Pemphigoid Gestationis Treatment & Management

Updated: May 25, 2022
  • Author: Richard Harold "Hal" Flowers, IV, MD; Chief Editor: William D James, MD  more...
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Treatment

Medical Care

Treatment for pemphigoid gestationis is aimed at relieving pruritus and preventing the formation of new blisters. Initially, tepid baths, compresses, and emollients may help alleviate pruritus.

While there are no established guidelines for pemphigoid gestationis treatment, patients with mild disease can be treated with oral antihistamines and mid-potency topical corticosteroids, such as triamcinolone 0.1% cream or ointment. Short courses of topical steroids over limited body surface areas are generally considered safe to use during pregnancy and decrease inflammation by reversing capillary permeability and suppressing the migration of polymorphonuclear (PMN) leukocytes. [22]  Low to medium potency steroids are generally preferred to stronger ones. Antihistamines prevent histamine response in sensory nerve endings and blood vessels, decreasing pruritus. Of the first-generation histamines, diphenhydramine and chlorpheniramine are considered safe for use in pregnancy. Nonsedating, second-generation antihistamines that are safe to use during pregnancy include loratadine, cetirizine, and levocetirizine. In general, first-generation antihistamines are preferred over second-generation antihistamines due to the greater availability of safety data.

In more severe cases that are resistant to topical treatment or exceed 10% of body surface area, systemic corticosteroids may be needed. An initial regimen of 0.5 mg/kg/d of prednisone is typically used. Corticosteroids have anti-inflammatory properties, modify the body’s immune response to diverse stimuli, and can cause profound and varied metabolic effects. Prednisone is an immunosuppressant used to treat autoimmune disorders that may decrease inflammation by reversing capillary permeability, suppressing PMN activity, limiting antibody production, and stabilizing lysosomal membranes. Use of short courses of medium-dose prednisone is considered fairly safe during pregnancy, though increased risk of oral clefts have been reported when oral steroids are used in the first trimester. 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, and patients may or may not need to remain on a suppressive dose.

If patients are still unresponsive to treatment, steroid-sparing agents can be added as adjuvant therapy. The most commonly used steroid-sparing agents include intravenous immunoglobulin, azathioprine, dapsone, cyclosporine, and pyridoxine. [23, 24, 25, 26, 27]

Although there is a paucity of data regarding prophylaxis against recurrent pemphigoid gestationis, rituximab has been used to lower anti-BP180 titers and prevent clinical recurrence of pemphigoid gestationis. [28]

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.