Antigen-presenting cells in the skin and placenta in pemphigoid gestationis

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.

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.

Dermatoses of pregnancy

Several reported dermatoses of pregnancy have not survived the scrutiny of time and thus including them in current classification schemes does not serve any useful purpose. This review resolves issues in the existing conflicting literature.

Anti-HLA antibodies in pemphigoid gestationis (herpes gestationis)

Pemphigoid gestationis (PG; herpes gestationis) is a rare autoimmune disease associated with pregnancy, currently defined by the presence of complement deposition along the cutaneous basement membrane zone. It is known to be associated with HLA-DR3 and DR4, and an increase in anti-HLA antibodies in those with a history of PG has been reported. We have studied 39 patients with an immunofluorescence-confirmed diagnosis of PG for the presence and specificity of anti-HLA antibodies. Anti-HLA antibodies were found in all 39 patients. Specificity was against class I antigens in 98% (controls 10%; P < 0.001) and class II antigens in 25% (controls 8.5%; P < 0.001). Almost all anti-HLA antibodies were cytotoxic. The universal presence of anti-HLA antibodies in PG suggests that they may develop coincidently with antibasement membrane antibodies, and may reflect a common immunological event.

Secondary autoimmune diseases in herpes gestationis (pemphigoid gestationis)

BACKGROUND

Herpes gestationis (HG) is an autoimmune disease of the skin that occurs exclusively in association with pregnancy (or trophoblastic disease). It is associated with the HLA-DR3 and -DR4 antigens that are also associated with several other autoimmune diseases. HG has previously been reported in association with Graves' disease.

OBJECTIVE

Our purpose was to determine the frequency of other autoimmune disease(s) in patients with a history of HG.

METHODS

Seventy-five patients with a history of HG were studied for the frequency of other autoimmune diseases.

RESULTS

We found an increased frequency of Graves' disease in patients with a history of HG. Those with HG have an increased risk for the development of other autoantibodies. There is an increased frequency of autoimmune diseases in the family members of patients with HG.

CONCLUSION

Secondary autoimmune disease in HG is unusual, but does occur. The most frequent is Graves' disease.

Fetal risks in herpes gestationis

BACKGROUND

The potential risks to the fetus in herpes gestationis have long been a controversial subject, but because of the rarity of the disease, have only occasionally been studied.

OBJECTIVE

The purpose of this study was to determine the incidence of fetal complications in herpes gestationis.

METHODS

We collected and analyzed the obstetric histories of 74 patients and compared their involved pregnancies with their uninvolved pregnancies.

RESULTS

There was an obvious tendency for premature delivery associated with herpes gestations. A slight tendency toward small-for-gestational-age newborns associated with herpes gestationis was confirmed, but, perhaps surprisingly, no increase in spontaneous abortions or stillbirths was noted. The use of systemic steroids did not appear to influence risk.

CONCLUSION

Herpes gestationis is associated with an increase in prematurity and small-for-gestational-age infants.