Objective

Eczema, also known as atopic dermatitis, is a chronic skin condition that causes dry, itchy, scaly patches. It's a common condition that usually starts in childhood, but it can affect people of any age. Eczema during pregnancy can be unpredictable, with some women experiencing flare-ups and others seeing improvement. It's common for women of childbearing age to experience eczema, and it can affect up to half of all pregnant women.

We report this case to highlight the complexities of managing severe infected eczema complicated by sepsis during pregnancy, emphasizing the importance of multidisciplinary care, the use of high-dose steroids, and the prevention of steroid crises during labour for optimal maternal and fetal outcomes.

Case Summary

A 29-year-old woman, gravida 2 para 1, at 28 weeks’ gestation, presented with a severe flare of atopic eczema complicated by secondary bacterial infection and systemic features suggestive of sepsis. Her medical history included eczema, hypothyroidism, thalassemia trait, latent tuberculosis, and a previous caesarean section.

She was admitted with widespread erythematous, exudative, and painful skin lesions, predominantly on the limbs and trunk, associated with pyrexia, dehydration, and tachycardia. Blood tests revealed elevated CRP and eosinophilia, and swabs grew methicillin-sensitive Staphylococcus aureus.

She received high-dose intravenous flucloxacillin, supportive care with fluids and emollients, and was commenced on oral prednisolone. Due to poor venous access and prolonged therapy, a PICC line was inserted. She was also treated empirically for suspected pulmonary embolism with therapeutic low molecular weight heparin.

During her prolonged hospital stay (over three weeks), dermatology, obstetric, infectious disease, and respiratory teams were involved. TB prophylaxis was initiated following latent TB re-evaluation. Her condition gradually improved with tapering steroids and continued antibiotic therapy.

At 35+4 weeks, she presented in spontaneous preterm labour and was given IV hydrocortisone intrapartum due to recent prolonged steroid use. She delivered a healthy baby via uncomplicated vaginal birth.

Postnatal recovery was uneventful.

Diagnosis

Diagnosing eczema in pregnancy involves a combination of clinical history, physical examination, and select investigations to rule out complications and alternative causes of rash in pregnancy.

Clinical Assessment

Personal or family history of atopy (eczema, asthma, allergic rhinitis)

Itch as a primary symptom

Chronicity or recurrent flares

Response to emollients or steroids

Intense pruritus

Dry, red, inflamed, or lichenified patches

Common sites: flexural areas, hands, face, neck, trunk

Physical Examination

Investigations

Indicated if superinfection is suspected

Most common pathogen: Staphylococcus aureus

Elevated C-reactive protein (CRP) in infection or inflammation

Eosinophilia in atopic disease

Low albumin in extensive disease or poor nutrition

From skin swabs or blood in systemic symptoms

If signs of systemic illness (e.g., dyspnea, hypoxia), consider chest X-ray or CTPA to rule out pneumonia or pulmonary embolism

Rarely needed during pregnancy unless the diagnosis is unclear or unusual features present

Differentials to Consider

Especially important in pregnancy as other dermatoses can mimic or co-exist: