Autoimmune progesterone dermatitis

Progestogen Hypersensitivity

Progestogen hypersensitivity (PH) is a heterogeneous disease characterized by diverse cutaneous manifestations, bronchospasm, and/or anaphylaxis. Possible triggers include ovarian progesterone and exogenous progestogens. The timing of symptoms is critical to diagnose PH: during the luteal phase of the menstrual cycle for the endogenous form and after exposure to progestins for exogenous PH. Diagnostic modalities such as progesterone skin testing have low sensitivity and specificity for PH. When exogenous PH is suspected, the allergist should consider a progestogen challenge. Treatment strategies should be tailored for each patient, including symptom-directed therapies, ovulation suppression, and progesterone desensitization. Future studies should explore the mechanisms of PH, validation of diagnostic criteria, and standardization of treatment strategies.

Autoimmune Progesterone Dermatitis: A Systematic Review

ABSTRACT

Autoimmune progesterone dermatitis (AIPD) is a cyclical, cutaneous reaction to endogenous progesterone that occurs throughout the menstrual cycle. The cutaneous manifestations of AIPD vary greatly from patient to patient, ranging anywhere from urticaria to erythema multiforme to anaphylaxis. As such, recognition, diagnosis, and management of this condition are difficult for clinicians. In the present article, we conducted a systematic review of 112 articles and 132 individual cases to summarize the clinical features and presentation of AIPD while also summarizing the successes and failures of different treatment plans. Despite the great variety in clinical presentations, it is clear from the data that ovulation-suppressing medical therapies and surgery have the greatest success in treating AIPD, whereas more commonly used therapies such as antihistamines and systemic corticosteroids frequently fail in providing any relief. Further research is necessary to determine the exact pathogenesis of AIPD and allow for more targeted treatment.

Hormonal Effects on Urticaria and Angioedema Conditions

Women appear to be more frequently affected with urticaria and angioedema. Sex hormones are believed to have an important mechanistic role in regulating pathways involved in these conditions. This effect is likely nonspecific for chronic spontaneous urticaria (CSU) or many forms of angioedema (AE), because many other chronic diseases such as asthma are also affected by sex hormones. The role of sex hormones has been better elucidated for hereditary AE, because they have been shown to have multiple effects including upregulation of FXII, an important activator of the kallikrein pathway. However, their role in the underlying pathogenesis for CSU is less clear. Autoimmunity is clearly linked to CSU, which is more common in women. This suggests that sex hormones could act as adjuvants in activating or upregulating autoimmune pathways. The purpose of this review is to discuss in detail the role of sex hormones in CSU and AE and how a better understanding of the impact hormones has on these conditions might lead to new treatment advancements with better clinical outcomes.

Ulcerative Stomatitis as the Sole Manifestation of Progesterone Hypersensitivity

Oral mucosal involvement of autoimmune progesterone dermatitis is exceedingly rare. This report presents a woman with very painful ulcerative stomatitis that recurred with every menstrual period, in the absence of other clinical manifestations. Ulcers were eventually controlled with oral tamoxifen treatment for three months. Subsequent follow-up visits showed complete resolution of her oral ulcerative lesions. The non-specific nature of her oral ulcers resulted in multiple medical and dental consultations and a delay in reaching the final diagnosis. Clinicians should be aware of the possibility of progesterone hypersensitivity when painful oral ulcerative lesions appear concurrently with each progesterone surge.

Progestogen Sensitization: a Unique Female Presentation of Anaphylaxis

PURPOSE OF REVIEW

Progestogen hypersensitivity (PH) is a condition which typically occurs in women in childbearing years with a spectrum of symptoms ranging from urticaria with or without angioedema, dermatitis to systemic anaphylaxis. Herein, a clinical case of PH is presented followed by a discussion on the evaluation, diagnosis, and management of PH.

RECENT FINDINGS

Progestogen hypersensitivity (a.k.a. "autoimmune progesterone dermatitis") symptoms are associated with exogenous progestin exposure (e.g., contraceptive medicines, in vitro fertilization therapy) or endogenous progesterone from progesterone surges during the luteal phase of the menstrual cycle and pregnancy. This condition can be difficult to recognize due to its heterogeneous clinical presentation. The mechanism of PH is believed to be primarily IgE-mediated; however, less commonly other immune responses may be involved. There is now a useful progesterone specific IgE immunoassay to assist in diagnosis and well-defined treatment algorithms that can be used to successfully manage PH. The epidemiology of PH is still poorly elucidated but is likely to be encountered by clinicians and especially allergists given the extensive use of oral contraceptives and increased use of supra-physiologic doses of progesterone required to support pregnancy in IVF. Including PH in the differential diagnosis of women presenting with cyclic hypersensitivity will accelerate diagnosis and successful management of this condition.

