Polymorphic eruption of pregnancy with bullae on the soles: a case report.

Pruritic urticarial papules and plaques of pregnancy (PUPPP) is among the most common dermatoses of pregnancy. Most reports of the effective treatment of PUPPP involve high potency topical corticosteroids or oral steroids. Many authorities have noted cases of PUPPP whose resolution followed parturition. A few have noted that PUPPP can arise and resolve the third trimester. A 36-year-old prima gravida at 38 weeks of gestation presented with a 2-week history of a pruritic papular abdominal eruption. She used fluticasone propionate 0.05 percent lotion twice a day. One week after starting this medication, the pruritus had resolved and the erythema/urticaria had abated; the pigmentary alteration had improved, but still remained. The PUPPP did not return after parturition. PUPPP can abate entirely during pregnancy. Fluticasone propionate 0.05 percent lotion, a class 5 (low-medium potency) corticosteroid, has a benign side effect profile and should be considered for the treatment of PUPPP during pregnancy.

The specific dermatoses of pregnancy represent a heterogeneous group of pruritic skin diseases that have been recently reclassified and include pemphigoid (herpes) gestationis, polymorphic eruption of pregnancy (syn. pruritic urticarial papules and plaques of pregnancy), intrahepatic cholestasis of pregnancy, and atopic eruption of pregnancy. They are associated with severe pruritus that should never be neglected in pregnancy but always lead to an exact work-up of the patient. Clinical characteristics, in particular timing of onset, morphology and localization of skin lesions are crucial for diagnosis which, in case of pemphigoid gestationis and intrahepatic cholestasis of pregnancy, will be confirmed by specific immunofluorescence and laboratory findings. While polymorphic and atopic eruptions of pregnancy are distressing only to the mother because of pruritus, pemphigoid gestationis may be associated with prematurity and small-for-date babies and intrahepatic cholestasis of pregnancy poses an increased risk for fetal distress, prematurity, and stillbirth. Corticosteroids and antihistamines control pemphigoid gestationis, polymorphic and atopic eruptions of pregnancy; intrahepatic cholestasis of pregnancy, in contrast, should be treated with ursodeoxycholic acid. This review will focus on the new classification of pregnancy dermatoses, discuss them in detail, and present a practical algorithm to facilitate the management of the pregnant patient with skin lesions.

Polymorphic eruption of pregnancy (PEP) and herpes gestationis (HG) are pregnancy-related dermatoses of unknown aetiology with eosinophil infiltration which, at early stages, may show similar clinical and histopathological features. To determine the relative contributions of eosinophils, neutrophils and mast cells to the pathogenesis of PEP and HG through deposition of granule proteins, we studied tissue and serum from 15 patients with PEP and 10 with HG. Using indirect immunofluorescence with antibodies to human eosinophil granule major basic protein (MBP), eosinophil-derived neurotoxin (EDN), eosinophil cationic protein (ECP), neutrophil elastase and mast cell tryptase, we determined and compared cellular and extracellular staining patterns in lesional skin biopsy specimens and, using immunoassay, measured MBP, EDN, and ECP in patients' sera. Eosinophil infiltration and extracellular protein deposition of all three eosinophil granule proteins were present in both PEP and HG indicating a pathogenic role for eosinophils in both diseases. Staining for eosinophil granule proteins was especially prominent in urticarial lesions and around blisters in HG. EDN and ECP serum levels in PEP and ECP serum levels in HG were significantly increased compared with those in normal pregnant and normal nonpregnant serum. Neutrophils were more prominent in HG specimens than in PEP specimens; extracellular neutrophil elastase was minimally present and similar in both diseases. Mast cell numbers and extracellular tryptase deposition did not differ between the two diseases and did not differ from mast cell counts in skin of normal pregnant women. This study shows that eosinophil granule proteins are deposited extracellularly in tissue and are increased in serum in both PEP and HG. Moreover, eosinophil involvement in the two diseases is more consistent than neutrophil and mast cell involvement. Comparatively, tissue eosinophil infiltration and extracellular protein deposition is more extensive in HG than in PEP, suggesting that eosinophil involvement is greater in the pathogenesis of HG than PEP and similar to that found in bullous pemphigoid.

