Medication Summary
Tepid baths, compresses, and emollients may help alleviate pruritus. Patients with mild disease can be treated with antihistamines and midpotency topical steroids, such as triamcinolone. However, these are usually ineffective in more severe cases, and systemic steroids remain the mainstay of therapy. Prednisone at 0.5 mg/kg/d is usually started, and the response to therapy is gauged by the abatement of pruritus and blister formation. Once blistering has ceased and lesions have begun to heal, the dose of prednisone is tapered to the minimum dose required to control the disease. Reported steroid-sparing agents used as the adjuvant therapy in the treatment of pemphigoid gestationis include azathioprine, dapsone, methotrexate, intravenous immunoglobulin, cyclosporine, pyridoxine, plasmapheresis, and minocycline/nicotinamide. Chemical oophorectomy with goserelin (a luteinizing hormone–releasing analog) also may hold promise.
Although there is a paucity of data regarding prophylaxis against recurrent pemphigoid gestationis, in a 2017 case report, Tourte et al [28] described the off-label use of rituximab to lower anti-BP180 titers and prevent clinical recurrence of pemphigoid gestationis.
The risks and benefits of each medication must be assessed for each patient before a therapeutic regimen is chosen. Patients should be made aware of the risks, adverse effects, contraindications, and drug interactions of their medications.
Corticosteroids
Class Summary
Corticosteroids have anti-inflammatory properties and cause profound and varied metabolic effects. In addition, they modify the body's immune response to diverse stimuli.
Triamcinolone (Aristocort)
Triamcinolone treats inflammatory dermatosis that is responsive to steroids. It decreases inflammation by suppressing the migration of PMN leukocytes and reversing capillary permeability.
Prednisone (Deltasone)
Prednisone is an immunosuppressant used for the treatment of autoimmune disorders. It may decrease inflammation by reversing increased capillary permeability and suppressing PMN activity. Prednisone stabilizes lysosomal membranes and suppresses lymphocytes and antibody production. In patients with severe blistering in whom topical steroids fail to elicit a response, oral prednisone may be indicated.
Antihistamines
Class Summary
Antihistamines prevent histamine response in sensory nerve endings and blood vessels. They are more effective in preventing histamine response than in reversing it.
Diphenhydramine (Benadryl, Belix)
Diphenhydramine is used for symptomatic control of severe unremitting pruritus not controlled with previous therapeutic regimens. It should be administered orally rather than used topically, as topical diphenhydramine may cause allergic contact dermatitis.
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Tense bullae are present on the arms of this otherwise healthy 32-year-old primigravida woman.
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Urticarial or hivelike plaques, as seen on the posterolateral neck of this woman in her third trimester, can be observed in patients with pemphigoid gestationis.
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Upon histologic evaluation, an incipient blister is present at the junction of the epidermis and dermis, as is a moderately dense perivascular inflammatory infiltrate.
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A close-up view of a blister reveals the tense primary lesion filled with clear fluid.
