The main goal of treatment for PG is to alleviate discomfort and relieve the pruritus, thereby addressing the psychological anxiety of the disease. Systemic treatment should only be started when symptom severity outweighs the possible risks to the fetus [4]. Prior to starting, baseline blood tests must be done. These include full blood count, liver and renal function tests, as well as specific enzyme levels related to specific systemic drugs (i.e., glucose-6-phosphate dehydrogenase [G6PD] for dapsone and thiopurine methyltransferase [TPMT] for azathioprine). These tests are ideally done every 2–4 weeks while on treatment [1].

The pruritus may be controlled with category A antihistamines (i.e., chlorpheniramine). First-generation H1 blockers are not associated with any risk of major adverse fetal effects [9]. There is less evidence on second-generation H1 blockers and no established link to adverse pregnancy outcomes [10, 11]. None of the antihistamines are excreted in the breast milk [12]. Cool compresses may also help alleviate the pruritus. Intact blisters may be drained with a sterile, large-bore needle and avoid unroofing the blister. Silicone dressings or nonstick Vaseline gauze may be applied to the blisters until they heal. Antibiotics may be given for secondary bacterial infections [1].

Potent topical CS (i.e., betamethasone dipropionate) is used to control limited forms of the disease [1]. In a large systematic review on the safety profile of topical CS in pregnancy, there were no significant associations with congenital anomalies, stillbirths, or premature delivery. However, they did report a link with low neonatal birth weights [13, 14].

Prednisolone is the preferred systemic CS as it bypasses the metabolism in the liver and therefore is safer in pregnancy compared to its prodrug, prednisone [15]. The dose may be started at 0.5–1 mg/kg/day, which may be increased or decreased slowly, depending on the response of the patient. This drug is generally safe during pregnancy, but the long-term complications of taking it must be kept in mind, such as Cushing syndrome, hypertension, impaired glucose metabolism, osteoporosis, as well as susceptibility to infection. Bone mineral density scan monitoring as well as calcium and vitamin D supplementation must be implemented for patients requiring long-term use of systemic CS [1]. There was a study comparing 39 PG patients with 22 normal controls and advised that the systemic use of CS is the ideal treatment as it did not have any adverse effects on pregnancy outcomes [4, 16].