Pruritic Urticarial Papules and Plaques of Pregnancy

PUPPP
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kiran Singh, M.D. [2]

Overview

Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP), known in United Kingdom as Polymorphic eruption of pregnancy (PEP), is a chronic hives-like rash that strikes some women during pregnancy. Although extremely annoying for its sufferers (because of the itch), it presents no long-term risk for either the mother or unborn child. PUPPP frequently begins on the stomach and spreads to the legs, feet, arms, chest, and neck.

Although affecting about one in two hundred pregnancies, the condition was only formally identified and described in 1979.

PUPPP is also known as Toxemic rash of pregnancy (not to be confused with "Toxemia of pregnancy" which is an alternative term for Pre-eclampsia), and Toxic erythema of pregnancy.

Etiology

The cause of the condition is unknown, but the distension of the skin is thought to play a role as this condition occurs mostly in first pregnancies (primagravida), in the third trimester and is more likely with multiple pregnancies (more so with triplets than twins or than singletons).

Other than additional associations with hypertension and induction of labour, there are no observed difference in the outcome of the pregnancy for mothers or babies.

Appearance

The appearance of the condition changes over time. It starts with pruritic (itchy) urticarial (wheals) papules (small, solid elevations of the skin) in 98% of cases. However over half develop multiple forms (polymorphic) with erythema (redness), vesicles (small blisters), and targetoid and eczematous (eczema-like) lesions. The two sets of appearances gives rise therefore to both the American term of 'Pruritic Urticarial Papules and Plaques of Pregnancy' and the British description of 'Polymorphic eruption of pregnancy'.

Papules and plaques usually start appearing on the abdomen (although not on the umbilicus/bellybutton/tummybutton itself) and often spreads to the legs, chest, underarms, etc. The face is also spared and does not seem ever to become affected.

Skin distension (stretching) is a common factor in PUPPP, which is more common in mothers with large fundal measurements and/or those who are carrying large babies, twins, and triplets. The papules and plaques often first appear within stretch marks.

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  Pruritic urticarial papules and plaques of pregnancy. Adapted from Dermatology Atlas.

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  Pruritic urticarial papules and plaques of pregnancy. Adapted from Dermatology Atlas.

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  Pruritic urticarial papules and plaques of pregnancy. Adapted from Dermatology Atlas.

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  Pruritic urticarial papules and plaques of pregnancy. Adapted from Dermatology Atlas.

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  Pruritic urticarial papules and plaques of pregnancy. Adapted from Dermatology Atlas.

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  Pruritic urticarial papules and plaques of pregnancy. Adapted from Dermatology Atlas.

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  Pruritic urticarial papules and plaques of pregnancy. Adapted from Dermatology Atlas.

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  Pruritic urticarial papules and plaques of pregnancy. Adapted from Dermatology Atlas.

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  Pruritic urticarial papules and plaques of pregnancy. Adapted from Dermatology Atlas.

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  Pruritic urticarial papules and plaques of pregnancy. Adapted from Dermatology Atlas.

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  Pruritic urticarial papules and plaques of pregnancy. Adapted from Dermatology Atlas.

Treatment

Treatment of mild cases during pregnancy consists mainly of the application of topical moisturising creams or aqueous/emmolient ointments. Class I or II corticosteroid creams and ointments are used in more aggressive cases, and oral (systemic) corticosteroids can be used to treat very severe cases--although the benefits of a pregnant woman's ingesting high-potency corticosteroids must be weighed carefully against possible (and mostly unknown) risks to the developing fetus or fetuses. Rarely, in unusually persistent and distressing cases, some women have had their labor induced as soon as they are considered to be at term (38 weeks).

Antihistamine tablets may be prescribed to provide relief from the itch, although they are generally considered much less effective than corticosteroid treatments and may act as little more than a sleep aid.

Anecdotally, a few sufferers have reported getting relief from taking dandelion root tablets, either on their own or in combination with flaxseed oil capsules (both taken 3x/day).. Also that baking soda paste and applied to the affected areas may provide some relief to the burning sensation, although it not with the itch.

In the majority of cases, PUPPP resolves spontaneously within a week of delivery. However, a few women continue to experience symptoms long into the postpartum period.

See also

• Intrahepatic Cholestasis of Pregnancy