Pruritic urticarial papules and plaques of pregnancy (PUPPP), also known as polymorphic eruption of pregnancy, is a benign inflammatory dermatosis that typically presents in primigravid women during the third trimester of pregnancy. Postpartum onset is rare and often underrecognized. We report a case of a 29-year-old primigravida with a BMI of 38 kg/m2 who delivered a healthy 4 kg male infant via emergency cesarean section for fetal distress. On postpartum day five, she developed a pruritic rash on the abdomen, initially suspected to be a drug reaction to low-molecular-weight heparin. Given the short duration of low molecular weight heparin (LMWH) exposure and persistence of symptoms after discontinuation, a drug-induced eruption was deemed unlikely. The rash progressed to the thighs and buttocks. Dermatologic examination revealed erythematous papules and urticarial plaques over abdominal striae with periumbilical sparing, typical of PUPPP. Laboratory evaluation was unremarkable, apart from a mildly elevated C-reactive protein (CRP), which was measured to assess for systemic inflammation or infection, neither of which was clinically evident. A clinical diagnosis of postpartum-onset PUPPP was made. Treatment with oral antihistamines resulted in a rapid resolution within two weeks. The patient was followed for four weeks after resolution, with no recurrence of symptoms. Although rare in the postpartum period, PUPPP should be considered in the differential diagnosis of pruritic eruptions following delivery. Classic distribution patterns, periumbilical sparing, and absence of systemic involvement are key diagnostic features. Risk factors for PUPPP include primigravidity, multiple gestation, excessive maternal weight gain, and high BMI; in this case, obesity was the primary risk factor identified. Conservative treatment is typically effective. This case underscores the importance of recognizing postpartum-onset PUPPP and differentiating it from drug reactions or other dermatoses. Awareness of its clinical presentation allows for timely diagnosis, appropriate reassurance, and effective symptom management.

To describe the risk factors for epidural abscess (EA) formation following epidural analgesia in a parturient with pruritic urticarial papules and plaques of pregnancy (PUPPP). A 33 yr-old gravida 2 nulliparous patient at 36 weeks gestation presented with severe pre-eclampsia, and PUPPP (treated with prednisone). Magnesium prophylaxis was started and labour was induced. An epidural catheter was placed at the L(3-4) level using standard aseptic technique. Bupivacaine was incrementally injected to achieve a T10 sensory level, and analgesia was maintained using a continuous infusion of 0.0625% bupivacaine with fentanyl. Nine days post-delivery, the patient developed back pain radiating to her right leg, but she was otherwise asymptomatic. She was afebrile; with a slightly tender, non-erythematous, non-draining, 1 cm nodule at the epidural catheter site. Motor and sensory examinations were normal at that time. However, the patient returned 24 hr later and further investigations revealed: WBC 17,800.mm(-3), platelets 486,000.mm(-3), erythrocyte sedimentation rate 50 mm.hr(-1), and C-reactive protein 8.8 mg.dL(-1). The magnetic resonance imaging demonstrated an EA at the L(3-4) level causing minimal cord compression. The patient underwent an emergency decompressive laminectomy. Cultures revealed methicillin-sensitive Staphylococcus aureus. Her pain improved, and she was discharged on the third postoperative day with a six-week course of iv ceftriaxone. Causative organisms for EAs include coagulase-negative Staphylococci, S. aureus, and Gram-negative bacilli. Infection can occur either hematogenously or by direct contamination during catheter placement. Risk factors include immunocompromised states and PUPPP, as with the case of this patient.