Catamenial dermatoses associated with autoimmune, inflammatory, and systemic diseases: A systematic review,

Background

Sex hormones are important in female sexual physiology, growth, and homeostasis. Through skin receptors, sex hormones contribute to the dermatologic pathology known as catamenial dermatoses.

Objective

This study aims to summarize the literature on catamenial dermatoses and menses-induced exacerbations of chronic dermatoses.

Methods

This systematic review used the PRISMA method. PubMed was searched using the terms “menses” and “skin” in July 2018, and an assessment was conducted of the relevant literature on skin diseases related to non-pathologic menstruation, such as polycystic ovarian syndrome. Pathology associated with androgenetic acne was excluded from the study.

Results

A total of 102 studies with 1269 female patients were included. The most commonly reported primary catamenial dermatoses were autoimmune progesterone dermatitis and autoimmune estrogen dermatitis. The most commonly reported chronic skin disorders exacerbated by menses were psoriasis, Behcet’s disease, and eczematous dermatoses.

Conclusion

Physicians should be aware of the nature of catamenial dermatoses and their presentation with normal sexual physiology. Patients with chronic dermatoses should be appropriately counseled on menstruation-related exacerbations. Further research needs to be conducted to determine the interplay between immune regulation and sex hormones in catamenial dermatoses and to elucidate effective therapies.

Progestogen Hypersensitivity

PURPOSE OF REVIEW

Progestogen hypersensitivity (PH) is a rare disorder which usually occurs in women of childbearing age with symptoms ranging from urticaria with or without angioedema, multiple organ involvement consistent with allergic anaphylaxis, to a spectrum of other non-evanescent skin eruptions. In this review, we present a clinical vignette of PH and discuss the clinical presentation and proposed pathomechanisms, diagnosis, and treatment of PH.

RECENT FINDINGS

The hypersensitivity symptoms are associated with exogenous progestin exposure (e.g., contraceptive medicines, in vitro fertilization therapy) or endogenous progesterone from progesterone surges during the luteal phase of the menstrual cycle and pregnancy. Recognition of this condition can be challenging to the clinician due to its heterogeneous clinical presentation. It has been recently proposed to use the new term "progestogen hypersensitivity" to replace "autoimmune progesterone dermatitis" due to the lack of evidence supporting an autoimmune mechanism for this disorder. In addition, diagnostic and treatment algorithms are now available that can lead to successful management of this condition. More new developments of Progesterone desensitization protocols are now available which appear to be the safest and most effective long-term treatment option for PH. With the extensive use of oral contraceptives and increased use of supra-physiologic doses of progesterone to support pregnancy in in vitro fertilization, there is likely to be a higher prevalence of PH in the future than currently recognized. Therefore, the allergist-immunologist will be required to collaborate with gynecologists and reproductive endocrinologists to diagnose and treat this condition.

Progestogen Hypersensitivity: An Evidence-Based Approach to Diagnosis and Management in Clinical Practice

Heterogeneous presentations of disease pose particular diagnostic and management challenges to the clinician. Progestogen hypersensitivity (PH) classically consists of hypersensitivity symptoms to endogenous progesterone during the luteal phase of the menstrual cycle. However, with the rise of assisted fertility and the exponential growth in the use of exogenous progestins for contraception, PH's prevalence and symptom heterogeneity have increased. In this article, we focus on the clinical approach to PH diagnosis with an emphasis on key elements of the history, physical, and testing modalities. We also review the current evidence for successful management and treatment across a broad range of patients.

Autoimmune progesterone dermatitis: Update and insights

Autoimmune progesterone dermatitis (APD) is rare autoimmune hypersensitivity reaction to the fluctuations of endogenous progesterone during a woman's menstrual cycle. It has a wide spectrum of clinical presentations including urticaria, eczema and vesiculobullous eruptions. The disease course depends on treatment modality. The pathogenic mechanisms of APD remain to be elucidated.

OBJECTIVE

We aim to review the literature on APD and evaluate the different theories of pathogenesis and treatments for this condition.

METHODS

A review of the English literature on APD was performed using PubMed, EMBASE and MEDLINE.

