Herpes Gestationis/Pemphigoid Gestationis
Saturday, January 01, 2011
Herpes gestationis is a subepidermal bullous disease of
pregnancy characterized by pruritic, inflammatory blisters
occurring during the second and third trimesters and often
recurring during the immediate postpartum period. The therapeutic
goal is to reduce symptoms and blistering to tolerable levels until
the disorder spontaneously remits. Use the minimum therapy
necessary to control symptoms. Mildly affected patients may be
managed with topical therapy alone, whereas more severely affected
individuals may require systemic medications as well.
- For mild, localized cases, prescribe a superpotent topical
steroid cream (eg, clobetasol, or betamethasone dipropionate) to be
applied once or twice daily. Once the condition improves the
strength of the steroid and frequency of application may be
- For moderate-to-severe cases, begin therapy with prednisone
40-60 mg/ day. Expect remission in 5-15 days. Attempt to reduce the
dose by half over the next 4-6 weeks, then gradually taper the dose
to the lowest possible daily or every other day dose to control
symptoms and maintain the minimum daily dose of prednisone
- Large blisters may be ruptured with a sterile needle to avoid
them spreading by hydrostatic pressure.
- Antihistamines may help to control pruritus. Both hydroxyzine
and diphenhydramine 25-50 mg 2 to 4 times daily are considered to
be safe in pregnant women.
- At times, herpes gestationis does not adequately respond to
systemic steroids given as a single morning dose. In such patients,
splitting the dose with 40 mg taken in the morning and 20 mg in the
evening will enhance efficacy without increasing the total steroid
- Virtually all cases of herpes gestationis respond to systemic
steroids in a dose of 40-60 mg daily. In severe refractory cases,
plasmapheresis can be considered.
- Anticipate a clinical flare at the time of delivery, and
clearing 1 month later. In the event of a postpartum flare,
increase prednisone to 40-60 mg/day. When the disease remits, taper
prednisone by 10-15 mg/week, and attempt to discontinue prednisone
in 4 weeks.
- Postpartum flares occasionally persist for an unusually long
period (3-4 months), often coinciding with menses. Brief courses of
systemic steroids may be required.
- The infant may have transient blistering in the first 2 weeks
of life. Expect spontaneous resolution requiring only bland topical
therapy (application of emollients and bathing).
- Advise the mother that herpes gestationis may recur with each
subsequent pregnancy, often with increasing severity.