of certainty (or confidence) in the body of evidence for each outcome assessed. | ND |
Discussion | |||
Discussion | 23a | Provide a general interpretation of the results in the context of other evidence. | Page 11; lines 219 to 266 |
23b | Discuss any limitations of the evidence included in the review. | Page 12; lines 267 to 299 | |
23c | Discuss any limitations of the review processes used. | Page 12; lines 267 to 299 | |
23d | Discuss implications of the results for practice, policy, and future research. | Page 12; lines 291 to 308 | |
Other information | |||
Registration and protocol | 24a | Provide registration information for the review, including register name and registration number, or state that the review was not registered. | Page 3; lines 81 to 84 |
24b | Indicate where the review protocol can be accessed, or state that a protocol was not prepared. | Page 3; lines 81 to 84 | |
24c | Describe and explain any amendments to information provided at registration or in the protocol. | Page 3; lines 81 to 84 | |
Support | 25 | Describe sources of financial or non-financial support for the review, and the role of the funders or sponsors in the review. | Page 13; line 316 |
Competing interests | 26 | Declare any competing interests of review authors. | Page 13; line 325 |
Availability of data, code and other materials | 27 | Report which of the following are publicly available and where they can be found; template data collection forms; data extracted from included studies; data used for all analyses; analytic code; any other materials used in the review. | ND |
Appendix C
Selection | Comparability | Outcome | Quality Score | Risk of Bias (0–3: High; 4–6: Moderate; 7–9: Low) | ||||||
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Article | Q1 | Q2 | Q3 | Q4 | Q5 | Q6 | Q7 | Q8 | ||
Panicker, et al. 2016 [1] | (B) somewhat representative of the average cohort | (B) drawn from the same community | * | * | One factor controlled | * | Yes | * | Moderate Quality Study (6) | Moderate Risk |
Vora, et al. 2014 [2] | (A) Truly representative of the average cohort | (A) Derived from the same population | ** | ** | Two factors controlled | ** | Yes | ** | Good Quality Study (8) | Low Risk |
Gupta, et al. 2024 [3] | (B) Somewhat representative of the average cohort | (B) Drawn from the same community | * | * | No comparability | * | Yes | * | Moderate Quality Study (5) | Moderate Risk |
Vk, et al. 1988 [4] | (C) Selected group of users | (C) No description of the non-exposed cohort | * | * | No comparability | * | No | * | Poor Quality Study (4) | Moderate Risk |
Kepley, et al. 2019 [5] | (A) Truly representative of the average cohort | (A) Derived from the same population | ** | ** | Two factors controlled | ** | Yes | ** | Good Quality Study (8) | Low Risk |
Sävervall, et al. 2015 [6] | (B) Somewhat representative of the average cohort | (B) Drawn from the same community | * | * | One factor controlled | * | Yes | * | Moderate Quality Study (6) | Moderate Risk |
Abu-Raya, et al. 2020 [7] | (A) Truly representative of the average cohort | (A) Derived from the same population | ** | ** | One factor controlled | * | Yes | ** | Good Quality Study (7) | Low Risk |
Pope, et al. 2022 [8] | (A) Truly representative of the average cohort | (A) Derived from the same population | ** | ** | One factor controlled | ** | Yes | ** | Good Quality Study (8) | Low Risk |
Thappa, et al. 2007 [15] | (B) Somewhat representative of the average cohort | (B) Drawn from the same community | * | * | One factor controlled | * | Yes | * | Moderate Quality Study (6) | Moderate Risk |
Aronson, et al. 1998 [23] | (A) Truly representative of the average cohort | (A) Derived from the same population | ** | ** | One factor controlled | ** | Yes | ** | Good Quality Study (8) | Low Risk |
Appendix D
Selection | Comparability | Outcome | Quality Score | Risk of Bias (0–3: High; 4–6: Moderate; 7–9: Low) | |||||
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Q1 | Q2 | Q3 | Q4 | Q5 | Q6 | Q7 | |||
Muzaffar, et al. 1998 [33] | * | * | * | * | * | * | * | Good Quality Study (7) | Low Risk |
Fernandes, et al. 2015 [34] | * | * | * | * | * | * | * | Good Quality Study (7) | Low Risk |
Rathore, et al. 2011 [35] | * | * | * | * | * | * | * | Good Quality Study (7) | Low Risk |
Appendix E
Articles | Bias Arising From the Randomization Process | Bias Due to Deviations from Intended Interventions | Blinding of Participants and Personnal | Bias Due to Missing Outcome Data | Bias in Measurement of the Outcome | Bias in Selection of the Reported Result | Overall RoB |
