What is the treatment for autoimmune progesterone dermatitis?

Treatment of Autoimmune Progesterone Dermatitis

The primary treatment goal for autoimmune progesterone dermatitis (APD) is complete suppression of endogenous progesterone through anovulation, with continuous combined oral contraceptives, GnRH agonists, or bilateral oophorectomy being the most effective options, while antihistamines and systemic corticosteroids frequently fail. 1, 2

First-Line Medical Management

Hormonal Suppression Strategies

• Continuous combined oral contraceptives are the most commonly successful first-line treatment, used in 28.6% of cases with reliable outcomes 1
• GnRH agonists (gonadotropin-releasing hormone agonists) represent the second-line hormonal approach, effective in 21.4% of cases 1
• Some patients achieve control with conjugated estrogen therapy alone 3

Treatments That Typically Fail

• Antihistamines and systemic corticosteroids frequently provide no relief despite being commonly prescribed 2
• Topical corticosteroids may be attempted but are generally ineffective for this systemic condition 4

Diagnostic Confirmation Before Treatment

• Intradermal progesterone sensitivity testing should be performed when APD is suspected, with positive results in approximately 67% of tested patients (6 of 9 in one series) 1
• The diagnosis is confirmed when symptoms develop 3-10 days before menstruation and resolve 1-2 days after menstruation ceases 4
• Nearly 45% of patients have a history of exposure to exogenous progesterone prior to symptom onset 3

Definitive Surgical Management

• Hysterectomy with bilateral salpingo-oophorectomy is the definitive treatment when medical management fails, used in 14.3% of cases with complete resolution 1
• Bilateral oophorectomy alone may be sufficient, as demonstrated in refractory cases after 48 months of failed medical therapy 5
• Surgery should be considered when patients remain refractory to hormonal suppression and symptoms significantly impact quality of life 5

Clinical Pitfalls and Diagnostic Delays

• There is an average delay of 3.9 years (range 0.4-20 years) between symptom onset and diagnosis, often because APD is misdiagnosed as allergic contact dermatitis, urticaria, or other dermatologic conditions 1, 4
• The condition presents with highly variable cutaneous manifestations including urticaria (64.3% of cases), dermatitis (28.6%), vesiculobullous eruptions, or even Stevens-Johnson syndrome-like presentations 1, 5
• APD should be suspected in any woman of reproductive age with cyclical skin eruptions that are refractory to standard dermatologic treatments 4

Treatment Algorithm

1. Confirm diagnosis with intradermal progesterone testing and documentation of cyclical symptoms 1
2. Initiate continuous combined oral contraceptives as first-line therapy to suppress ovulation 1
3. Escalate to GnRH agonists if oral contraceptives fail after 3 months 4
4. Consider bilateral oophorectomy for patients who remain refractory after extended medical management (typically after 12-48 months) 5
5. Avoid exogenous progesterone exposure in all forms, as this can trigger or worsen symptoms 3

The wide spectrum of clinical presentations and variable response to therapy suggests multiple immunological subsets exist within APD, but the fundamental principle remains progesterone suppression 3.