A severe persistent case of pemphigoid gestationis treated with intravenous immunoglobulins and cyclosporin

Pemphigoid Gestationis - Case Report and Review of Literature

Pemphigoid gestationis (PG) is a rare autoimmune bullous skin disorder which usually presents with intense pruritus and urticarial lesions that may evolve into vesicles and tense blisters. In majority of patients, it starts in the second or third trimester of pregnancy and resolves spontaneously after delivery. Lesions appear in the periumbilical area in 90% of patients and rapidly spread centrifugally to other parts of the body. The diagnosis needs to be confirmed by direct immunofluorescence test (DIF) with indirect immunofluorescence test (IIF), ELISA and immunoblot techniques playing role in diagnosis and/or monitoring antibodies level. Mild symptoms of PG can be treated with topical therapy only, but in severe course of the disease the treatment may be escalated to oral corticosteroids. We present an unusual case of PG started 2 weeks after delivery with an updated overview on the epidemiology, pathology, clinical picture, treatment, and complications of the disease.

Managing Pemphigoid Gestationis

Pemphigoid gestationis (PG) is important to diagnose and treat because it carries considerable morbidity for the pregnant woman and can also constitute a risk to the fetus. Herein, the treatment options for PG and a proposed treatment algorithm for PG during pregnancy, breastfeeding, and late postpartum are reviewed.

A resistant case of pemphigus gestationis successfully treated with cyclosporine

Pemphigoid gestationis (PG) is a rare autoimmune blistering disease of pregnancy caused by antibasement membrane zone auto-antibodies. The usual clinical findings are multiple pruritic urticarial papules and plaques, target lesions, vesicles, and blisters that occur during the second and third trimesters of pregnancy or in the immediate postpartum period. The disease is often treated with topical corticosteroids and oral antihistaminics. In more severe cases, systemic corticosteroids are needed. Herein, we report a case of resistant PG that responded to treatment with cyclosporine.

Gestational pemphigoid

Gestational pemphigoid (pemphigoid gestationis, PG) is a rare autoimmune skin disorder occurring characteristically during pregnancy. Autoantibodies against placental BP180 (also known as BPAG2 or collagen XVII) cause damage to the skin basement membrane, resulting in severe itching and blistering rash over the body and the extremities. The diagnosis of PG is confirmed by immunofluorescence analysis of a skin biopsy, while serum levels of pemphigoid antigen BP180 antibody can be used to assess disease activity. PG with mild symptoms can be treated with topical corticosteroids, while oral corticosteroids are the mainstay in treatment of severe PG. PG usually flares up at the time of delivery, and resolves spontaneously shortly after. However, relapses in subsequent pregnancies are common. As PG has been linked to the risk of prematurity and fetal growth restriction, prenatal monitoring jointly by a dermatologist and an obstetrician is recommended. Mothers should also be informed of the potential risk of re-activation of the disease in subsequent pregnancies and during hormonal contraception.

Specific dermatoses of pregnancy and their treatment

The specific dermatoses of pregnancy represent a diverse group of intensely pruritic dermatoses, occurring only in the puerperal state. The relative rarity of these conditions, the often variable clinical appearance, and the lack of definitive diagnostic tests have led to confusion regarding the appropriate diagnosis and management of the specific dermatoses of pregnancy. Herein we review the clinical characteristics, diagnosis and treatment of five dermatoses occurring during pregnancy: pruritic urticarial papules and plaques of pregnancy, atopic eruption of pregnancy, pemphigoid gestationis, intrahepatic cholestasis of pregnancy, and pustular psoriasis of pregnancy.