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Siemens, et al. 2016 [47] | Low Risk | Low Risk | Low Risk | Low Risk | Low Risk | Low Risk | Low Risk |
Kondrackiene, et al. 2005 [52] | Low Risk | Low Risk | Low Risk | Low Risk | Low Risk | Low Risk | Low Risk |
Chappell, et al. 2020 [65] | Low Risk | Low Risk | Low Risk | Low Risk | Low Risk | Low Risk | Low Risk |
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Authors | Country | Study Design | Sample Size | Summary | Level of Evidence |
---|---|---|---|---|---|
Thappa, et al. [15] | India | RCTs | 607 | Pigmentary changes were the most frequent specific dermatosis, while candidal vaginitis was the most common dermatosis affected by pregnancy. | IV |
Szczęch, et al. [16] | Poland | RCTs | 292 | Pruritus is a common physiological or indicative underlying condition in pregnancy. Proper diagnosis and management are needed to prevent adverse maternal and fetal outcomes. | IV |
Wong JH. [17] | USA | Retrospective Cohort Study | 66 | The study found that pregnancy does not negatively affect the prognosis of stage I melanoma. | III |
Cobo, et al. [18] | Brazil | Clinical Study | 7 | Pregnant women with PG who were positive for PG factor and BP180 reactivity. They had a good outcome with no skin lesions and normal birth parameters. | IV |
Nowecki, et al. [19] | Poland | Case Report | 5 | The study found that there is no clear evidence suggesting that pregnancy worsens melanoma prognosis. | V |
Bushkell, et al. [20] | South Africa | Case Report | 1 | A patient with PG and a history of repeated abortion and stillbirths, contradicting the modern concept of a favorable fetal prognosis. | V |
Bercovitch L [21] | USA | Case Report | 1 | A pregnant woman with pustular PG presented with no vesicular or bullous lesions. | V |
Yaliwal, et al. [22] | India | Case Report | 1 | The study found that prurigo of pregnancy is a benign, pruritic skin disorder occurring during pregnancy. Management involves symptomatic relief, with no significant maternal or fetal complications. | V |
Aronson, et al. [23] | USA | Clinical Study | 57 | The study categorized the PG into three types based on the clinical presentations: urticarial papules and plaques, no urticarial erythema/papules/vesicles, and mixed forms. | IV |
Yancey, et al. [24] | Maryland | Prospective Study | 25 | Pruritus was the major symptom of PUPPP, but excoriations were rare in the third trimester of pregnancy. | II |
Rudolph, et al. [25] | Austria | Multicenter Retrospective Study | 181 | PEP mainly affected primigravidae; it began as pruritic urticarial papules and plaques, evolving into polymorphic features in over 50% of cases. | III |
Kroumpouzos, et al. [26] | USA | Case Report | 1 | A rare case of pruritic folliculitis of pregnancy, a dermatosis that resolved spontaneously postpartum. | V |
Roger D [27] | France | Prospective Study | 3192 | The study highlighted the higher-than-expected incidence of PG (1 in 1700) and the need to consider pruritus gravidarum (1 in 145) in pregnancy-related itching. | II |
Ambros-Rudolph, et al. [28] | Austria | Multicenter Retrospective Study | 505 | The study reclassified pregnancy dermatoses into PG, PEP, AEP, and ICP groups. AEP started early, while PEP, PG, and ICP presented in late pregnancy. | III |
Chávez, et al. [29] | Mexico | Case Report | 1 | The study indicated that the SARS-CoV-2 infection should be considered in differential diagnoses of erythematous maculopapular rashes during pregnancy. | V |
Mehedintu, et al. [30] | Romania | Case Report | 1 | The study highlighted the need for more awareness of PUPPP in pregnancy. | V |
Liu, et al. [31] | China | Case Report | 1 | The study shows that pregnancy-related or hormonal factors may have contributed to the development of nodular vulgar lesions. | V |
Kannambal, et al. [32] | India | Cross-sectional Study | 500 | The study highlighted the importance of differentiating benign changes from pathological conditions. | IV |
Muzaffar, et al. [33] | Pakistan | Observational Study | 140 | The most common physiologic skin changes are pigmentation (90.7%) and striae (77.1%). | III |
Fernandes, et al. [34] | Brazil | Cross-sectional Study | 905 | No significant differences in skin changes were observed between low-risk and high-risk pregnancies. | IV |
Rathore, et al. [35] | India | Prospective Study | 2000 | The study found physiological cutaneous changes in 87.55% of cases, with pigmentary changes the most common (85.9%), followed by connective tissue changes (64.8%). | II |
