Autoimmune progesterone dermatitis: Case report of an unexpected treatment reaction

A focused report on progestogen hypersensitivity

INTRODUCTION

Progestogen Hypersensitivity (PH) is caused by increased sensitivity to either exogenous or endogenous progestogens. It is characterized by recurrent cutaneous eruptions including erythema multiforme, eczema, urticaria, and angioedema, which may be associated with systemic symptoms including asthma and anaphylaxis.

AREAS COVERED

Symptoms may be persistent or cyclical, coinciding with progestogen levels. With increased use of oral contraceptives and hormonal treatments for fertility, the prevalence of PH is expected to continuously increase. Several proposed immunological mechanisms, diagnostics, and treatment modalities have been proposed. Most treatments focus on suppressing ovulation and progesterone secretion or inducing tolerance through progesterone desensitization.

EXPERT OPINION

Although there has been increased recognition both clinically and in the medical literature, there is still a general lack of knowledge of PH and its clinical features in the medical community. An improved understanding of the underlying pathophysiology as well as more available commercial testis, such as ELISA that accurately measures specific IgE to progesterone, are expected to broaden and improve opportunities for disease recognition and symptom control. It is essential for physicians across specialties to recognize how to diagnose PH and either manage this condition or refer these patients to a specialist with experience treating PH.

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.

Effect of omalizumab for autoimmune progesterone dermatitis refractory to bilateral oophorectomy: a case report

BACKGROUND

Autoimmune progesterone dermatitis (APD) is a rare skin condition caused by sensitivity to high levels of progesterone secreted during the luteal phase of the menstrual cycle. This may be due to various pathophysiological mechanisms including a Type I and Type IV hypersensitivity reaction. Here we present the case of a patient with APD whose episodic flares were controlled by the addition of omalizumab, after a bilateral oophorectomy failed to resolve her symptoms.

CASE PRESENTATION

A 34-year-old female presented to our Endocrine clinic with marked Cushingoid features secondary to high-dose oral prednisone prescribed for APD diagnosed 6 years earlier. She first developed a pruritic maculopapular rash on her arms and legs just after the birth of her second child in 2009. The rash was also associated with headaches and diffuse angioedema. Symptoms occurred for 1-2 weeks, in a cyclical fashion, during the luteal phase of each menstrual cycle and subsided within a few days after menses. The severity of symptoms increased as time went on, and flare-ups began to also include dyspnea, nausea, vomiting and abdominal pain. Her symptoms improved with administration of oral prednisone, but she continued to experience breakthrough symptoms. After multiple failed treatment modalities, she elected bilateral oophorectomy in 2018. However, her symptoms of APD persisted and she still required high-dose oral prednisone. Her condition was further complicated by vasomotor menopausal symptoms and progressive iatrogenic Cushing's syndrome. She eventually was started on Omalizumab, which suppressed further recurrences of APD symptoms and allowed her to wean off prednisone. Vasomotor menopausal symptoms responded well to the addition of conjugated estrogens with bazedoxifene. However, her symptoms of diffuse bony pain and arthralgias which started whilst on prednisone have persisted in spite of discontinuing prednisone.

CONCLUSIONS

To our knowledge, this is only the third case of APD which was successfully treated with Omalizumab and the first case where a bilateral oophorectomy failed to resolve symptoms of APD in the literature. This case also demonstrates the complications of vasomotor menopausal symptoms secondary to a bilateral oophorectomy, as well as the adverse effects of long-term glucocorticoid therapy.

A case report of eosinophilia associated with an etonogestrel implant

Progestogen hypersensitivity is a rare adverse effect of endogenous and exogenous progestogens. Etonogestrel implant is very effective for contraception; however, a few progestogen hypersensitivity cases have been reported. Here, we present a case of delayed-type progestogen hypersensitivity with marked eosinophilia against etonogestrel that resolved after implant removal.

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.

Contraception in autoimmune diseases

Autoimmune diseases (AIDs) affect women and men with a 2:1 ratio, which suggests that hormonal contraceptives play a role in their clinical course. Combined oral contraceptives have complex, sometimes contradictory, effects on AIDs; they can worsen the situation in women with systemic lupus erythematosus and with anti-phospholipid syndrome, conditions in which they are contraindicated. Early studies indicated a positive effect on rheumatoid arthritis (RA), whereas more recent trials failed to do so, possibly because of the lowering of oestrogen content. Evidence of effects on multiple sclerosis (MS) is conflicting: risk may vary depending on the progestin used. Minor adverse effects may exist on inflammatory bowel diseases, and no significant effect was found on autoimmune thyroid diseases. Women can become sensitised to sex hormones. Progestin-only contraceptives may be used, although copper-releasing intra-uterine devices represent the best option. Finally, several organisations have issued guidelines for contraceptive use in women with AIDs.

Progesterone hypersensitivity: Case report with favorable evolution

Progesterone hypersensitivity or autoimmune progesterone dermatitis is characterized by heterogeneous skin eruptions that cyclically aggravate during the second half of the menstrual cycle, corresponding to a rise in the progesterone level. Clinical presentation is highly variable and includes all urticaria manifestations with or without angioedema, vesiculobullous, eczematous, purpuric or target-like lesions on the skin and mucous membrane. Both endogenous progesterone as well as exogenous progestogens may represent an initial trigger. We report a case of progesterone hypersensitivity in a 27-year old woman with favorable evolution only on topical therapy, the positive clinical outcome being maintained during a subsequent pregnancy and postpartum period.

Presentation and natural history of progestogen hypersensitivity

OBJECTIVE

To review the published medical literature on the clinical presentation, risk factors, and natural history of hypersensitivity reactions to progestogens.

DATA SOURCES

Through the use of PubMed, we conducted a review of allergy, dermatology, and obstetric literature for cases and case series of patients with hypersensitivity reactions to exogenous or endogenous progestogens. There are no longitudinal, prospective studies related to progestogen hypersensitivity.

STUDY SELECTIONS

Publications were selected that described cases that were clinically consistent with progesterone hypersensitivity and positive test results or clear symptoms with exposure to progestogens to confirm the diagnosis.

RESULTS

Progestogen hypersensitivity symptoms can be triggered by endogenous progesterone or exogenous progestins used for contraception or fertility treatments. Symptoms are varied and include dermatitis, urticaria, asthma, and anaphylaxis.

CONCLUSION

Although the medical literature on progestogen hypersensitivity is limited to case reports and small case series, significant heterogeneity exists in clinical presentation among patients.