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Therapeutic Strategies

Herpes Gestationis/Pemphigoid Gestationis

Timothy Berger Bruce Wintroub

Saturday, January 01, 2011

Overview

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.

First Steps

  1. 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 reduced.
  2. 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 throughout pregnancy.
  3. Large blisters may be ruptured with a sterile needle to avoid them spreading by hydrostatic pressure.
  4. 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.

Alternative Steps

  1. 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 dose.
  2. 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.

Pitfalls

  1. 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.
  2. Postpartum flares occasionally persist for an unusually long period (3-4 months), often coinciding with menses. Brief courses of systemic steroids may be required.
  3. 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).
  4. Advise the mother that herpes gestationis may recur with each subsequent pregnancy, often with increasing severity.

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