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Bullous pemphigoid
0%
0/21
Herpes simplex virus
5%
1/21
Herpes zoster virus
Pemphigoid gestationis
76%
16/21
Pemphigus vulgaris
14%
3/21
Select Answer to see Preferred Response
This pregnant patient is presenting with erythematous urticarial patches and plaques that progress to tense vesicles and blisters suggesting a diagnosis of pemphigoid gestationis. Pemphigoid gestationis is a pruritic blistering dermatologic disorder unique to pregnancy. It is not associated with past or present herpes infections. The onset is generally later in pregnancy (second trimester or later). The distribution involves the abdomen or extremities but may be generalized. It can present with intense pruritus followed by visible skin lesions including urticarial plaques, papules, and vesicles with sparing of the palms, soles, and mucous membranes. Tense blisters are often formed subsequently, which can rupture. It is thought to be an autoimmune condition triggered by pregnancy, with antibodies against hemidesmosomal proteins that causes separation of the epidermis from the dermis. It is associated with other autoimmune diseases such as Hashimoto thyroiditis, Grave disease, or pernicious anemia. Figure A displays the classic findings of vesicular skin lesions and ruptured bullae which can be seen in pemphigoid gestationis. Incorrect Answers: Answer 1: Bullous pemphigoid is an autoimmune skin condition commonly affecting the elderly. It presents with pruritic skin lesions and tense bullae that do not rupture under pressure. Answer 2: Herpes simplex virus is a possible diagnosis in this patient; however, it would be more likely to present as a reactivation rather than a generalized rash over the abdomen. Electric pain may precede reactivation and vesicles may be present. Answer 3: Herpes zoster is a viral skin condition that (when it reactivates causing shingles) is painful and typically is limited to 1 dermatome. Answer 5: Pemphigus vulgaris occurs secondary to anti-desmosomal antibodies as well as painful bullae which rupture easily and can be found on mucosal surfaces. It is possible but less likely given this patient's age and current pregnancy. Bullet Summary: Pemphigoid gestationis occurs after the 2nd trimester of pregnancy and presents with pruritic bullae which may rupture.
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