What is the treatment for progesterone dermatitis?

Treatment for Progesterone Dermatitis

The most effective treatment for progesterone dermatitis is ovulation suppression through continuous combined oral contraceptives, with gonadotropin-releasing hormone agonists as an alternative for refractory cases. 1

Understanding Progesterone Dermatitis

Progesterone dermatitis, also known as autoimmune progesterone dermatitis (APD), is a rare hypersensitivity reaction to endogenous progesterone characterized by:

• Cyclical cutaneous eruptions that occur during the luteal phase of the menstrual cycle
• Symptoms typically beginning 3-10 days before menstruation and resolving 1-2 days after menstruation ceases
• Various presentations including eczematous eruptions, erythema multiforme, urticaria, folliculitis, and angioedema 2, 3

Diagnostic Approach

Diagnosis is often delayed (average 3.9 years from symptom onset to diagnosis) due to its rarity and variable presentation 4. Key diagnostic elements include:

• Cyclical nature of symptoms correlating with the menstrual cycle
• Intradermal testing with progesterone (positive test supports diagnosis) 2
• Exclusion of other causes of cyclical dermatitis

Treatment Algorithm

First-Line Treatment:

• Continuous combined oral contraceptives 3, 4
  • Mechanism: Suppresses ovulation and endogenous progesterone production
  • Demonstrated reliable outcomes in 28.6% of cases in retrospective analysis 4
  • Consider estrogen-dominant formulations to minimize progesterone exposure

Second-Line Treatment:

• Gonadotropin-releasing hormone (GnRH) agonists 2, 4
  • Mechanism: Creates a reversible medical menopause by suppressing ovarian function
  • Effective in 21.4% of cases in retrospective analysis 4
  • Typically administered monthly for 3-6 months
  • Monitor for side effects including hot flashes, vaginal dryness, and bone mineral density loss with prolonged use

Refractory Cases:

• Surgical intervention: Hysterectomy with bilateral salpingo-oophorectomy 4, 5
  • Reserved for severe, treatment-resistant cases
  • Provides definitive treatment by removing the source of endogenous progesterone
  • Consider age, fertility desires, and surgical risks before proceeding

Adjunctive Treatments:

• Antihistamines and systemic corticosteroids
  • Limited efficacy as standalone treatments 1
  • May provide symptomatic relief during acute flares
  • Not effective for long-term management

Treatment Considerations

• Prior exposure to exogenous progesterone may be a trigger in some patients (64% in one series) 4
• Avoid progestin-only contraceptives as they may worsen symptoms 6
• Spironolactone, while effective for hormonal acne, is not specifically indicated for progesterone dermatitis 6

Monitoring and Follow-up

• Assess treatment response after 2-3 menstrual cycles
• If using GnRH agonists long-term, monitor for hypoestrogenic side effects
• Consider transitioning to maintenance therapy with continuous oral contraceptives after initial control with GnRH agonists

Common Pitfalls

• Misdiagnosis as allergic contact dermatitis or other recurrent skin conditions 2
• Failure to recognize the cyclical nature of symptoms
• Treating with antihistamines or topical steroids alone without addressing the hormonal cause 1
• Not considering progesterone dermatitis in women with treatment-resistant cyclical skin eruptions

By following this treatment algorithm and recognizing the characteristic cyclical pattern of symptoms, progesterone dermatitis can be effectively managed to improve quality of life and prevent recurrent symptoms.