Intravenous immunoglobulin in the treatment of autoimmune bullous dermatoses: an update

High-dose intravenous immunoglobulin (IVIg) is being increasingly utilized as an off-label therapy for a variety of autoimmune and inflammatory conditions across various specialties. Numerous reports have shown that it is an effective treatment for autoimmune skin blistering disorders. Unlike most therapies for blistering disorders, IVIg is not immunosuppressive and has a favorable side effect profile. This has allowed its use to expand dramatically over the last decade. However, due to the rarity and severity of autoimmune skin blistering diseases, well-designed prospective trials are generally lacking. This work highlights major research developments and the best evidence to date regarding the treatment of autoimmune pemphigus, bullous pemphigoid, mucous membrane pemphigoid, epidermolysis bullosa acquisita, pemphigoid gestationis, and linear IgA dermatosis with IVIg, providing an update on its efficacy, proposed mechanisms of action, side effect profile, and indications for use.

Pemphigoid gestationis: current management

Pemphigoid gestationis is an autoimmune blistering disease of pregnancy caused by autoantibodies directed against BP180 (type XVII collagen) in the basement membrane zone. This article discusses the current management of this rare disease.

Pemphigoid gestationis

A 39-year-old woman in the 39th week of her fifth pregnancy presented with severe itching. In recent weeks she had developed an increasingly itchy rash on her trunk and arms. Upon examination we observed multiple erythematous plaques and vesicles. Histological examinations of two skin biopsies confirmed the diagnosis of pemphigoid gestationis. Because the patient's complaints worsened we decided to deliver the baby, and as it was in transverse lie this was by caesarean section. A healthy son without rash was born. Although pemphigoid gestationis occurs in only 1 in 50,000 pregnancies, it is very important to be aware of this condition when a pregnant woman has itching. Not recognising pemphigoid gestationis may lead to inadequate maternal treatment and possible preterm birth and neonatal pemphigoid gestationis.

Antepartum Intravenous Immunoglobulin Therapy in Refractory Pemphigoid Gestationis: Case Report and Literature Review

Background:

Pemphigoid gestationis is an autoimmune blistering disease affecting pregnant women. Treatment often consists of topical corticosteroids, oral antihistamines, and oral prednisone followed by immunosuppressants. Refractory cases in antepartum patients present a particular therapeutic challenge as the majority of second-line agents are contraindicated until the patient has delivered.

Objective:

The following report describes the case of a 34-year-old woman pregnant for the third time at 16 weeks' gestation. Her previous two pregnancies were complicated by pemphigoid gestationis but were successfully managed with oral prednisone and topical agents. During her third pregnancy, the initial lesions were controlled with oral prednisone, but attempts to decrease her dose resulted in disease flare.

Conclusion:

Monthly infusions of intravenous immunoglobulin (40 g intravenously for 3 consecutive days for 120 g total) proved to be successful in reducing the dose of oral prednisone required to maintain disease remission. A healthy baby was delivered at 37.5 weeks.

Evidence for the use of intravenous immunoglobulins--a review of the literature

Intravenous immunoglobulins (IVIg) were first introduced in the middle of the twentieth century for the treatment of primary immunodeficiencies. In 1981, Paul Imbach noticed an improvement of immune-mediated thrombocytopenia, in patients receiving IVIg for immunodeficiencies. This opened a new era for the treatment of autoimmune conditions with IVIg. Since then, IVIg has become an important treatment option in a wide spectrum of diseases, including autoimmune and acute inflammatory conditions, most of them off-label (not included in the US Food and Drug Administration recommendation). A panel of immunologists and internists with experience in IVIg therapy reviewed the medical literature for published data concerning treatment with IVIg. The quality of evidence was assessed, and a summary of the available relevant literature in each disease was given. To our knowledge, this is the first all-inclusive comprehensive review, developed to assist the clinician when considering the use of IVIg in autoimmune diseases, immune deficiencies, and other conditions.

