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CASE REPORT |
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| Year : 2012 | Volume
: 57
| Issue : 2 | Page : 146-148 |
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| Postpartum pemphigoid gestationis |
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Sumi Thomas, Uma Rajan, Sandhya George, Mamatha George
Department of Dermatology, Government Medical College, Calicut, Kerala, India
| Date of Web Publication | 20-Apr-2012 |
Correspondence Address:
Sumi Thomas
Department of Dermatology and Venereology, Government Medical College, Kozhikode - 673 008, Kerala
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0019-5154.94291
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 Abstract | | |
Pemphigoid gestationis (PG) or herpes gestationis is a rare autoimmune subepidermal blistering disorder associated with pregnancy. The condition typically develops during the second or third trimester of pregnancy, but has been rarely reported in the first trimester and postpartum period. Here, we report a case of PG that presented for the first time in the postpartum period, associated with a low birth weight baby.
Keywords: Direct immunofluorescence, herpes gestationis, pemphigoid gestationis, postpartum
How to cite this article:
Thomas S, Rajan U, George S, George M. Postpartum pemphigoid gestationis. Indian J Dermatol 2012;57:146-8 |
| Introduction | |  |
Pemphigoid gestationis (PG) is a rare disease with a reported incidence of 1:50,000. [1] Milton coined the term herpes gestationis in 1872. Although PG is considered as a specific dermatosis of pregnancy, it has also been reported in association with hydatidiform mole and choriocarcinoma. This condition can be confused with other dermatoses of pregnancy like pruritic urticarial papules and plaques of pregnancy and other autoimmune blistering diseases like bullous pemphigoid. Direct immunofluorescence (DIF) is the preferred test for confirmation of diagnosis. [2]
| Case Report | | |
A 19-year-old housewife presented with multiple fluid-filled lesions on the body of 5 days duration. Within hours after her first delivery, pruritic reddish raised lesions appeared over the abdomen and limbs. On the next day, she noticed fluid-filled lesions over the same sites. Newer lesions started developing in the subsequent days and she was referred to our hospital.
On examination, multiple tense vesicles and bullae were present over abdomen, flexural aspects of forearms, thighs and back of trunk [Figure 1] and [Figure 2]. Urticarial plaques were also seen. Nikolsky sign and bulla spread sign were negative. Mucosal lesions were absent. Palms and soles appeared normal. Systemic examination was within normal limits. Her baby was healthy and did not show any skin lesions. However, the birth weight was only 1.8 kg (low birth weight), which could not be attributed to any other cause. We made a provisional diagnosis of PG and the patient was investigated.
Routine investigations including hemogram, liver and renal function tests, blood sugar levels, chest X-ray and urine examination were within normal limits. Tzanck smear showed both eosinophils and neutrophils. Skin biopsy showed subepidermal bulla, dermal edema and a perivascular inflammatory infiltrate composed of lymphocytes, eosinophils and plasma cells [Figure 3]. | Figure 3: Subepidermal bulla with mixed inflammatory infiltrate (H and E, stain ×100)
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These findings were consistent with a diagnosis of PG. DIF findings included a strong linear basement membrane zone (BMZ) band of C3 and a weak discontinuous BMZ band of IgG. IgM, IgA and fibrinogen were negative. The DIF findings were highly suggestive of PG [Figure 4]. | Figure 4: Direct immunofluorescence photomicrograph showing linear band of C3 at the dermoepidermal junction (×200)
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The patient was started on oral prednisolone 30 mg daily along with supportive measures. Her condition improved and she did not develop any further lesions [Figure 5].
Prednisolone was gradually tapered and she was discharged after 2 weeks. During the subsequent visits, the patient did not have any lesions, and steroids were stopped after 8 weeks. Patient is under follow-up for the past 9 months and she is asymptomatic till now.
| Discussion | | |
PG is an uncommon autoimmune blistering disease with autoantibodies targeting the hemidesmosomal proteins BP180 and less commonly BP230. [3] The circulating IgG antibody, mainly of the IgG 1 subclass, which fixes complement at the BMZ is known as the herpes gestationis (HG) factor. Immunogenic studies have revealed a marked increase in HLA antigens DR3 and DR4. It is considered that HLA mismatch between mother and fetus triggers an immune response which initiates an allogenic response to placental BMZ, which then cross reacts with skin. Recent immunohistochemical studies have identified a T-cell population with a prevalent T helper (Th2) phenotype in the lesional skin of PG subjects, [4] which may be implicated in the recognition of self-antigens and production of pathogenic autoantibodies.
