Cutaneous and Ocular Toxicology, 2012; 31(1): 67–69

© 2012 Informa Healthcare USA, Inc.

ISSN 1556-9527 print/ISSN 1556-9535 online
DOI: 10.3109/15569527.2011.602035

Case Report

A case of recurrent impetigo herpetiformis treated with

systemic corticosteroids and narrowband UVB
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Kubra Bozdag1, Serap Ozturk1, and Murat Ermete2

1
Department of Dermatology and 2Department of Pathology, Ataturk Education and Research Hospital, Izmir, Turkey

Abstract
Impetigo herpetiformis is a rare pustular eruption with usual onset during the third trimester of pregnancy. The
disease tends to remit after delivery, but may recur in subsequent pregnancies. Here we present a recurrent case of
impetigo herpetiformis with earlier onset and poor response to corticosteroids in the subsequent pregnancy. She had
widespread, erythematosquamous patches with tiny superficial pustules in the third trimester of her first pregnancy.
Histopathological and clinical findings were consistent with impetigo herpetiformis. She was treated with systemic
prednisolone and had a healthy baby without any complication. Three years later, the patient presented with impetigo
herpetiformis again in the second trimester of her second pregnancy. After six weeks of oral prednisolone treatment,
the lesions improved, but there were still new pustule formations and narrowband ultraviolet B treatment was added.
Skin eruption cleared and she had a healthy baby in the 38th week of her second pregnancy. The corticosteroid dose
was tapered gradually and stopped after delivery. Early diagnosis and treatment is crucial in impetigo herpetiformis
For personal use only.

because of the risk of maternal and fetal complications. When prednisolone is not enough to control the eruption
alone, narrowband UVB can safely be added to the treatment.
Keywords:  Impetigo herpetiformis, narrowband ultraviolet B, pregnancy

Introduction bacteria and fungi. A skin biopsy specimen showed sub-

Impetigo herpetiformis (IH) is a rare pruritic sterile pus-
tular eruption of pregnancy. It is classified as a form of
generalized pustular psoriasis occurring as early as the
first, but generally during the third trimester of preg-
nancy, significantly improving in the puerperium with
possible recurrences in subsequent pregnancies (1–4).
Here we present a recurrent case of IH with earlier onset
and poor response to oral prednisolone in the subse-
quent pregnancy.
Case report
A 19-year-old woman presented with a pruritic, pustular,
annular eruption of 2 weeks’ duration. She was in week
24 of her first, otherwise uncomplicated, pregnancy.
Dermatological examination revealed erythematous
patches with pustules and crusts on the periphery in
annular pattern on the trunk and extremities (Figure 1).
She also had onycholysis and tiny pustules on her
tongue. Her laboratory findings including serum calcium
level were within normal limits. Pustules were sterile for
corneal pustules filled with neutrophils and eosinophils
(Figure 2), psoriasiform hyperplasia and spongiosis.
Histopathological and clinical findings were consistent
with impetigo herpertiformis (IH).
The patient was treated with oral prednisolone
started at 60 mg/day. The eruption cleared in two
weeks and prednisolone dose was tapered to 30 mg/day
gradually. The fetus was evaluated by fetal ultrasound
images weekly until delivery. She had a healthy baby
without any complication in the 38th week of her preg-
nancy. After delivery, corticosteroid dose was tapered
and stopped.
Three years later, the patient presented with IH again
in the second trimester (18th week) of her second preg-
nancy (Figure 3). A 60mg/day oral prednisolone treat-
ment was initiated. After six weeks of treatment, the
skin lesions improved, but there were still new pustule
formations and narrowband ultraviolet B treatment was
commenced in conjunction with oral prednisolone. The
eruption resolved and prednisolone dose was tapered to

Address for Correspondence:  Dr. Kubra Bozdag, Ataturk Education and Research Hospital, Izmir, Turkey. E-mail: bozdagk@gmail.com
(Received 10 May 2011; revised 06 June 2011; accepted 26 June 2011)