Use of intravenous immunoglobulin therapy in autoimmune blistering diseases

Autoimmune mucocutaneous blistering diseases (AMBD) are an interesting group of rare diseases that affect the mucous membranes and the skin and are frequently or potentially fatal. The clinical presentation is significantly variable, as is the course and prognosis. The immunopathology is well characterized and the target antigens to which the autoantibodies are directed have been studied by various investigators. A significant majority of the patients respond to conventional therapy, which consists of high-dose long-term systemic corticosteroids and immunosuppressive agents. This treatment program has significantly improved the prognosis in many patients. In such patients, significant side effects of the drugs may appear and produce a very poor quality of life. In patients with progressive diseases, especially those with mucous membrane pemphigoid, the significant sequela; such as blindness, aphonia, and stenosis of the anal and vaginal canals can occur. In several patients treated with conventional immunosuppressive therapy, death occurs as a consequence of prolonged immune suppression leading to opportunistic infections. In this manuscript, the published data on the use of immunoglobulins intravenous (IGIV) in patients with AMBD is presented. The most important features of IGIV in patients with AMBD are: 1) the ability to clinically control the disease; 2) the ability to induce and maintain a long-term clinical remission; 3) a lower incidence of side effects; and 4) a higher quality of life. The important characteristic of the IGIV therapy in the AMBD is two-fold. First, the therapy, when given according to a published protocol, produces a lasting and long-term clinical remission, rather than a temporary arrest of the disease. Second, the therapy, as described in the protocol, has a very definitive endpoint. Consequently, once the patients are treated and go into long-term remission, the therapy is no longer required. The significant positive results obtained with IGIV are to a large extent also due to the associated aggressive topical therapy that was used and the frequent use of sublesional injections with triamcinolone. The rapid and early detection of cutaneous and mucosal infections and their treatment with systemic antibiotics is also a very important feature of IGIV therapy. When patients are under long-term conventional therapy, the infections are often not detected because they lack the ability to mount signs of inflammation. It is also becoming increasingly clear for patients to have a successful outcome, in treatment with IGIV therapy, it is critical that the physician spends a significant amount of time with each patient, monitor the therapy closely, and be familiar with the overall health of the patient. It is also best if the therapies are instituted by a physician who has significant interest and experience in blistering diseases and IGIV therapy.

Treatment of autoimmune mucocutaneous blistering diseases with intravenous immunoglobulin therapy

Autoimmune mucocutaneous blistering diseases (AMBDs) are a group of rare diseases that affect the skin and mucous membranes and are potentially fatal. They have variable clinical presentation, course and prognosis. Their immunopathology is well-characterised and target antigens have been studied. Many patients respond to conventional therapy, which consists of high-dose long-term systemic corticosteroids with an immunosuppressive agent, but side effects develop that can produce a poor quality of life. Many patients develop significant sequelae, such as blindness, loss of voice, vaginal and anal stenosis. In most patients cause of death is opportunistic infections secondary to immune suppression. To date, intravenous immunoglobulin (IVIg) has been reported to have benefited 156 patients with AMBDs. Its most important features include the ability to reduce or eliminate conventional therapy, the enabling of clinical control, the ability to induce and maintain long-term clinical remission, the capacity for usage based on a defined protocol with a described end point and a resulting increase in quality of life. IVIg produces the best clinical outcome when combined with aggressive topical therapy, sublesional injections of triamcinolone and rapid detection, and early treatment of cutaneous and mucosal infection. Successful therapy requires a physician to spend significant time with each patient. This manuscript provides the opinion of the author on the current use of IVIg to treat AMBDs.

Efficacy and safety of intravenous immunoglobulin for immune-mediated skin disease: current view

