Pemphigus during pregnancy: Management requires tailored approaches
Today’s report also covers research into 'data wobbles' in hidradenitis suppurativa clinical trials, a case of extragenital lichen sclerosus, and more (1,263 words, 6 minutes)
The Women in Dermatology e-newsletter is supported without restriction by Galderma Canada
Good morning, and welcome to the Women in Dermatology e-newsletter from Chronicle Companies. We’re pleased to have you join us. This biweekly bulletin will update you on new findings regarding dermatologic issues that affect women and the dermatologists who treat them. We welcome your feedback and opinions, so let us know if you have any comments, observations, or suggestions. You can email them to us at health@chronicle.org
A review in the Indian Dermatology Online Journal (May 2024) aimed to consolidate existing literature on the challenges of managing pemphigus during pregnancy. The review found that pregnancy can significantly exacerbate the course of pemphigusdue to the predominantly Th2 immune response that characterizes this period.
For this study, the authors searched PubMed for the keywords “pemphigus” and “pregnancy,” focusing on English articles from 1950 to May 11, 2023. They reviewed clinical presentations, maternal and fetal outcomes, and pemphigous management strategies during pregnancy. The final review included 83 studies.
During the first and second trimesters, the predominance of Th2 immune responses tends to worsen pemphigus symptoms. In the third trimester, the increased production of endogenous corticosteroids in the placenta may temporarily suppress autoimmune activity, potentially alleviating symptoms.
The authors note that maternal pemphigus, especially when severe or associated with high levels of autoantibodies, can lead to adverse outcomes such as stillbirth, neonatal pemphigus, miscarriage, pre-eclampsia, low birth weight, premature delivery, and congenital anomalies. However, they highlight that most pemphigus patients can have healthy, full-term deliveries with appropriate management.
The authors also note that pemphigus management during pregnancy should be multidisciplinary and tailored to disease severity and pregnancy stage. Topical corticosteroids are considered safe for mild cases. For more severe disease, oral corticosteroids such as prednisolone are the first-line systemic treatment, ideally at the lowest effective dose to mitigate adverse maternal and fetal outcomes. Azathioprine, intravenous immunoglobulin, or rituximab may be used for severe or refractory cases.
Reduced cortisol levels during the postpartum period may cause the disease to flare. Topical therapies remain safe for both mother and child unless directly applied to the nipple-areola area. Systemic corticosteroids are also considered safe for breastfeeding, but administration timing should minimize neonatal exposure. Azathioprine may be used cautiously, and other drugs should be evaluated for safety in breastfeeding.
Takeaway: Pregnancy can exacerbate pemphigus symptoms, particularly in the first and second trimesters, because of a Th2-dominant immune environment. Pemphigus could lead to adverse fetal outcomes such as stillbirth, early delivery, and neonatal pemphigus. Managing the condition during pregnancy requires tailored approaches to mitigate maternal flares and fetal risks.
Data wobbles in hidradenitis suppurativa clinical trials and potential contributing factors
Research in the InternationalJournal of Women’s Dermatology examined hidradenitis suppurativa (HS) clinical trials to understand the occurrence of a phenomenon termed “wobble,” where there is a decline in efficacy between the penultimate visit and the primary endpoint week. The researchers found that some clinical trials for HS treatment show unexpected declines in effectiveness before reaching their primary endpoint, possibly because they include more mildly affected patients and more women.
The authors analyzed 21 studies using the Hidradenitis Suppurativa Clinical Response (HiSCR) outcome measure for this study. They found that HiSCR wobble was more common in randomized controlled trials than in open-label studies. They also found that wobble happened more often in studies with a primary endpoint week of 16 rather than 12. The study suggests considering 12-week endpoints in trial design to address this issue.
Hormone replacement therapy modulates skin and immune responses to irritants in post-menopausal women
A British Journal of Dermatology study investigated the impact of menopause and hormone replacement therapy (HRT) on the skin barrier and immune system in post-menopausal women after applying an irritant. The researchers found HRT enhanced the skin barrier response to irritants and increased immune cell presence in the dermis, potentially affecting inflammation and skin repair processes.
For this study, 18 women were divided into two groups: one receiving HRT and one not receiving it. Skin irritation was induced using topical sodium lauryl sulphate. The results showed enhanced skin barrier response in HRT users. Additionally, the HRT group exhibited elevated counts of inflammatory dendritic cells and macrophages in the dermis.
The impact of laser therapy on the quality of life in women with polycystic ovary syndrome-associated hirsutism
A study published in Cureus examined the impact of laser-assisted hair removal (LAHR) on the quality of life of women with polycystic ovary syndrome (PCOS)-related hirsutism. The researchers found that LAHR significantly improves the quality of life for women with PCOS-associated hirsutism in the short term. For this study, the authors recruited 172 women with PCOS-related hirsutism at a specialized laser clinic. They used the Ferriman-Galway score to assess hirsutism severity and administered laser therapy with ruby diode or alexandrite lasers. Participants completed a questionnaire, including the Dermatology Life Quality Index, before and after treatment at 12, 18, and 24 weeks to evaluate changes in quality of life. The results showed a reduction in stress, anxiety, and depression over time, but hair regrowth at six months suggested limited long-term efficacy of LAHR.
Long-term dermatological considerations of the vulva and vagina in transgender women after gender-affirming surgery
A comprehensive review in the American Journal of Clinical and Medical Research examined the long-term dermatological implications for transgender women after gender-affirming surgery. It revealed an increased tendency toward conditions such as lichen sclerosus (LS), vulvar atrophy, and other cutaneous diseases affecting the vulva and vagina. The authors emphasize the need for comprehensive postoperative care and highlight the intricate relationship between hormonal changes, surgical interventions, and dermatological outcomes in transgender women.
VIDEO: The link between depression and inflammation in hidradenitis suppurativa (HS)
Rochester, Minn.-based dermatologist Dr. Afsaneh Alavi discusses the connection between HS and depression.
An unusual presentation of extragenital lichen sclerosus
A case report in Skin Health and Disease described a 71-year-old woman with keratotic and atrophic plaques on her lower limbs, causing movement limitation and occasional pain. Lab tests, including a tuberculin skin test, were normal. A skin biopsy revealed abnormal keratinization, epidermal atrophy, collagen hyalinization, and lymphoplasmacytic infiltrate, leading to a diagnosis of extragenital lichen sclerosus. Treatment with clobetasol, tacrolimus, and prednisone resulted in partial keratosis regression within a month. Subsequent systemic glucocorticoid therapy led to significant improvement over five months.
On June 22, 2024, from 10 a.m. to 1 p.m. EDT, Skin Spectrum Summit presents the inaugural Acne Summit, a one-day virtual free medical education event seeking the highest-quality acne education to help Canadian patients receive the best care possible. Drs. Geeta Yadav and Jerry Tan are the co-chairs of the event.
With the support of our sponsors Bausch Health, Cipher Pharmaceuticals, Sun Pharma, Galderma, L’Oreal and Dermtek Pharma, you can join your colleagues to learn more about the incidence of and the latest therapies for acne through live Q&As and lectures.
The Acne Summit is a landmark opportunity to learn to:
Effectively communicate about acne with patients and their families
Diagnose acne across all skin phototypes
Manage post-acne sequelae, including scarring and pigmentary changes
“I do cosmetics all day where people come in asking me for Botox or fillers, but when I look at their faces, it’s the colour that’s really off. If you focus on your skin tone, you can really fake it [make it appear better] by 80 per cent.”
— Dr. Shereene Idriss, a New York City-based dermatologist, in an interview with Observer.
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