The physician diagnosed pemphigoid gestationis based upon the multiple bullae on the patient’s skin, including one prominent periumbilical bulla (FIGURE). A more careful history revealed that this was the patient’s third episode of pemphigoid gestationis. A biopsy was not performed because her previous biopsy was on file and the clinical picture was consistent with a recurrence of this disease.
Pemphigoid gestationis is a rare autoimmune bullous dermatosis of pregnancy. The pathophysiology of the disease involves immunoglobulin (Ig) G antibodies that attack cells in the skin. The IgG attacks the same antigen (bullous pemphigoid antigen) as in bullous pemphigoid. This antigen is a transmembrane protein that is part of the hemidesmosome, which connects the basal cells of the epidermis to the basement membrane. When the inflammatory response is activated, the hemidesmosomes are destroyed and the epidermis separates from the dermis. It is not known why some patients form these antibodies.
Pemphigoid gestationis typically regresses spontaneously without scarring within weeks to months of delivery. In this case, the patient was treated with oral prednisone and improved rapidly. The dose was tapered over time and eventually discontinued.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux, EJ. Pemphigoid gestationis. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:471-474.
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