Intravenous immunoglobulins (IVIgs) exert a variety of immunomodulating activities and are, therefore, increasingly being used for the treatment of immune-mediated as well as autoimmune diseases. There is also accumulating evidence that high-dose IVIg (hdIVIg) is highly efficacious in the treatment of skin diseases, despite the lack of evidence from randomized, double-blind, placebo-controlled trials. A major advantage of hdIVIg in comparison with other commonly used immunomodulating therapeutic strategies is the excellent safety profile. Accordingly, IVIgs have been used successfully for the treatment of bullous autoimmune diseases such as pemphigus and bullous pemphigoid, dermatomyositis, scleroderma, cutaneous lupus erythematosus, toxic epidermal necrolysis, and erythema exudativum multiforme. In most cases, hdIVIg is effective only in combination with other immunomodulating strategies and allows for the reduction of adjuvants. Adverse effects of hdIVIg are generally mild and self-limiting. These include headache, myalgia, flush, fever, nausea or vomiting, chills, lower backache, changes in blood pressure, and tachycardia. To avoid infusion-related rigors, headaches, and other adverse events, pre-treatment with analgesics, NSAIDs, antihistamines, or low-dose intravenous corticosteroids may be beneficial. Controlled, double-blind, long-term clinical trials and a better understanding of the complex immunomodulating mechanism of IVIg are required to ultimately optimize dose, frequency, duration, and mode of IVIg administration.

Use of IGIV in the treatment of immune-mediated dermatologic disorders

Immunoglobulin (Ultravenous, IGIV) is now used in a variety of immune-mediated diseases. Its presumed mechanism of action involves both anti-inflammatory and immunomodulatory activities. A number of dermatologic conditions are believed to be immune mediated and in these disorders, IGIV has shown benefit in reducing symptoms and the need for cortecosteroids or cytotaxic drugs. In many of these diseases, the initial benefits seen in open-labeled trials must be confirmed in controlled clinical trials.

Chronic pemphigoid gestationis: comparative clinical and immunopathological study of 10 patients

BACKGROUND

Pemphigoid gestationis (PG) is a rare autoimmune bullous disorder occurring during the last trimester of pregnancy and usually regressive within 3 months after delivery. Prolonged forms of the disease lasting more than 6 months after delivery have been reported as chronic PG.

OBJECTIVE

The aim of the present study was to compare the clinical and immunopathological findings between 4 patients presenting a normal regression of the disease after delivery and 6 patients with a chronic course.

METHODS

All patients were evaluated and studied by clinical patterns (age, mucosal and cutaneous involvement, obstetrical history, duration of the blistering disease and response to treatment), by direct and indirect immunofluorescence and Western blot. Eight patients were studied by immunoelectron microscopy (IEM) and 3 patients had an indirect IEM.

RESULTS

Patients with chronic PG were older, had multigravidity, a history of PG during previous pregnancies, widespread cutaneous eruption and mucosal involvement. Subclass analysis of circulating autoantibodies showed an IgG1 anti-BP180 response in all patients except 1 with disease of 7 years' duration. Direct IEM was positive in 6/8 patients showing a labeling of the lamina lucida, and indirect IEM using colloidal gold probes confirmed the localization of the target antigens to the proximal part of the anchoring filaments in the lamina lucida.

CONCLUSION

This study suggests that, even in chronic long-lasting PG, IgG1 remains the predominant subtype of IgG. Therefore no biological and predictable marker of chronicity can be ascertained from this series.

Specific dermatoses of pregnancy: an evidence-based systematic review

OBJECTIVE

We conducted an evidence-based systematic analysis of the literature on specific dermatoses of pregnancy.

STUDY DESIGN

The bibliographic databases MEDLINE and EMBASE were screened for studies and reports in all languages about herpes gestationis, pruritic urticarial papules and plaques of pregnancy, pruritic folliculitis of pregnancy, and prurigo of pregnancy from January 1962 to January 2002. As main index terms, including analogs and derivatives, we used the names of specific dermatoses of pregnancy. Intrahepatic cholestasis of pregnancy, not a primary dermatosis, was included herein because this disorder is associated with pregnancy and its secondary skin manifestations must be differentiated from specific dermatoses of pregnancy. Other sources were abstract books of symposia and congresses, theses, textbooks, monographs, reviews, editorials, letters to the editor, free or rapid communications, and the reference lists from all the articles that were retrieved. All articles selected for inclusion in this review were evaluated critically with regard to their impact factor and evidence-based contribution to this field, as measured by their citation index and impact factor of the journal in which they were published. Approximately 39% of articles met the selection criteria.

