Autoimmune Progesterone Dermatitis (APD) is a rare, cyclical skin condition resulting from an immune reaction to naturally produced progesterone. This reaction leads to recurring skin symptoms that coincide with hormonal fluctuations. Since pregnancy involves extremely high progesterone levels, the question of whether a woman with APD can conceive and carry a child is complex. While the condition itself does not typically prevent conception, managing the symptoms safely throughout the nine months requires careful medical planning and a specialized approach.
Understanding Autoimmune Progesterone Dermatitis
Autoimmune Progesterone Dermatitis is a hypersensitivity reaction to endogenous progesterone, the hormone that rises significantly after ovulation during the luteal phase of the menstrual cycle. This immune response is thought to be a Type I or Type IV hypersensitivity, sometimes triggered by prior exposure to exogenous progestogens, such as oral contraceptives or fertility treatments. The mechanism involves the immune system generating an inflammatory response against the body’s own progesterone.
Symptoms are cyclical, appearing three to ten days before menstruation when progesterone levels peak, and resolving after the period begins as hormone levels drop. This cyclical pattern is a hallmark of the condition. Skin manifestations are highly variable.
Skin Manifestations
- Recurrent hives (urticaria)
- Eczema-like rashes
- Erythema multiforme
- Progesterone-induced anaphylaxis (rare)
Diagnosis of this condition is challenging and requires a high degree of clinical suspicion. It is typically confirmed by reproducing the rash after an intradermal injection of progesterone, which demonstrates a hypersensitivity reaction. Because the skin lesions are diverse and resemble other conditions, APD is often a diagnosis of exclusion.
APD’s Impact on Conception and Fertility
Autoimmune Progesterone Dermatitis itself generally does not affect the ability to conceive. APD is a dermatological disorder that does not interfere with the underlying reproductive processes of ovulation, fertilization, or implantation. Provided the woman is ovulating regularly and has no other fertility issues, conception is possible. The primary concern centers on the treatment required to manage the condition before pregnancy.
Standard treatments for APD often suppress or modulate progesterone production to prevent the immune reaction. Therapies like Gonadotrophin-releasing hormone (GnRH) agonists, which suppress ovulation, or high-dose hormonal therapies effectively stop cyclical flares by keeping progesterone levels low. However, these treatments are incompatible with trying to conceive and must be discontinued, often leading to an immediate and severe flare-up of APD symptoms.
The challenge during the conception phase is managing these returning symptoms without using medications that could harm a potential early pregnancy. This pre-conception period requires careful communication between the dermatologist and the reproductive specialist. They must switch to safe, short-term symptom-control medications, such as certain antihistamines or topical corticosteroids, while maximizing the chances of conception.
Treatment and Management During Pregnancy
Managing APD during pregnancy is challenging because progesterone is necessary for maintaining the pregnancy. Progesterone levels are extremely high in gestation, which can lead to severe and continuous APD flares. The management strategy must shift from suppressing progesterone to safely managing the maternal immune response and the resulting skin symptoms.
The course of APD during pregnancy is unpredictable. Some women experience a paradoxical improvement, possibly due to the sustained rise in progesterone acting as a natural desensitizer or a general dampening of the maternal immune system. However, for those whose symptoms worsen, the priority is finding interventions safe for the developing fetus.
Systemic corticosteroids, such as prednisone, are often used to control severe flares due to their relatively safe profile later in pregnancy. The dosage and duration of corticosteroid use must be carefully monitored by a high-risk obstetrics team to ensure maternal and fetal safety.
Advanced Interventions
In extremely severe and refractory cases, more advanced interventions may be considered. These include:
- Plasmapheresis, which filters autoantibodies from the blood.
- Certain immunosuppressants studied for use in pregnancy for other autoimmune conditions.
- Progesterone desensitization, where increasing doses of progesterone are administered to build tolerance.
Any comprehensive treatment plan must involve a multidisciplinary team, including a maternal-fetal medicine specialist, a dermatologist, and an immunologist. This collaboration is necessary to balance maternal well-being with fetal safety throughout the pregnancy.
Post-Partum Considerations and Maternal Outlook
The period immediately following delivery usually brings a rapid improvement in APD symptoms. Delivery of the placenta causes a rapid decline in progesterone, resulting in the immediate remission of the cyclical skin eruptions, offering significant relief to the mother.
For mothers who choose to breastfeed, the safety profile of any necessary ongoing APD medications must be considered. While symptoms often resolve, some women may still require supportive medication to manage residual inflammation. The medical team must select medications compatible with lactation to prevent transmission to the infant.
Long-term management focuses on preventing the recurrence of cyclical symptoms. For women not planning future pregnancies, hormonal suppression, often using GnRH agonists to prevent ovulation, remains a primary option. In rare, severe, and medically refractory cases, bilateral oophorectomy (surgical removal of the ovaries) may be discussed to eliminate the source of endogenous progesterone. A successful pregnancy outcome is achievable with appropriate medical management.