An unravelling journey from diagnosis of furunculosis to autoimmune progesterone dermatosis

Abstract

Autoimmune progesterone dermatitis represents cyclical, pruritic eruptions of variable morphology of lesions corresponding to upsurge of the levels of progesterone in second half of the menstrual cycle. Eczematous, urticarial, target lesions are the most common manifestations, though unrelatable presentations like fixed drug eruption, anaphylactic shock, purpuric lesions, and acute generalized pustules are also reported in the literature. The authors report a case of a 38-year-old woman who first presented to our OPD with gravida 2, para 2, 32 weeks of gestation, being treated for recurrent furunculosis caused by methicillin-resistant Staphylococcus aureus with antibiotics. Biopsy of the lesions for histopathology and direct immunofluorescence was suggestive of furunculosis. The patient was reviewed 1.5-year after delivery and emphasized on history of premenstrual flare-ups and flare-up during third trimester of first pregnancy as well. Based on consolidating history by the patient, intradermal progesterone test conducted with progesterone 50 mg/ml showed a wheal and flare response of 18 mm as opposed to 3 mm of negative control. The patient was advised oral contraceptives containing desogestrel-ethinyl estradiol, after which the patient reported significant long-lasting improvement, preventing relapses premenstrually every month. This case highlights the versatile clinical presentation of autoimmune progesterone dermatitis, but consistent history of premenstrual flare-up with positive intradermal progesterone test helps in confirming the diagnosis and providing targeted treatment by temporary or permanent cessation of ovulation, resulting in cessation of apprehended flare-ups.

Keywords

• atypical autoimmune progesterone dermatosis
• autoimmune progesterone dermatitis
• autoimmune progesterone dermatosis
• furuncles
• progesterone hypersensitivity