RESULTS

The clinical features and prognosis of the specific dermatoses of pregnancy have been delineated through a number of retrospective and cohort studies. The molecular biologic and immunogenetic properties of herpes gestationis, pruritic urticarial papules and plaques of pregnancy, and intrahepatic cholestasis of pregnancy have been further clarified. A meta-analysis in this review reveals a higher prevalence of multiple gestation pregnancy (11.7%) among patients with pruritic urticarial papules and plaques of pregnancy. Several investigations have unraveled the fetal complications in intrahepatic cholestasis of pregnancy and herpes gestationis. New treatment modalities in intrahepatic cholestasis of pregnancy (cholestyramine, ursodeoxycholic acid) and herpes gestationis (cyclosporin, intravenous immunoglobulin, and tetracyclines postpartum) have shown promise and warrant further evaluation.

CONCLUSION

During the past few decades, a significant amount of new data has provided new insights into the classification, pathogenesis, treatment, prognosis, and fetal risks that are associated with the specific dermatoses of pregnancy.

Dermatoses of pregnancy

The dermatoses of pregnancy can be classified into the following 3 groups: physiologic skin changes in pregnancy, dermatoses and cutaneous tumors affected by pregnancy, and specific dermatoses of pregnancy. Correct diagnosis and classification are essential for the treatment of these disorders, when necessary. Laboratory investigations are required when the diagnosis remains in question despite a careful history and thorough physical examination. A discussion with the pregnant woman about the nature of her skin condition, and the possible fetal risks associated with it, is imperative.

High-dose intravenous immunoglobulins: An approach to treat severe immune-mediated and autoimmune diseases of the skin

Adjuvant high-dose intravenous immunoglobulins (IVIgs) are being used increasingly in a range of immune-mediated and autoimmune diseases. Although numerous immunomodulatory mechanisms have been suggested, the exact mechanisms of action are poorly understood. The efficacy of IVIg in certain diseases has been proven in clinical trials, insofar as IVIg is approved as the therapy of choice for Kawasaki syndrome or idiopathic thrombocytopenic purpura. IVIg treatment has been shown to be safe, without the many drug-related adverse effects, including systemic immunosuppression, that are related to corticosteroids and other immunosuppressive agents. Current dermatologic uses of IVIg are increasing, which calls for adequately controlled clinical trials. This review focuses on experiences with IVIg therapy for skin diseases and discusses current opinion concerning its potential immunomodulating mechanisms.

The specific dermatoses of pregnancy: a re-appraisal

Pregnancy is associated with immunological, endocrine, metabolic and vascular changes that may adversely affect the skin. The specific dermatoses of pregnancy are disease entities almost exclusively related to the pregnancy or the puerperium.

LEARNING OBJECTIVE

At the conclusion of this learning activity, participants should be aware of the main entities of the specific pregnancy dermatoses, their clinical presentations, the main diagnostic criteria and therapeutic options.

A review of high-dose intravenous immunoglobulin (hdIVIg) in the treatment of the autoimmune blistering disorders

High-dose intravenous immunoglobulin (hdIVIg) is being used increasingly for dermatological indications. Its mode of action is via a number of proposed mechanisms and it is not associated with the many side-effects of steroids and other immunosuppressive agents. The evidence for using hdIVIg in the treatment of autoimmune bullous disorders is based on uncontrolled trials and case reports. However, there are now 62 reported patients and this review aims to make a critical assessment of the current data. This has been obtained from a Medline search of the English literature from 1966 to 2000 for pemphigus vulgaris, pemphigus foliaceus, bullous pemphigoid, pemphigoid gestationis, cicatricial pemphigoid, epidermolysis bullosa acquisita and linear IgA disease. Taken together hdIVIg was effective in 81% of the patients with blistering disease. Patients appear to be more likely to respond when hdIVIg is used as adjunctive therapy (91% response rate) than as monotherapy (56% response rate). hdIVIg may offer a safe potential therapeutic avenue for resistant cases of the autoimmune bullous disorders but should be further assessed using double-blind placebo-controlled trials.

