Impetigo herpetiformis is a rare pustulosis of pregnant women of unclear etiology. Clinically characterized by a spontaneous onset with a rise in temperature, the appearance of edematous erythema and small pustules on the inner surface of the thighs, in the folds of the skin. The hearth grows along the periphery, takes the form of a ring: in the center there are pustules covered with crusts, along the perimeter there is a growth zone, a rim of bright pink color, dotted with new primary elements. The diagnosis is based on clinical manifestations and a specific histological picture (a pustule in the epidermis). Treatment is reduced to the correction of hormonal disorders, calcium deficiency, and symptomatic therapy.
Impetigo herpetiformis (impetigo of the Gebra) is a pustular dermatosis that occurs most often in pregnant women against the background of hypoparathyroidism, hypocalcemia. The impetigo of the Gebra can cause stillbirth, cause miscarriage, which makes its connection with endocrine disorders obvious. This fact is confirmed by the occurrence of relapses in the menopausal period, which, in combination with joint damage, gave rise to many dermatologists to attribute the disease to manifestations of pustular psoriasis. Impetigo herpetiformis has a bright gender coloring. As a casuistry, the disease may occur in men, non-pregnant women, and children. There is no information about the endemic nature of the process and the structure of morbidity.
For the first time , the impetigo herpetiformis under the guise of purulent lichen was described in 1872 by the Austrian dermatologist F. Gebra. The Hungarian dermatologist M. Kaposi detailed the clinical manifestations in 1887. An important role in understanding the essence of dermatosis was played at the beginning of the twentieth century by the work of V. Freund, who linked the development of skin pathology with hormonal disorders of pregnant women and proposed to consider pathology as a harbinger of a possible miscarriage. The urgency of the problem is associated with an unfavorable prognosis for pregnant women.
The exact cause of the disease is not clear. In dermatology, it is customary to consider the endocrine, metabolic, and infectious pathogenesis of impetigo Gebra. Endocrine genesis is associated with a malfunction of the parathyroid glands. Normally, these glands produce a parathyroid hormone that controls, together with vitamin D, calcitonin (thyroid hormone), the exchange of calcium, magnesium, and phosphorus in the body. A decrease in the synthesis of parathyroid hormone leads to a violation of the metabolism of these trace elements responsible for the nutrition of tissues, changes the trophism of the skin. Itching occurs, the skin becomes dry, flaky. Against this background, bubbles with serous, serous-purulent contents appear, pustulosis occurs. The cause of hypoparathyroidism is most often a traumatic or infectious lesion of the thyroid gland (due to the anatomical proximity of glandular formations).
The metabolic genesis is based on a low content of calcium in the blood (less than 2.2 mmol/ l) as a result of metabolic and biochemical processes. Calcium regulates intracellular processes, controls cell functions. Normal calcium metabolism is impossible without the participation of vitamin D synthesized in the skin. These elements complement each other. With insufficient intake of calcium into the body with food, with a violation of the synthesis of vitamin D in the skin, leading to a decrease in calcium levels, dysfunction of the cells of the epidermis and dermis occurs. There are manifestations of dermatosis.
The infectious theory of the occurrence of impetigo herpetiformis is taken into account by few dermatologists, since it is based on the accidental release of staphylococcus and streptococcus from some pustules, while other pustules remain sterile. There is evidence of HLA incompatibility of mother and fetus as the cause of the disease.
The primary elements in the clinic of the disease are small, the size of lentils, closely spaced pustules occupying hyperemic skin in the area of large folds, the inner surface of the thighs. Rashes are accompanied by a sharp deterioration in the general condition of the pregnant woman (headache, fever, joint pain). The process tends to peripheral growth, the fusion of small elements into large ring–shaped foci, spreads to the trunk, other areas of the skin, rarely to the mucous membranes.
Over time, the pustules shrink into crusts, which, falling away, leave behind areas of depigmentation. It is possible to aggravate the severity of the general condition of the patient with the development of chills, vomiting, convulsions, delirium. Such a progression of the process can lead to the loss of a child, a fatal outcome. Along with the acute course, there is a chronic variant of impetigo Gebra with a milder course, relapses after 10-20 years or more.
Diagnosis and treatment
The disease is diagnosed clinically, taking into account the anamnesis data (surgical interventions on the thyroid, parathyroid glands), the results of histology. Pathomorphology gives a picture of neutrophilic infiltration of the epidermis with the formation of pustules in the thorny layer, eosinophilic infiltration of the dermis. Differentiate Impetigo herpetiformis with pustular psoriasis, During dermatitis, herpes.
Treatment is dictated by the severity of the pathology. In severe cases, medical care is provided in intensive care with mandatory supervision of the patient by a dermatologist. The therapy regimen combines hormonal drugs (corticosteroids, estrogens), antibiotics with hemotherapy, blood transfusion, calcium metabolism regulators (dihydrotachysterol). Sometimes pregnancy is interrupted. In milder cases, they are limited to therapy with vitamin D, parathyroidin, calcium preparations, blood injections of a healthy immunologically compatible pregnant woman. When a secondary infection is attached, antibiotics, local aniline paints are prescribed. The prognosis is unfavorable (spontaneous termination of pregnancy, stillbirth, death). Mandatory dispensary observation.