Iatrogenic autoimmune progesterone dermatitis treated with a novel intramuscular progesterone desensitization protocol

Abstract

Autoimmune progesterone dermatitis (APD), or progesterone hypersensitivity, is a rare disorder caused by an immune response to progesterone. It was first described by Geber in 1921 and is characterized by cyclic cutaneous eruptions that occur during the luteal phase of the menstrual cycle, coincident with peak endogenous progesterone. The rash develops 3 to 10 days before onset of menses and regresses or resolves after menstruation cessation. The skin eruptions most commonly manifest as urticaria; however, the presentation is variable, and cutaneous lesions may also include erythema multiforme, folliculitis, purpura, stomatitis, eczema, angioedema, papulovesicular eruptions, and vulvovaginal pruritis. The literature primarily reports cases of cyclic APD related to endogenous progesterone, although cases are documented of local and systemic reactions related to exogenous exposure, suggesting isolated hypersensitivity to synthetic progesterone. Women undergoing in vitro fertilization (IVF) are exposed to high doses of exogenous hormones which may induce hypersensitivity, leading to iatrogenic APD. The cutaneous lesions of APD are resistant to antihistamine and corticosteroid therapy. Conventionally, patients are treated by way of ovulation suppression; however, definitive treatment is hysterectomy and oopherectomy. Desensitization offers a therapeutic option in women with APD who wish to maintain their fertility and also in women who are undergoing infertility treatment. To our knowledge, no cases are reported in the literature of rapid desensitization with intramuscular progesterone. We report a case of iatrogenic APD induced by synthetic progesterone in association with IVF and describe a novel desensitization protocol with intramuscular progesterone in oil (PIO).