A 29-year-old primigravida woman presents in her 31st week of pregnancy with an itchy rash on her chest and abdomen first noted 5 days ago. An over-the-counter antihistamine has not provided relief. On examination, the patient is afebrile. She denies malaise, sore throat, and swollen glands.
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Pruritic urticarial papules and plaques of pregnancy (PUPPP), also known as polymorphic eruption of pregnancy (PEP), is the most common dermatosis of pregnancy. Although the condition is benign with no adverse outcomes for the mother or fetus, it can interfere with the mother’s quality of life due to severe pruritus.
The pathogenesis of PUPPP is uncertain. One theory proposed by Aractingi et al. suggests that the condition results from an immunologic response to circulating fetal antigens.1 Another proposed by Matz et al. postulates that stretching of the abdominal skin leads to damage of the underlying connective tissue and the release of antigens, which causes a reactive inflammatory response.2
Patients typically present in the third trimester with an erythematous, pruritic rash arising within the abdominal striae. Lesions may coalesce to form larger urticarial plaques with surrounding blanched halos that spare the periumbilical area. An acral dyshidrosiform pattern may be seen with vesicles as well as targetoid and polycyclic lesions.3 Over time, the rash may spread to the breasts, arms, and buttocks. Involvement of the hands, feet, and face is rare. Diagnosis is typically based on history and physical examination. Skin biopsy may be necessary to rule out other diagnoses.4
Treatment is primarily symptomatic. Topical steroids and oral antihistamines are first-line therapies; more severe cases may warrant oral steroids. The condition resolves in the postpartum period.
Lauren Ax, MSPAS, PA-C, is a physician assistant on staff at the DermDox Center for Dermatology in Hazleton, Pennsylvania, Lawrence Schiffman, DO, is the director of Miami Skin Dr in Doral, Florida, and Stephen Schleicher, MD, is director of the DermDox Center for Dermatology, as well as an associate professor of medicine at Commonwealth Medical College and a clinical instructor of dermatology at Arcadia University and Kings College.
1. Aractingi S, Berkane N, Bertheau P, et al. Fetal DNA in skin of polymorphic eruptions of pregnancy. Lancet. 1998;352(9144):1898–1901.
2. Matz H, Orion E, Wolf R. Pruritic urticarial papules and plaques of pregnancy: polymorphic eruption of pregnancy (PUPPP). Clin Dermatol. 2006;24(2):105–108
3. Jeon IK, On HR, Oh SH, Hann SK. Three cases of pruritic urticarial papules and plaques of pregnancy (PUPPP) treated with intramuscular injection of autologous whole blood. J Eur Acad Dermatol Venereol. 2015;29(4):797-800.4. Taylor D, Pappo E, Aronson IK Polymorphic eruption of pregnancy.Clin Dermatol. 2016;34(3):383-391.