Introduction: Pruritic urticarial papules and plaques of pregnancy (PUPPP), also known as polymorphic eruption of pregnancy (PEP), is a common, self-limiting dermatosis of pregnancy. However, its specific characteristics and management outcomes in Indonesia, a diverse and populous nation, remain understudied. This study aimed to comprehensively assess the clinical features, risk factors, and management outcomes of PUPPP in an Indonesian population. Methods: A retrospective cohort study was conducted at Private Hospital in Jakarta, Indonesia, between January 2019 and December 2023. Medical records of pregnant women diagnosed with PUPPP were reviewed. Data collected included demographics, gestational age at onset, clinical presentation (lesion morphology, distribution, pruritus severity), associated symptoms, parity, pre-pregnancy BMI, weight gain during pregnancy, smoking history, presence of comorbidities, treatment modalities, and treatment outcomes (symptom resolution time, recurrence). Statistical analysis was performed using SPSS version 28. Results: A total of 285 pregnant women were included in the study. The mean age was 29.5 years (SD ± 4.8). The majority (72.3%) were primigravida. Onset was most common in the third trimester (88.4%). The most frequent presenting symptom was severe pruritus (94.7%), followed by erythematous papules (98.2%) and urticarial plaques (91.6%). Lesions predominantly affected the abdomen (96.5%), particularly the striae distensae (89.1%), with frequent involvement of the thighs (75.4%) and buttocks (62.1%). Higher pre-pregnancy BMI (p=0.012) and excessive gestational weight gain (p=0.003) were significantly associated with PUPPP development. Topical corticosteroids (85.6%) were the most commonly used treatment, followed by oral antihistamines (68.4%). Symptom resolution occurred within a mean of 10.2 days (SD ± 3.5) after treatment initiation. Recurrence was observed in 8.4% of cases. Conclusion: PUPPP in Indonesian women predominantly affects primigravida in the third trimester, presenting with severe pruritus and characteristic lesions on the abdomen, thighs, and buttocks. Higher pre-pregnancy BMI and excessive gestational weight gain appear to be significant risk factors. Topical corticosteroids and oral antihistamines are effective in achieving symptom resolution. These findings highlight the need for increased awareness and appropriate management of PUPPP in Indonesia.

Pruritic urticarial papules and plaques of pregnancy (PUPPP) is a rare dermatosis of unknown etiology that is most frequently seen in primiparas and twin/multiple pregnancies. The prognosis is favorable. We report a case of PUPPP in a primipara and review the clinical signs, differential diagnosis, possible etiologic factors, diagnosis, and therapy.

The specific dermatoses of pregnancy represent aheterogeneous group of inflammatory skin diseases related to pregnancy and/or the postpartum period. Aclinically relevant classification has been well established over the past 10years and includes pemphigoid gestationis, polymorphic eruption of pregnancy, intrahepatic cholestasis of pregnancy, and atopic eruption of pregnancy. The hallmark of all four entities is severe pruritus that is accompanied by characteristic skin changes. While some of these dermatoses are distressing only to the mother because of pruritus, others may be associated with significant fetal risks. Early diagnosis and prompt treatment are therefore essential. In this review, we discuss in detail pemphigoid gestationis, polymorphic and atopic eruptions of pregnancy whereas intrahepatic cholestasis of pregnancy is discussed in aseparate article (Kremer A, Ständer S, DOI 10.1007/s00105-016-3923-y ). Furthermore, we present ahelpful algorithm for diagnosis and management of pruritus in pregnancy.

PUPPP, a Polymorphic Eruption of Pregnancy (PEP), is a chronic hives-like rash that strikes some women during pregnancy. The condition typically develops in the third trimester of pregnancy or immediately in the postpartum period. Clinically, it appears as an intensely pruritic (itchy) rash consisting of raised, edematous areas of small papules coalescing into larger plaques. The case report concerns a primigravida woman (period of gestation – 36 weeks) diagnosed with pruritic urticarial papules and plaques of pregnancy (PUPPP). She had been married since 10 months and this is her first pregnancy. The patient was admitted to labor room of Hakeem Abdul Hameed Centenary (HAHC) Hospital, New Delhi, with chief complaints of fever since 2 days, cellulitis since 7 days. During physical examination, rashes were seen on the face, abdomen and legs. Per abdomen examination revealed cephalic presentation of the fetus with FHR as 142 bpm. Routine blood investigations revealed that the patient had gestational hypertension (albumin trace in urine) and the serum bilirubin total was also raised (1.58 mg/dL). The Liver Function Test (LFT) results were, SGOT (200 IU/L), SGPT (144 IU/L) and ALP (262 IU/L). After all the required investigations, she was diagnosed with PUPPP with GHTN.

