Abdominal rash in a primigravida
A 24-year-old woman's first
pregnancy was uneventful until the
sixth month when mild malaise and a
highly pruritic abdominal rash occurred
(Figure 1). A biopsy and direct
the suspected diagnosis of herpes
Herpes gestationis (or pemphigoid
gestationis) is an autoimmune,
bullous disorder of pregnancy that
can also occur in patients with hydatidiform
mole and choriocarcinoma.
The skin protein targeted in herpes
gestationis is among those involved
in bullous pemphigoid. A preponderance
of affected patients are white,
which is probably related to the disease's
association with certain human
leukocyte antigen haplotypes.1
The onset of herpes gestationis is
usually in the second trimester, but the
disorder may not occur until the early
postpartum period. Cutaneous erythema,
edema, and pruritus are characteristic;
a prodrome of flu-like symptoms
has been reported.2The plaques can
occur anywhere on the body but have
a predilection for the abdomen, especially
the area of the umbilicus. Mucous
membranes are rarely involved.
Papules, vesicles, and bullae begin to
appear, often in a polycyclic pattern,
within a few days. The presence of
vesicles and bullae helps to differentiate
herpes gestationis from other disorders
that may occur in pregnancy,
such as erythema multiforme, drug
eruptions, or pruritic and urticarial
papules and plaques of pregnancy. A
leukocytosis may be present. A biopsy,
as well as direct immunofluorescence,
can help confirm the diagnosis.
Herpes gestationis tends to wax
and wane, and outbreaks may occur
for months after delivery. Often, a
major flare erupts at the time of delivery,
even if the disease has been under
control. Postpregnancy episodes
may be related to menses or to the
initiation of oral contraceptives. Outbreaks
in subsequent pregnancies are
common and are often more severe
and of earlier onset.
The relationship between herpes
gestationis and stillbirth is being investigated;
the disease has been associated
with the birth of premature and
small-for-gestational-age infants.4 The
neonate with cutaneous involvement
typically has mild, transient disease that
clears without treatment; this spontaneous
resolution may be attributed to
clearance of the maternal HG factor, an
IgG antibody. If necessary, topical corticosteroids
and antihistamines can be
given. No long-term sequelae have
been reported in the children of women
with herpes gestationis.5
Oral antihistamines and highpotency
topical corticosteroids were
prescribed for this patient, whose relatively
mild disease occurred intermittently
throughout the remainder
of her pregnancy. A flare at childbirth
gradually faded over several months;
the newborn was not affected.
Hivelike lesions in a teenager.
During the 38th week of her first
pregnancy, a 16-year-old patient with
no history of systemic illness was affected
with pruritic, hivelike, edematous,
bullous lesions on her abdomen
and legs (Figure 2). At 40 weeks' gestation,
a healthy child was delivered;
the neonate was free of lesions and
continued to develop normally.
1. Shornick JK, Meek TJ, Nesbitt LT Jr, Gilliam JN.
Herpes gestationis in blacks. Arch Dermatol. 1984;
2. Winton GB, Lewis CW. Dermatoses in pregnancy.
J Am Acad Dermatol. 1982;6:977-998.
3. Kolodny RC. Herpes gestationis. A new assessment
of incidence, diagnosis, and fetal prognosis.
Am J Obstet Gynecol. 1969;104:39-45.
4. Holmes RC, Black MM. The fetal prognosis in
pemphigoid gestationis (herpes gestationis). Br J
5. Shornick JK. Herpes gestationis. J Am Acad Dermatol.