Blisters during pregnancy—just with the second husband

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Blisters during pregnancy—just with the second husband

J Fam Pract. 2006 November;55(11):953-956

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References

1. Coupe RL. Herpes gestationis. Arch Dermatol 1965;91:633-636.

2. Jenkins RE, Hern S, Black MM. Clinical features and management of 87 patients with pemphigoid gestationis. Clin Exp Dermatol 1999;24:255-259.

3. Al-Fouzan AW, Galadari I, Oumeish I, et al. Herpes gestationis (Pemphigoid gestationis). Clinics Dermatology 2006;24:109-112.

4. Shornick JK. Herpes gestationis. J Am Acad Dermatol 1987;17:539-556.

5. Holmes RC, Black MM, Dann J, et al. A comparative study of toxic erythema of pregnancy and herpes gestationis. Br J Dermatol 1982;106:499-510.

6. Cozzani E, Basso M, Parodi A, Rebora A. Pemphigoid gestationis post partum after changing husband. Intn J Dermatol 2005;44:1057-1058.

7. Shornick JK, Black MM. Fetal risks in herpes gestationis. J Am Acad Dermatol 1992;26:63-68.

8. Diaz LA, Ratrie H, III, Saunders WS, et al. Isolation of a human epidermal cDNA corresponding to the 180-kD autoantigen recognized by bullous pemphigoid and herpes gestationis sera. Immunolocalization of this protein to the hemidesmosome. J Clin Invest 1990;86:1088-1094.

9. Giudice GJ, Emery DJ, Diaz LA. Cloning and primary structural analysis of the bullous pemphigoid autoantigen BP180. J Invest Dermatol 1992;99:243-250.

10. Zillikens D, Giudice GJ. BP180/typeXVIII collagen: its role in acquired and inherited disorders of the dermal-epidermal junction. Arch Dermatol Res 1999;291:187-194.

11. Borradori L, Sonnenberg A. Hemidesmosomes: roles in adhesion, signaling and human diseases. Curr Opin Cell Biol 1996;8:647-656.

12. Zillikens D. Acquired skin disease of hemidesmosomes. J Dermatol Sci 1999;20:134-154.

13. Schmidt E, Zillikens D. Autoimmune and inherited subepidermal blistering diseases: advances in the clinic and the laboratory. Adv Dermatol 2000;16:113-157.

14. Shornick JD. Dermatoses of pregnancy. Semin Cutan Med Surg 1998;17:172-181.

15. Holmes RC, Black MM, Jurecka W, et al. Clues to the aetiology and pathogenesis of herpes gestationis. Br J Dermatol 1983;109:131-139.

16. Shornick JK, Stastny P, Gilliam JN. High frequency of histocompatibility antigens DR3 and DR4 in herpes gestationis. J Clin Invest 1981;68:553-555.

17. Shornick JK, Stastny P, Gilliam JN. Paternal histocompatibility (HLA) antigens and maternal anti-HLA antibodies in herpes gestationis. J Invest Dermatol 1983;81:407-409.

18. Ortonne JP, Hsi BL, Verrando P, et al. Herpes gestationis factor reacts with the amniotic epithelial basement membrane. Br J Dermatol 1987;117:147-154.

19. Kelly SE, Bhogal BS, Wojnarowska F, Black MM. Expression of a pemphigoid gestationis-related antigen by human placenta. Br J Dermatol 1988;118:605-611.

20. Fairley JA, Heintz PW, Neuburg M, et al. Expression pattern of the bullous pemphigoid-180 antigen in normal and neoplastic epithelia. Br J Dermatol 1995;133:385-391.

21. Kelly SE, Black MM, Fleming S. Antigen-presenting cells in the skin and placenta in pemphigoid gestationis. Br J Dermatol 1990;122:593-599.

22. Borthwick GM, Holmes RC, Stirrat GM. Abnormal expression of class II MHC antigens in placentae from patients with pemphigoid gestationis. Placenta 1988;9:81-94.

23. Kelly SE, Black MM, Fleming S. Pemphigoid gestationis: a unique mechanism of initiation of an autoimmune response by MHC class II molecules. J Pathol 1989;158:81-82.

24. Borradori L, Saurat JH. Specific dermatoses of pregnancy. Toward a comprehensive view. Arch Dermatol 1994;130:778-780.

25. Shimanovich I, Bröcker EB, Zillikens D. Pemphigoid gestationis: new insights into the pathogenesis lead to novel diagnostic tools. Br J Obstet Gynaecol 2002;109:970-976.

Pathology and immunology

Histopathologic findings demonstrate subepidermal vesicles, spongiosis, and perivascular lymphocyte, and histiocyte infiltrates with a preponderance of eosinophils.³ The sine qua non of the disease, though, is the demonstration through direct immunofluorescence of complement deposition and IgG in a linear band along the basement membrane.¹⁴

There appears to be a genetic predisposition toward the development of pemphigoid gestationis. Associations with human leukocyte antigens (HLAs) DR3 (61%–85%), DR4 (52%), or both (43%–50%) have been reported.^3,15,16 Interestingly, 85% of persons with a history of pemphigoid gestationis were found to have anti-HLA antibodies, some of which were directed against paternal HLAs expressed in their placentae.¹⁷ These findings raised speculation about a possible immunologic insult against placental antigens during pregnancy. Evidence suggests that circulating autoantibodies in patients with pemphigoid gestationis bind to the dermal-epidermal junction of skin and amnion in which BP180 antigen is also present.^18-20

It has been demonstrated that in patients with pemphigoid gestationis the cells of the placenta stroma express abnormal major histocompatibility complex (MHC) class II molecules.^21,22 This lead to the proposition of 2 possible mechanisms for the initiation of an autoimmune response in pemphigoid gestationis. The first proposes that placental BP180 is presented to the maternal immune system in association with abnormal MHC molecules, which then trigger the production of autoantibodies that cross-react with the skin. Alternatively, the placental stromal cells may evoke an allogeneic reaction against the BP180 antigen presented by paternal MHC molecules of the placental stroma, which then cross-reacts with the skin.²³ The latter theory supports the findings in this patient, who developed pemphigoid gestationis during the 2 pregnancies with her second husband and not during the pregnancies with her first husband.