Pemphigoid gestationis (PG) and polymorphic eruption of pregnancy (PEP) are pregnancy-related dermatoses. Definitive diagnosis often relies upon histopathology and direct immunofluorescence (DIF). PG is associated with fetal and neonatal risks, while PEP confers minimal risk. We aimed to compare histopathologic features to determine key differentiators. A retrospective cohort study of PG and PEP cases, with accompanying DIF, conducted from 1995 to 2020. Skin biopsies were examined independently in a blinded fashion by two dermatopathologists for a list of histopathological features. Twenty-one cases of PG and 10 cases of PEP were identified. PG had significantly denser eosinophils than PEP (mean 155 vs. 48 cells/5 hpf; p < 0.018). PG was also noted to have eosinophilic spongiosis and eosinophils at the dermal-epidermal junction more frequently compared to PEP (80% PG vs. 10% PEP; p < 0.001). A mean cutoff value of 86 eosinophils and a mean optimal sensitivity and specificity of 81% and 83%, respectively, for eosinophils density's diagnostic power of PEP versus PG were achieved. Subepithelial separation was exclusively seen in PG (40% vs. 0%; p < 0.007). Eosinophilic spongiosis, eosinophilic epitheliotropism, and dense superficial dermal eosinophils were diagnostic of PG. Given overlapping clinicopathologic features, however, DIF results with clinicopathologic correlation, remain the gold standard.

Dear Editor: Pruritic urticarial papules and plaques of pregnancy (PUPPP) is one of the most common diseases associated with pregnancy, and is characterized by urticarial papules and plaques with pruritus on the abdomen, buttocks and thighs1. In most cases, the skin lesions develop in the third trimester of primigravida and disappear within 7 to 10 days after labor1. Lesions mostly appear first on the abdomen, and then spread to the proximal extremities. Therefore, the abdomen is involved in most cases, especially the stria distensae. A 30-year-old female patient visited our department due to pruritic erythematous papules and plaques on both arms and both legs (Fig. 1 A~C). She complained that the erythematous skin lesions had first developed on both legs and were very pruritic. The lesions then spread to both arms. The patient's abdomen was spared. She went through labor seven days before the lesions developed in both thighs. She was in a postpartum period, which is the period beginning immediately after the birth of a child and extending for about six weeks. It was her first labor and a single pregnancy. She had no specific medical or dermatological history. We did laboratory studies including complete blood counts, liver function tests, renal function tests, thyroid function tests urinalysis and autoimmune study. She has no specific abnormal findings during these studies. We performed a biopsy of the lower leg for an exact diagnosis. Histopathological findings showed spongiosis of the epidermis, edema of the papillary dermis and perivascular infiltration of lymphocytes and eosinophils (Fig. 1D, E). The results of direct immunofluorescence were negative. The patient began to take prednisolone 20 mg daily for 4 days and then tapered to 5 mg per week. She was also treated with an oral antihistamine and a topical corticosteroid. After two weeks of treatment, the patient's symptoms of pruritus and erythematous skin rash were improved. In most cases, this disorder develops in the third trimester of pregnancy. Tiny pruritic erythematous papules first appear in the striae distensae of the abdomen, and then spread to the buttocks and legs. In our case, multiple pruritic erythematous papules and plaques occurred after labor, and the lesions were limited to the legs and arms, sparing the abdomen. Postpartum PUPPP is very rare (Table 1)2-5. In previous cases, the lesions first developed on the abdomen, and then spread to other parts of the body. In our patient, the pruritic skin lesions were limited to the extremities, while the abdomen was spared. Some previous cases also exhibited unique distributions. In contrast to all these cases, our case spared the abdomen and involved only the extremities. Generally, histological findings of PUPPP showed dyskeratosis, spongiosis of the epidermis, edema of the papillary dermis and perivascular lymphocytic infiltrations1. Direct immunofluorescence studies are negative. We also noted these histological features in our case. Based on these histopathological and clinical findings, we diagnosed the case as PUPPP developed in postpartum-period. Although our case was similar to urticarial vasculitis, clinically, the specimen did not show findings of leukocytoclastic vasculitis, and she improved without hyperpigmentation. Thus, we can rule out the urticarial vasculitis. Our case characterized itself by postpartumperiod developments which simultaneously show unique distributions of the disease that only limits the lesions to the extremities and sparing abdomen. This pattern of the disease has never been reported, and thus, display the strength of our case report. In conclusion, we report a case of PUPPP in which the lesions developed after labor and were limited to both the legs and arms. Fig. 1 Multiple itchy erythematous papules and plaques were observed on both the arms and legs. (A) Lesions on the lower extremities. (B, C) Lesions on the upper extremity. Histopathology of the skin lesions. (D) There were mild epidermal spongiosis and perivascular ... Table 1 Summary of postpartum pruritic urticarial papules and plaques of pregnancy cases