Cyclosporine and tacrolimus in dermatology

Immune modulators are being used with increasing frequency in dermatology. This article reviews two such agents, cyclosporine and tacrolimus. Discussion emphasizes the pharmacology, side effects, and uses of these two drugs in dermatologic disorders.

Pemphigoid gestationis: a review

Pemphigoid gestationis is a rare autoimmune vesiculobullous skin disease closely related to the pemphigoid group of blistering disorders. It is unique in that it is most frequently associated with pregnancy. Diagnosis is made on the basis of the presence of a subepidermal vesicle on routine histologic examination and of linear deposition of the third component of complement along the basement membrane zone of perilesional skin. Abnormal expression of major histocompatibility complex class II molecules in the placenta may trigger the initiating immunologic event in this organ, which is followed by cross-reactivity with an antigen present in the skin and the characteristic cutaneous signs of the disease. The immunogenetics of this disorder are interesting. A role for the involvement of major histocompatibility complex class II antigens seems likely because of the association with human leukocyte antigens DR3 and DR4. Major histocompatibility complex class III associations have also been observed, as has a high frequency of anti-human leukocyte antigen antibodies. We review the current understanding of the molecular biologic and immunogenetic properties of this disease and discuss treatment and potential impact on the fetus.

Intravenous immunoglobulin in autoimmune and inflammatory dermatoses. A review of proposed mechanisms of action and therapeutic applications

Off-label use of intravenous immunoglobulin (IVIG) at high doses has resulted in numerous anecdotal reports of its effectiveness in a variety of autoimmune and inflammatory conditions. Despite its growing acceptance as a viable therapeutic option in the management of several such disorders, the poorly defined mechanism of action of IVIG has stifled its rational therapeutic application. The lack of carefully designed prospective randomized clinical trials has further fueled controversy and mitigates against optimal application of this burgeoning therapy. Nevertheless, some standardization of IVIG therapy is slowly advancing that promises to support the use of this treatment for a growing number of autoimmune and inflammatory dermatoses.

High-dose intravenous immune globulin for the treatment of autoimmune blistering diseases: an evaluation of its use in 14 cases

High-dose intravenous immune globulin (IVIG) is used to treat a wide variety of autoimmune diseases. We report our experiences of its use in a retrospective study of 14 patients with autoimmune blistering diseases, namely epidermolysis bullosa acquisita (EBA), two; bullous pemphigoid (BP), two; pemphigoid gestationis (PG), one; nodular pemphigoid, two; and pemphigus vulgaris (PV), seven. Two patients with refractory EBA improved following regular courses of IVIG given as monotherapy. IVIG had a steroid-sparing effect in 10 patients with PV, BP and PG. However, the clinical effects were transient and of variable intervals, and repeated courses of IVIG were required. The rapid actions of IVIG were of particular benefit in two patients with extensive, rapidly progressive PV and in one patient with BP in whom swift disease control was required. In such cases, when rapid disease control is paramount, we recommend IVIG used in conjunction with conventional treatments as a safer and less invasive alternative to plasmapheresis. IVIG was ineffective in two patients with nodular pemphigoid. Analysis of indirect immunofluorescence (IIF) titres before and after IVIG showed that a fall in titre occurred after 78% of treatments and was observed in all disease groups. However, like the clinical improvements, the falls in IIF titres were transient and of variable interval, and titres rose back to pretreatment levels in all but one patient. IVIG appears to be beneficial under certain circumstances for the treatment of autoimmune blistering diseases but controlled trials are required to define its therapeutic role further.