Pemphigoid Gestationis

What is Pemphigoid Gestationis?

Pemphigoid gestationis (PG), formerly called herpes gestationis, is a rare autoimmune skin disease of pregnancy that causes intense itching and blisters.^{[1, 2]} Despite the old name, it has nothing to do with the herpes virus.^[1]

In PG, the immune system makes antibodies against a protein found in the placenta and the skin's basement membrane, which damages the skin and causes blisters.^{[2, 3]} It is one of several skin conditions specific to pregnancy.^{[4, 5]} For a condition like this, we ask that you are under a physician's care for it and that your treating team knows you are receiving complementary care.

Common symptoms

The main symptoms are severe itching and an inflamed rash with blisters.^[1] The rash usually begins around the navel, spreads across the abdomen and then to the arms and legs, and often spares the face.^[1]

It most often starts in the third trimester, but it can begin in any trimester or after delivery.^[1] It often flares around the time of delivery.^[2]

Causes and risk factors

The cause is an autoimmune reaction to proteins called BP180 and BP230 in the skin's basement membrane.^{[2, 3]} Why it develops in some pregnancies is not fully known.

PG tends to recur in 30% to 50% of later pregnancies, usually starting earlier and often more severe.^[1] It can also reactivate with hormonal contraception.^[2]

How it is diagnosed and treated conventionally

PG is diagnosed from the typical rash and confirmed with a skin biopsy using direct immunofluorescence. Blood tests for the BP180 antibody can help follow disease activity.^{[1, 2]}

Mild disease is treated with topical corticosteroids, and oral corticosteroids are the mainstay for severe disease.^{[2, 6]} A systematic review found no randomized trials of PG treatment, and 114 of the 136 patients with outcome data (about 84%) reached complete remission, although many needed more than one treatment. The review was based on case reports and small series.^[6]

PG is linked to preterm birth and small-for-gestational-age babies, so a dermatologist and an obstetrician usually monitor the pregnancy together.^{[1, 2]} It usually resolves on its own after delivery.^[1]

Why Pemphigoid Gestationis calls for a whole-person approach

PG affects both the mother and the pregnancy, and itch is the symptom that most disrupts daily life. Pruritus in pregnancy is common and burdensome, it is often undertreated, and there is little safety data on itch medicines in pregnancy.^[7]

The clinic's supportive care can only address comfort-related concerns. It does not treat the autoimmune process, and we are not able to monitor the pregnancy.

Itch and skin comfort

Severe itch can interrupt sleep and cause distress. Pregnancy-related itch can be a sign of several different conditions, some of which need urgent evaluation, which is why any new itch in pregnancy should be examined by a physician.^{[5, 7]}

Pregnancy and medication limits

Many drugs and herbs are limited in pregnancy because of possible harm to the fetus.^{[7, 8]} This is a major reason that supportive care must be coordinated with your obstetrician.

Pregnancy outcomes and monitoring

PG has been linked to preterm birth and growth restriction of the baby, so regular obstetric monitoring is part of medical care.^{[1, 3]}

Sleep and stress

Itching, discomfort and worry about the pregnancy can disturb sleep and raise stress. A Cochrane review of acupuncture for insomnia found the trials too poor in quality to support or refute a benefit.^[9]

Acupuncture as supportive care in Pemphigoid Gestationis

What the research shows

We found no clinical trials of acupuncture in pemphigoid gestationis. Acupuncture has not been shown to affect the autoimmune process, heal blisters or prevent flares.

Some research on itch in other skin conditions exists. A 2015 review of 24 studies found that acupuncture improved outcomes in conditions including itch, atopic dermatitis and urticaria in 17 of the studies, and a 2021 update found improvement in itch, atopic dermatitis, urticaria and uremic itch, but not in itch after cesarean section under spinal anesthesia. Both said better-designed, sham-controlled trials are needed.^{[10, 11]} A meta-analysis of 8 trials (463 participants) in atopic dermatitis found less itch than controls, with limited quantity and quality of studies.^[12] These conditions are not PG, and the results cannot be assumed to apply.

Acupuncture has also been tested in pregnancy for other problems. In a sham-controlled trial of 352 women with moderate to severe nausea and vomiting of pregnancy, acupuncture reduced symptoms modestly, and the authors said the clinical importance was uncertain.^[13] A meta-analysis of 24 trials of acupuncture for pregnancy nausea reported no significant difference in severe adverse events compared with medicine or sham, with evidence ranging from moderate to very low certainty.^[14]

How acupuncture may work

For PG, no mechanism has been tested. In general, acupuncture is proposed to influence how the nervous system processes itch, pain and stress. This is a proposed explanation, not a settled fact.