Pruritic urticarial papules and plaques of pregnancy (PUPPP), also known as polymorphic eruption of pregnancy, is a common and benign but exceedingly uncomfortable dermatosis of pregnancy. Investigation of new treatment options has been limited by patient concerns about the negative fetal effects of medication. To assess the efficacy of intramuscular injection of autologous whole blood (AWB) for treatment of PUPPP. This is a retrospective descriptive case series of three patients with PUPPP, all of whom were treated with intramuscular injection of AWB. All patients showed good responses to intramuscular injection of AWB, tolerated the treatment, and there were no adverse effects to the patients or their babies. AWB may be an alternative treatment option for patients with PUPPP who are worried about the risk of medication use during pregnancy or breastfeeding. Whole blood collected from the patient's own body may be preferable to foreign medications. Future investigation into the exact mechanism with controlled clinical studies using a large number of patients will be necessary to provide supporting evidence for this potential treatment.

The specific dermatoses of pregnancy represent a recently reclassified heterogeneous group of pruritic inflammatory skin diseases unique to pregnancy that include pemphigoid gestationis, polymorphic eruption of pregnancy (PEP), intrahepatic cholestasis of pregnancy, and atopic eruption of pregnancy (AEP). Among them, PEP and AEP are the most frequent ones. We performed a histopathological study of a series of PEP and AEP patients (n = 41). Twenty-two patients had PEP that started in the third trimester in 16 (73%) patients and postpartum in 6 (27%) patients. Histopathology revealed a superficial or superficial and deep perivascular dermatitis with eosinophils in all biopsies and signs of a lymphocytic vasculitis in 5 (23%) cases. Epidermal changes, including epidermal hyperplasia, spongiosis, and parakeratosis, occurred in 8 cases, in particular in elder lesions. Nineteen patients had AEP that started earlier [less than third trimester, 14 (74%) patients; third trimester, 5 (26%) patients]. Clinically, 5 (26%) patients showed eczematous lesions, 7 (37%) papular lesions, 3 (16%) presented both eczematous and prurigo lesions, and 4 (21%) experienced exacerbation of preexisting atopic dermatitis. Histopathologically, AEP was characterized by a perivascular lymphohistiocytic infiltrate with frequent eosinophils (74%) and epidermal changes in all but most of P-type biopsies. No definitive differential histopathological criteria between PEP and AEP were found. Only lymphocytic vasculitis with a mixed infiltrate with eosinophils was more frequent in PEP patients. Timing of onset, morphology of skin lesions, and a detailed clinicopathologic correlation are essential for diagnosis.

Background: Skin lesions in pregnant women could be caused by physiologic or pathologic changes. Polymorphic eruption of pregnancy (PEP), which manifests as various types of skin lesions, is the most common pregnancy dermatosis. Thus, PEP could mimic other skin diseases related to unfavorable maternal and fetal outcomes. Main Observations: Two PEP patients with targetoid lesions are presented here. One of them was a primigravida, whereas the other was a secundigravida. Both patients had singleton pregnancies and skin rash which started during the third trimester. The lesions began on the abdomen and then spread to the trunk and extremities. The face, palms, soles, and mucosa were not affected. Pruritus was observed but no other systemic symptoms were reported. Both patients delivered healthy, term infants without complications. Conclusion: Targetoid lesions in PEP are an uncommon presentation, and the differential diagnosis of PEP along with other dermatoses should be considered. However, the prognosis for this type of PEP is not different from that for classic PEP.

Polymorphic eruption of pregnancy, formerly known as pruritic and urticarial papules and plaques of pregnancy, is an uncommon cutaneous eruption that can affect women during their third trimester of pregnancy. As its name implies, it has a variety of morphologies and it is important to consider other diagnoses, such as pemphigoid gestationis, which polymorphic eruption of pregnancy can mimic. Sometimes, as in this case, polymorphic eruption of pregnancy can have a targetoid morphology reminiscent of erythema multiforme. A thorough workup and conservative management plan helps reassure the patient that the correct approach is being taken during the challenging period of a pregnancy nearing completion.