M. Daboubi, T. Maaita, M. Al-Ruhaibeh

Herpes gestations must be differentiated from
other pruritic skin diseases such as prurigo
gestationis, impetigo herpetiformis and pruritic
urticarial papules and plaques of pregnancy. (8) The
histopathology of Herpes gestationis shows
edematous papillae with sub epidermal vesicles and
dense dermal eosinophilic infiltrate forming
eosinophilic spongiosis. (4)
Direct Immunofluorecence of peri-lesional skin
demonstrated linear deposits of C3 at basement
membrane; IgG deposits may be found in 40-50% of
reported cases. (4,7)
The cause of Herpes gestationis may be related to
abnormal expression of major histocompatibility
complex class П Ag within the placenta that initiate
an allogenic response to the placenta basement
membrane which cross react with skin. (9,10) This
theory is based on an association of Herpes
gestationis with HLA DR3 and DR4 antigens. (1,11,12)
Fabbri et al. suggested that an inflammatory
infiltrate is involved in the production of
Pemphigoid gestationis bullous lesions assuming
that Th2 cells (T helper type 2 cells) might be
implicated in the very early stages of autoimmune
response and may exercise a broad influence in
blister formation in this disease. (13) Jenkins reported
that 13.8% of patients with Herpes gestations had
associated autoimmune disease. (4)
Our patient delivered a full term baby with no
congenital abnormality or cutaneous lesions and
with a normal birth weight. There is no clear
evidence that Herpes gestationis poses significant
risk to either mother or child, (14) in Jenkins study of
278 cases there was 16% spontaneous abortions and
only 2.8 % of infants had evidence of skin lesions. (4)
Cutaneous involvement of the neonate occurs in 2-
10%. (15) In our case no cutaneous involvement
occurred. Neonates should be evaluated for adrenal
insufficiency when affected mother has received
steroids for prolonged periods. (14)
Systemic steroids are the treatment of choice to
relieve pruritus and to suppress the eruption; in
severe reluctant cases intravenous Immunoglobulins
may be needed for few days to initiate remission.
Chlorpheniramine appeared to suppress pruritus,
also topical steroids help. Azathioprine, dapsone,
pyridoxine are used as adjuvant therapy and one
case was helped with goserelin for continuing
disease several years post partum with only initial
success. (16)
Immunoblotting and ELISA are sensitive tools for
the detection of auto antibodies to bullous
pemphigoid antigen (17) 180 KD in patients with
pemphigoid gestations; the ELISA is useful to
monitor auto antibody serum levels.
Conclusion
Herpes gestationis is a pregnancy specific
dermatosis, which usually recurs with each
pregnancy with more severe course and earlier
onset, but disease-free pregnancies may occur.
The disease usually flares up in the early
postpartum period. Early diagnosis and
management may help to prevent maternal and fetal
complications.
References
1. Nanda A, AL-Saeed K, Dvorak R, et al.
Clinicopathological features and HLA tissue typing
in pemphigoid gestationis patients in Kuwait. Clin
Exp Dermatol 2003; 28(3); 301-306.
2. Jamel K, Wahiba K, Youssef BB, et al.
Pemphigoid gestationis: A pregnancy related
pathology underestimated by obstetricians. Tunis
Med 2005; 83(7): 437-440.
3. Jenkins RE, Jones SA, Black MM. Conversion
of pemphigoid gestationis to bullous pemphigoid -
two refractory cases highlighting this association.
Br J Dermatol 1996; 135(4): 595-598.
4. Jenkins RE, Hern S, Black MM. Clinical features
and management of 87 patients with pemphigoid
gestations. Clin Exp Dermatol 1998; 24(4); 255-
259.
5. Al-Nawafleh A, Al-Maeteh T. Herpes Gestationis:
A case report. Jordanian Medical Journal 2005;
39(2): 176-178.
6. Holmes R. Black MM, William-son DM, Scutt
RW. Herpes gestationis and Bullous pemphigoid: a
disease spectrum. Br J Dermatol 1980; 103(5):
535-541.
7. Hern S, Harman K, Bhogal BS, Black MM. A
severe persistent case of pemphigoid gesatationis
treated with intravenous immunoglobulins and
cyclosporins. Clin Exp dermatol 1998; 23(4): 185-
188.
8. Yancey KB, Hall RP, Lawley TJ. Pruritic
urticarial Papules and plaques of pregnancy. J Am
Acad Dermatol 1984; 10: 473-476.
9. Borthwick GM, Holmes RC, Stirrat GM.
Abnormal expression of class 11 MHC antigens in
placenta from patients with pemphigoid gestationis.
Placenta 1988; 9(1): 81-94.
10. Kelly SE, Black MM, Fleming S. A unique
mechanism of inhibition of an autoimmune
response by MHC class II molecules. J Pathol
1989; 158: 81-82.
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JOURNAL OF THE ROYAL MEDICAL SERVICES
Vol. 17 Supp No. 2 July 2010