What treatment involves

Treatment uses fine, sterile, single-use needles, with sessions usually lasting about 20 to 40 minutes. A course of several visits is followed by reassessment of whether it is helping with itch, sleep or stress. Needles are placed away from blistered, open or infected skin. In pregnancy, some acupuncture points are traditionally avoided, and treatment would be considered only with your obstetrician's agreement.

In prospective studies, about 9 in 100 patients had a minor reaction such as bleeding, soreness or redness at a needle site, and serious events occurred in about 1 in 10,000 patients.^[15] Tell the practitioner first if you have a bleeding disorder, take blood thinners, are pregnant, or have a pacemaker (relevant to electroacupuncture). Also tell us if you take steroids or other immune-suppressing medicine, or have open or weeping skin lesions.

Ayurvedic medicine as supportive care in Pemphigoid Gestationis

The Ayurvedic view

Ayurveda has no classical name that matches PG. Blistering, itchy skin eruptions are traditionally described as involving Pitta and Kapha, and pregnancy is traditionally treated with special care. These are traditional frameworks, not biomedical diagnoses.

Therapies that may be used

Care in pregnancy is limited to gentle measures that your obstetrician agrees with:

• Cooling, simple diet and regular meals, in line with your obstetrician's advice
• Regular daily routine and consistent sleep and waking times
• Stress-reducing practices such as breathing exercises and relaxation

Panchakarma is not appropriate in pregnancy, and we would not use it for PG at any stage while the skin is blistered or while you are acutely ill. Herbal preparations are generally avoided in pregnancy unless your obstetrician agrees, because some plants can harm the fetus.^[8] A traditional oil or herbal paste should not be put on blistered or open skin.

What the research shows

We found no clinical trials or systematic reviews of Ayurvedic medicine for PG, so any benefit is unknown. Quality is a real concern: about one fifth of Ayurvedic medicines bought online contained detectable lead, mercury or arsenic.^[16] Contaminated products are a particular concern in pregnancy.

Herbal medicine as supportive care in Pemphigoid Gestationis

Herbs and formulas that have been studied

We found no clinical trials of herbal medicine, Chinese or Ayurvedic, for PG. Because the evidence is absent, we do not suggest any herb for PG.

What the research shows

For PG itself, there is no evidence. Herbs should never be used to replace corticosteroids or other prescribed treatment, and they should not be used to try to avoid medical monitoring of the pregnancy.

Safety and herb-drug interactions

Pregnancy is the main concern. A review of medicinal plants in pregnancy explained that natural does not mean safe: some plants can be toxic to the fetus, cause malformations, or stimulate the uterus and lead to miscarriage. It listed many plants to avoid, including aloe vera, ginkgo, fenugreek, valerian and chaste tree.^[8] Because of this, we do not use herbs in pregnancy without your obstetrician's approval.

Herbs can also interact with medicines. A literature review described bleeding when warfarin was combined with danshen or ginkgo, and lowered levels of some immune-suppressing drugs with St John's wort.^[17] If you are taking oral steroids or other prescribed medicines, any herb needs review by your prescriber. Tell us if you are breastfeeding or have liver or kidney disease. Herbal preparations should not be applied to blistered or open skin without your dermatologist's approval.

Translating traditional medicine into modern biological language

This is interpretation, not equivalence. Chinese medicine would describe an itchy blistering rash with patterns such as damp-heat or wind-heat in the skin. Ayurveda would speak of Pitta-Kapha imbalance with impure blood.

Researchers instead study autoantibodies against BP180 and BP230 and the damage they cause at the skin's basement membrane.^{[2, 3]} No study has shown that a traditional pattern corresponds to this process. What the traditions offer is a way to organize individual complaints such as itch, poor sleep and stress for supportive care.

How this care fits with your medical care

The clinic's role is complementary. We do not diagnose PG or monitor your pregnancy, prescribe or change medicines, or replace your obstetrician or dermatologist. Do not stop or change corticosteroids or other prescribed treatment without your prescriber.

Please bring your diagnosis, your obstetrician's and dermatologist's names, and a full list of medicines and supplements. We would want your treating team to know about, and agree to, any supportive care during pregnancy.

When to seek urgent medical care

Some changes in PG or pregnancy need prompt medical evaluation.^{[1, 2]}

• Decreased or absent baby movements
• Contractions, leaking fluid or vaginal bleeding before your due date
• Fever or chills with painful, spreading, warm or oozing skin, which can mean infection
• Blisters spreading quickly, or widespread raw skin
• New severe itching with dark urine or yellowing of the skin or eyes
• Severe headache, vision changes or sudden swelling

For emergencies, call 911 or go to the nearest emergency department.