RESULTS

89 patients are included in this review. Initial symptom development in association with the menstrual cycle was reported in 65 (73%) patients. In some patients, it occurred shortly after hormone therapy (8.9%) or in relation to a pregnancy (14.6%). Associated factors were not defined in three patients (3.4%). Nearly 45% had a history of exposure to exogenous progesterone. Diagnosis of APD was usually confirmed with an intradermal progesterone sensitivity test. The goal of treatment was to suppress progesterone secretion through anovulation. Some cases were controlled with oral contraceptives or conjugated estrogen, while some patients had complete resolution post-hysterectomy.

CONCLUSION

The wide spectrum of clinical presentations, histology, and response to therapy would suggest that there are multiple subsets in APD. The increase in the levels of progesterone may also influence the clinical profile and the corresponding immunological response. Further research on the pathogenesis of APD is required to provide a satisfactory treatment modality.

Autoimmune progesterone dermatitis: a diagnosis easily missed

Autoimmune progesterone dermatitis (AIPD) is a rare, poorly characterized dermatosis, with about 60 previously reported cases. It typically undergoes cyclical flares relating to the menstrual cycle, especially the luteal phase, when levels of progesterone are at their highest. We report the case of a 34-year-old woman with an 8-year history of a profoundly pruritic eruption, associated with her menstrual cycle, in whom the diagnosis had proved elusive. Buserelin nasal spray resulted in complete clearance. AIPD is a diagnosis to consider in intractable eruptions in women, particularly if there is cyclical variation.

Urticarial lesions: if not urticaria, what else? The differential diagnosis of urticaria: part I. Cutaneous diseases

Acute urticaria is self-limiting, and a cause can be identified in many patients. Chronic urticaria is a long lasting disease, and patients are commonly examined for an autoimmune origin and for associated diseases. Although the diagnosis of urticaria is straightforward in most patients, it may pose some difficulties at times and it may require a careful differential diagnosis with a number of conditions. Urticarial syndromes comprise both cutaneous and systemic disorders. Part I of this two-part series focuses on the clinical and histologic features that characterize common urticaria and on the cutaneous diseases that may manifest with urticarial lesions and must be considered in the differential diagnosis.

LEARNING OBJECTIVES

After completing the learning activity, participants should be able to distinguish between the typical wheals of urticaria and urticarial lesions suggesting other diagnoses and to assess patients with urticarial lesions in order to exclude or confirm other cutaneous diseases.

Oral stomatitis induced by endogenous progesterone: Case report

Oral stomatitis induced by endogenous progesterone is a rare clinical condition which may be associated with cutaneous involvement. That is probably due to the peak of progesterone production during the luteal phase of the menstrual cycle. In the present case report, a 21-year-old patient displayed recurrent ulcerative lesions located on the buccal mucosa or the upper lip, on a monthly basis since the age of 15. Such lesions would always manifest themselves on the second day until the end of the menstrual cycle.

Physiological changes associated with the menstrual cycle: a review

The cyclic hormonal changes that regulate the menstrual cycle are a significant biological influence on the female body, one with both physical and emotional ramifications. Menstruation is governed by tightly orchestrated changes in the levels of ovarian estrogen and progesterone, which produce varying responses in diverse tissues and organs. The skin, the largest organ in the body, is replete with estrogen receptors (in both dermis and epidermis) and to a lesser extent, progesterone receptors. Cyclically fluctuating levels of estrogen and progesterone influence numerous characteristics of the epidermis, including skin surface lipid secretion and sebum production, skin thickness, fat deposition, skin hydration, and barrier function. Dermal collagen content, which contributes to skin elasticity and resistance to wrinkling, is also influenced. Interestingly, estrogen levels also influence skin pigmentation and UV susceptibility, as well as resident microflora. In addition, changing hormone levels across the menstrual cycle produce measurable variations in immune function and disease susceptibility. An understanding of the profound influence that fluctuating estrogen and progesterone levels have on the biological responses of the premenopausal adult woman is critical to optimizing the efficacy of medical therapies in this population.

Autoimmune progesterone dermatitis. Case report with histologic overlap of erythema multiforme and urticaria

BACKGROUND

Autoimmune progesterone dermatitis is a rare eruption that recurs monthly as progesterone levels peak during the menstrual cycle. Clinical and histologic features are variable, and the eruption is thought to represent a hypersensitivity response to endogenous progesterone.

METHODS

We present the case of a 38-year-old woman with a pruritic intermittent facial eruption of 18 months' duration that recurred predictably in the days surrounding menses.

RESULTS

The histology showed interface dermatitis with features of both erythema multiforme and urticaria. Intradermal injection of medroxyprogesterone acetate was positive. Her symptoms responded to antihistamine therapy.

CONCLUSION

This unusual case is particularly distinctive both in terms of the histologic findings and the response to therapy.