A 37-year-old primigravid woman at 35 weeks of pregnancy was seen for a 20-day history of multiple inflammatory skin lesions on her upper chest wall and both breasts. She had a past history of systemic lupus erythematosus (SLE) with active kidney disease, positive antinuclear antibodies at a titer of 1/360, anti-double-stranded DNA, and anti-Ro, and she was on treatment with prednisone (15mg/d), hydroxychloroquine (200mg/d), azathioprine (100mg/d), and methyldopa (500mg/d). Over the following 3 weeks, the lesions spread to the upper third of her back and to her abdomen and limbs. Twenty-four hours after delivery, she presented a bilateral facial rash and widespread bullous lesions on the lateral aspect of both arms, upper chest wall (Fig. 1A), back (Fig. 1B), and lower limbs, including acral regions. The Nikolsky sign was positive. Histology revealed a subepidermal blister and an inflammatory infiltrate with abundant neutrophils; direct immunofluorescence was positive for C3 and immunoglobulin G. She required combined treatment with mycophenolate (2g/d) and 6 infusions of belimumab (10mg/kg per infusion), with a rapid response following the first infusion and complete reepithelialization in the subsequent months, with no recurrence during follow-up. SLE is a disease with particularly varied cutaneous manifestations. Vesicular rashes are uncommon in the context of LE, but toxic epidermal necrolysis-type or exudative erythema multiforme-type lesions can develop, leading to a long list of differential diagnoses. Pregnancy and the puerperium can provoke a clinical deterioration.

Figure 1

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