Recurrence of the skin lesions in subsequent pregnancies and postpartum flare up may indicate the persistence of circulating autoantibodies. Satoh et al. [5] reported that antibodies to BP antigen (AG)2 were detectable for several months in the serum of patients with postpartum PG even after subsidence of skin lesions. However, the HG factor is not detected in all cases. Therefore, there may be some factors other than antibodies to BP AG2, which may contribute to blistering in PG. The finding that DIF for C3 remained positive for intervals ranging from 6 months to 4 years after the cessation of clinical activity in eight of nine patients with PG supports this speculation. [6]
Histopathology shows subepidermal bulla containing numerous eosinophils. The essential component for the diagnosis of PG is the finding of C3 with or without IgG in a linear band along the BMZ of perilesional skin on DIF. C3 and IgG deposits are seen in the placenta and fetal skin also. [7] Indirect immunofluorescence demonstrates circulating IgG autoantibodies in 20-60% of cases, but complement fixation test reveals these specific autoantibodies in 90% of PG patients. [1],[6]
PG typically occurs during the second or third trimester of pregnancy or rarely in the immediate postpartum period and usually resolves within 3 months after delivery. [1] It starts as intensely pruritic, erythematous annular urticarial plaques on which blisters develop. The lesions are described more frequently on the abdomen, with extension to flexural areas. Face, mucus membranes, palms and soles are usually spared. The disease often resolves during the later part of gestation and flares at the time of delivery. Rarely, the disease may manifest within hours of parturition [8] as in our patient. Most patients experience spontaneous regression over weeks to months postpartum. Recurrent disease flares have been reported from 2 weeks up to 12 years postpartum. [2] Recurrence with menstruation or with subsequent use of oral contraceptives has often occurred. Fetal risks may also be present in PG and include miscarriages, prematurity, low birth weight babies and transient erythema and blistering. [9]
As HG is a rare disease, controlled studies are not available. However, systemic corticosteroids remain the mainstay of treatment. [10] Most patients respond to a dose of 0.5 mg/kg of prednisolone daily. Maintenance therapy, generally at a lower dosage, may be required throughout gestation. Dapsone, cyclosporine, methotrexate, cyclophosphamide and azathioprine have been tried in individual cases with variable results.
In conclusion, though PG is considered as a specific dermatosis of pregnancy, it can manifest for the first time in the immediate postpartum period and may be associated with fetal risks like low birth weight, as in our case.
| References | | |
| 1. | Shornick JK, Bangert JL, Freeman RG, Gilliam JN. Herpes gestationis: Clinical and histologic features of twenty-eight cases. J Am Acad Dermatol 1983;8:214-24. 
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| 2. | Castro LA, Lundell RB, Krause PK, Gibson LE. Clinical experience in pemphigoid gestationis: Report of 10 cases. J Am Acad Dermatol 2006;55:823-8.
[PUBMED] [FULLTEXT] |
| 3. | Kelly SE, Bhogal BS, Wojnarowska F, Whitehead P, Leigh IM, Black MM. Western blot analysis of the antigen in pemphigoid gestationis. Br J Dermatol 1990;122:445-9.
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| 4. | Fabbri P, Caproni M, Berti S, Bianchi B, Amato L, De Pità O, et al. The role of T lymphocytes and cytokines in the pathogenesis of pemphigoid gestationis. Br J Dermatol 2003;148:1141-8.
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| 5. | Satoh S, Seishima M, Sawada Y, Izumi T, Yoneda K, Kitajima Y. The time course of the change in antibody titres in herpes gestationis. Br J Dermatol 1999;140:119-23.
[PUBMED] [FULLTEXT] |
| 6. | Holmes RC, Black MM, Jurecka W, Dann J, James DC, Timlin D, et al. Clues to the aetiology and pathogenesis of herpes gestationis. Br J Dermatol 1983;109:131-9.
[PUBMED] |
| 7. | Katz A, Minto JO, Toole JW, Medwidsky W. Immunopathologic study of herpes gestationis in mother and infant. Arch Dermatol 1977;113:1069-72.
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| 8. | Kroumpouzos G, Cohen LM. Dermatoses of pregnancy. J Am Acad Dermatol 2001;45:1-19.
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| 9. | Shornick JK, Black MM. Fetal risks in herpes gestationis. J Am Acad Dermatol 1992;26:63-8.
[PUBMED] |
| 10. | Jenkins RE, Hern S, Black MM. Clinical features and management of 87 patients with pemphigoid gestationis. Clin Exp Dermatol 1999;24:255-9.
[PUBMED] [FULLTEXT] |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5] |
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| Authors of Document Niaz, F., Wahid, Z., Ahmed, I., Nasreen, S. | | Journal of Pakistan Association of Dermatologists. 2013; | | [Pubmed] | |
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