An Bras Dermatol. Edoxaban Th1 and Th17 cells. It has been suggested that there is a greater targeting of Th2 cells, which is essential for the maintenance of the normal pregnancy state. It is important to emphasize that an initial environment with Th1 predominance is necessary for the success of uterine implantation. However, at the later stages of pregnancy, the predominance of the Th2 lymphocyte response is necessary for an environment of transient tolerance to fetal antigens (Fig. 1). Open in a separate window Figure 1 Suppression of cytotoxicity and the state of immunomodulation at the maternal-fetal interface. Considering the physiological changes in the immune response during pregnancy, the occurrence of autoimmune diseases in pregnant women is a high-risk factor and can lead to changes in their Prp2 disease status during this period.3 Pregnancy is characterized by predominance of the Th2 lymphocyte response, a profile that coincides with the development of autoimmune bullous dermatoses. Due to the reduction in the Th1 response and possibly in Th17 during normal pregnancy, skin diseases with a predominance of the Th1 response, such as psoriasis, rheumatoid arthritis, and multiple sclerosis, show improvement during pregnancy. On the other hand, diseases with a Th2 response pattern such as pemphigus, lupus erythematosus, and asthma may not benefit from this alteration in the immune pattern, due to the predominance of the Th2 response in the activity of these diseases.2, 9 Thus, the coexistence of autoimmune bullous dermatosis in pregnant women would precipitate or increase the occurrence of pemphigus and pemphigoids (Table 1). However, the course of AIBD tends to oscillate during pregnancy due to immunological alterations caused by estrogen and progesterone levels, but also due to cortisol, norepinephrine, and dehydroepiandrosterone.2 Table 1 Course of autoimmune bullous diseases and adverse effects during pregnancy. (FS), which corresponds to the South American endemic form of the disease.16 There is no report of gender predominance in PF or FS, but the endemic forms of PF observed in North Africa (Tunisia) show a characteristic female predominance, especially among young women (female-male ratio of 4:1). In a series of cases of 23 Tunisian patients with pemphigus, the triggering role of pregnancy in the development of this disease was suspected, as Tunisia is a country where young women have a high fertility rate.17 PF can have Edoxaban a variable course during pregnancy, with no effect on the fetus. The association with neonatal PF is extremely rare in the context of exceptionally high Edoxaban antibody titers.18 Desmoglein 3 is expressed throughout the epidermis, including the subcorneal layers in neonatal skin, and may Edoxaban be protective against disease-causing anti-desmoglein 1 antibodies.13, 19 A study carried out in Brazil with 19 pregnant women with FS did not observe any clinical neonatal disease, direct immunofluorescence was negative in 12 of the 17 neonatal skin specimens, IgG autoantibodies were present in low titers (less than 1:40) and IgG4 was the predominant IgG subclass in 9 of 19 umbilical cord blood samples. The authors suggest that the placenta may serve as a biological immunosorbent for pathogenic autoantibodies.20 Epidermolysis bullosa acquisita EBA is a rare, phenotypically heterogeneous subtype Edoxaban of AIBD, predominant in females and characterized by autoantibodies against type VII collagen. Two studies analyzed EBA and its associated data, with a total of 83 cases, showing a female-male ratio of 1 1.56.21, 22 Linear IgA Dermatosis Linear immunoglobulin A (IgA) dermatosis (LAD) is a rare autoimmune bullous disease with subepidermal blisters, in which IgA autoantibodies recognize as antigens the collagen type.