67
 68  K. Bozdag et al.
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Figure 1.  Annular erythematous patches with pustules and crusts
on the periphery in the first pregnancy
For personal use only.
Figure 3.  Close-up of a plaque showing peripheral pustules in the
second pregnancy (18th week)
50mg/day (Figure 4). She had a healthy baby in the 38th
week of her second pregnancy. The corticosteroid dose
was tapered gradually and stopped after delivery. Six
months after delivery, the patient was seen in follow-up,
and she had no lesions and both of the babies were
healthy and showed no evidence of growth retardation
or immunosupression.
Discussion
Impetigo herpetiformis, first described by Hebra, is a rare
pruritic, pustular eruption that primarily affects pregnant
woman. The disease tends to remit after delivery, but may
recur in subsequent pregnancies (1,2). Onset is usually in
the last trimester of pregnancy. The eruption characteris-
tically recurs earlier and with increasing severity during
each subsequent pregnancy (1,3), as was the case in our
patient.
The diagnosis is mainly based on typical clinical
findings. The initial lesions are infiltrated erythematous
patches primarily in flexural areas, then the trunk and
extremities. Small pustules develop on this inflamed
background and enlarge by peripheral growth. It may
 Cutaneous and Ocular Toxicology
Figure 2.  Subcorneal pustule filled with neutrophils and
eosinophils (Hematoxylin-eosin stain X 120)
Figure 4.  Improvement after oral prednisolone + narrowband
UVB treatment (34th week)
be associated with systemic symptoms such as fever,
chills, diarrhea and nausea and potential complication
of bacterial infection. Laboratory findings have included
leukocytosis, elevated erythrocyte sedimentation rate,
hypocalcemia, hypoalbuminemia and low thyroid hor-
mone levels. Subcorneal and spongiform pustules are
seen in skin biopsy specimens (1,2,5). Our patient had
the typical clinical and histological features of IH, but
did not demonstrate any of the systemic symptoms and
laboratory findings.
The more severe and longstanding the disease, the
greater are the risks of placental insufficiency lead-
ing to stillbirth, neonatal death or fetal abnormalities.
Because of the risk of maternal and fetal complications,
immediate diagnosis and treatment is crucial (1,6,7).
IH is best treated with prednisolone, the drug that car-
ries the least hazard for the fetus (1). Usually 60–80 mg/
day prednisolone is sufficient to control the eruption.
It should be tapered very slowly to avoid flares and

continued at least until the pregnancy is over (2). As
methotrexate is fetotoxic and abortifactant and retin-
oids are potent teratotoxins, the use of these agents
is absolutely contraindicated in pregnancy (1,2,5).
Methotrexate may be an alternative treatment after
delivery (1,8,9). Cyclosporin, which is categorized as
pregnancy category “C” and nonteratogenic, may be
considered to treat the cases of IH that do not respond
to corticosteroids (1,2,5). Several of the biologic agents
are category “B” and can be used in pregnancy (2,10).
Recently, successful infliximab therapy in a pregnant
woman with psoriasis, who presented IH during her
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Recurrent impetigo herpetiformis  69
with prednisolone, but when systemic corticosteroids
cannot control the eruption alone, narrowband UVB can
safely be added to the treatment.
Declaration of interest
The authors report no declarations of interest.
References
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pregnancy and could not be completely controlled with  
oral prednisolone alone. Than narrowband UVB treat-  
ment was added to systemic corticosteroid in the 24th
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The fetuses were evaluated by fetal ultrasound images
weekly in both pregnancies and the babies were born
via cesarean section without any complication. The
babies were healthy and showed no evidence of growth
retardation or immunosuppression.
Immediate diagnosis and treatment is crucial in
impetigo herpetiformis because of the risk of maternal
and fetal complications. Since possible recurrences are
expected in subsequent pregnancies, the patients should
be closely followed in future pregnancies. It is best treated
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