Aiholli, et al. [36] | India | Case Report | 1 | The study found that neonatal pemphigus vulgaris is a rare condition caused by transplacental transfer of maternal autoantibodies against desmogleins 1 and 3. | V |
Authors | Dermatosis | Primary Symptoms | Maternal Complications | Fetal Complications | Common Treatments |
---|---|---|---|---|---|
Sävervall, et al. [51] | Pemphigoid gestationis | Pruritic blisters, erythematous plaques | Increased risk of postpartum flares, association with autoimmune diseases | Small-for-gestational-age infants, preterm birth | Systemic corticosteroids, antihistamines |
Kondrackiene, et al. [52] | Intrahepatic cholestasis of pregnancy | Intense pruritus (especially on palms and soles), jaundice | Increased bile acid levels, liver dysfunction | Preterm birth, stillbirth, fetal distress | Ursodeoxycholic acid, early delivery if bile acids are high |
Massone, et al. [53] | Atopic eruption of pregnancy | Eczematous plaques, excoriations, dryness | Sleep disturbances, worsening of pre-existing atopy | None | Emollients, topical corticosteroids, antihistamines |
Charles-Holmes R [54] | Polymorphic eruption of pregnancy | Urticarial papules, pruritic rash in abdominal striae | Severe itching, sleep disruption | None | Topical corticosteroids, antihistamines, emollients |
Breier-Maly, et al. [55] | Pustular psoriasis of pregnancy | Pustular lesions, systemic symptoms (fever, malaise) | Risk of secondary infections, severe systemic inflammation | Increased risk of fetal growth restriction, preterm birth, stillbirth | Systemic corticosteroids, immunosuppressive therapy in severe cases |
Authors | Dermatosis | Hormonal Influence | Genetic Predisposition | Gestational Age at Onset | Multiparity vs. Primiparity | Pre-Existing Skin Condition |
---|---|---|---|---|---|---|
Shornick, et al. [56] | Pemphigoid gestationis | High estrogen/progesterone fluctuations | HLA-DR3, HLA-DR4 association | Second to third trimester | More common in multiparous women | Associated with other autoimmune diseases (e.g., Graves’ disease) |
Wasmuth, et al. [57] | Intrahepatic cholestasis of pregnancy | Increased estrogen affects bile acid clearance | Family history of ICP, genetic mutations (ABCB4, ABCB11) | Third trimester | More common in multiparous women | Not strongly linked to pre-existing skin conditions |
Stefaniak, et al. [58] | Atopic eruption of pregnancy | Elevated IgE, Th2 immune shift | Strong familial history of atopy (asthma, eczema) | First trimester | More common in primigravidas | Pre-existing eczema and atopic dermatitis increase the risk |
Zejnullahu, et al. [59] | Polymorphic eruption of pregnancy | Skin stretching, hormonal factors uncertain | No known genetic link | Third trimester | More common in primigravidas | No strong association with pre-existing skin conditions |
Liu, et al. [60] | Pustular Psoriasis of Pregnancy | Dysregulated immune response, IL-17 involvement | Strong genetic link to psoriasis-associated loci (HLA-Cw6) | Third trimester | Occurs in both primiparous and multiparous women | Pre-existing psoriasis and inflammatory conditions increase the risk |
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Alhomieed, M.F.; Al Hartany, L.O.; Alghorab, M.A.; Alsharif, A.; Kaleemullah, A.; Wasaya, H.I.; Alsubaie, K.A.; Al Jehani, A.N.; Kayali, A.M.; AlBasri, S. The Effect of Pregnancy on Dermatological Disorders: A Systematic Review. Clin. Pract. 2025, 15, 68. https://doi.org/10.3390/clinpract15040068
Alhomieed MF, Al Hartany LO, Alghorab MA, Alsharif A, Kaleemullah A, Wasaya HI, Alsubaie KA, Al Jehani AN, Kayali AM, AlBasri S. The Effect of Pregnancy on Dermatological Disorders: A Systematic Review. Clinics and Practice. 2025; 15(4):68. https://doi.org/10.3390/clinpract15040068
Chicago/Turabian StyleAlhomieed, Maya Faissal, Lara Osama Al Hartany, Marya Aref Alghorab, Arwa Alsharif, Ahlam Kaleemullah, Hanan Ismail Wasaya, Khlood Abdulaziz Alsubaie, Ayah Nabil Al Jehani, Amal Mohamed Kayali, and Samera AlBasri. 2025. "The Effect of Pregnancy on Dermatological Disorders: A Systematic Review" Clinics and Practice 15, no. 4: 68. https://doi.org/10.3390/clinpract15040068
APA StyleAlhomieed, M. F., Al Hartany, L. O., Alghorab, M. A., Alsharif, A., Kaleemullah, A., Wasaya, H. I., Alsubaie, K. A., Al Jehani, A. N., Kayali, A. M., & AlBasri, S. (2025). The Effect of Pregnancy on Dermatological Disorders: A Systematic Review. Clinics and Practice, 15(4), 68. https://doi.org/10.3390/clinpract15040068