Three cases of pruritic urticarial papules and plaques of pregnancy (PUPPP) treated with intramuscular injection of autologous whole blood

Pruritic urticarial papules and plaques of pregnancy (PUPPP) is one of the most common diseases associated with pregnancy. In most cases, the skin lesions develop in the third trimester of primigravidas. There are no systemic alterations seen in PUPPP; however, most patients report severe pruritus. A 34-year-old woman presented 1 week postpartum with typical clinical features of PUPPP. The patient showed good response to intramuscular injection of autologous whole blood with no adverse effects to the patient or her baby. Presentation of PUPPP in the postpartum period is rare. Conservative management with topical corticosteroids and oral antihistamines is commonly used to relieve pruritus. In severe cases, skin lesions and symptoms are controlled with a brief course of systemic corticosteroids. Investigation of new treatment options has been limited by patient concerns about the negative effects of medication on the fetus or breastfeeding. Intramuscular injection of autologous whole blood could be an alternative treatment option for PUPPP, especially for women who worry about the use of medications during pregnancy or breastfeeding.

Pruritic urticarial papules and plaques of pregnancy (PUPPP) is a specific dermatosis of pregnancy common to primigravid women in the third trimester. The rash usually begins on the lower abdomen within striae and spreads to the proximal extremities. Involvement of face, palms, and soles is unusual. Although intensely pruritic, the fetus is unaffected, and the condition does not usually recur. It can be difficult to distinguish PUPPP from pemphigoid gestationis, an autoimmune bullous disorder with potential fetal consequences that may recur with subsequent pregnancy, menses, or hormonal therapy. A young secundagravida at 36 weeks of gestation with monochorionic twins presented with a 3-week history of a pruritic papular eruption that began on the abdomen and spread to the extremities. She had extensive involvement of the distal extremities, including the palmoplantar surfaces, with small vesicles of 2-4 mm on acral skin. Because of her unusual presentation, she was thought initially to have pemphigoid gestationis. Subsequent dermatological evaluation and a biopsy confirmed the diagnosis of PUPPP. Shortly after admission she delivered 2 healthy male infants, and her rash cleared with conservative management. Pruritic urticarial papules and plaques of pregnancy often, but not always, spares the face, palms, and soles. Small vesicles can occur in PUPPP, but formation of true bullae is not observed. Careful dermatological examination and cutaneous biopsy can assist in differentiating PUPPP from pemphigoid gestationis, which is essential for treatment and prognosis.

Objective. The study was designed to investigate obstetric risk factors and pregnancy outcome of patients with pruritic urticarial papules and plaques of pregnancy (PUPPP).Methods. A population-based study comparing all pregnancies of women with and without PUPPP was conducted. Deliveries occurred during the years 1988–2002 at the Soroka University Medical Center. A multivariable logistic regression model was constructed in order to find independent risk factors associated with PUPPP.Results. During a 15-year period, 159 197 deliveries took place. PUPPP complicated 42 (0.03%) of all pregnancies. Using a multivariable analysis, the following conditions were significantly associated with PUPPP: multiple pregnancies (odds ratio (OR) = 4.9, 95% confidence interval (CI) 1.7–14.1), hypertensive disorders (OR = 2.2, 95% CI 1.1–4.7), and induction of labor (OR = 7.6, 95% CI 4.0–14.5). Higher rates of 5-minute Apgar scores lower than 7 (OR = 8.0, 95% CI 4.4–14.9) and of cesarean deliveries (OR = 2.9, 95% CI 1.5–5.6) were noted in the PUPPP as compared to the comparison group. While investigating other perinatal outcome parameters such as oligohydramnios, intrauterine growth restriction, meconium-stained amniotic fluid and perinatal mortality, no significant differences were observed between the groups.Conclusion. Pruritic urticarial papules and plaques of pregnancy is a condition significantly associated with multiple pregnancies, hypertensive disorders, and induction of labor. Perinatal outcome is comparable to pregnancies without PUPPP.

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

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 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.

Aronson, Iris K.; Bond, Shirley; Fiedler, Virginia C.; Vomvouras, Stephanie; Gruber, David; Ruiz, Catherine Author Information

Pruritic urticarial papules and plaques of pregnancy: Clinical and immunopathologic observations in 57 patients

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.

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.

Pruritic urticarial papules and plaques of pregnancy (PUPPP) is a benign pruritic inflammatory skin disorder that usually affects primigravidae in their third trimester of pregnancy. Studies on this condition from our area are lacking. To describe the epidemiological, clinical, and histopathological findings of all patients diagnosed with PUPPP at the American University of Beirut Medical Center (AUB-MC) between 1998 and 2009 and compare our findings with those published in the literature. PUPPP mainly affected primigravidae (72%) in the third trimester of pregnancy (89%). Multiple gestation pregnancies were observed in 50% of cases. The abdomen and proximal thighs were the most commonly involved sites (67%), with exclusive involvement of the extremities in four cases. Although pruritic urticarial papules and plaques were the main morphological feature of PUPPP observed (98%), five cases had additional features, and one case presented exclusively with papulovesicular lesions. Microscopically, all cases biopsied showed the typical features of PUPPP, including negative direct immunofluorescence findings. Emollients, topical corticosteroids, and/or oral antihistamines were generally adequate to control symptoms in all cases, in which skin lesions resolved in an average of three weeks. This study showed a lower incidence of PUPPP in our population compared with its incidence in other populations. It also confirmed the previously described clinical features, benign course, and excellent outcome of the condition, although variations may occur. Significant associations mainly included multiple gestation pregnancies, excessive maternal weight, and Rh-positive blood type, while fetal gender and weight gain did not contribute.

Thirty women who were seen at our institution between 1984 and 1988 for pruritic urticarial papules and plaques of pregnancy (PUPPP) were retrospectively evaluated and interviewed. We found a significantly increased maternal weight gain and newborn birth weight in patients with PUPPP, compared with age and parity-matched controls. The average weight gain during pregnancy was 18.1 +/- 0.9 (SEM) kg for the patients with PUPPP (excluding twin gestations) and 14.6 +/- 1.0 kg for the controls. The mean newborn birth weight was 3.6 +/- 0.09 kg for the PUPPP group and 3.3 +/- 0.08 kg for the control group. There were three twin pregnancies (10%), compared with the twin gestation rate at our institution of 1.6%. Therefore, based on our findings of an increased maternal weight gain and neonatal birth weight, an increased twin rate, and an abdominal eruption that occurs in primigravidas in their third trimester of pregnancy, we suggest that abdominal distention or a reaction to it may play a role in the development of PUPPP.

Pruritic urticarial papules and plaques of pregnancy (PUPPP) is a common dermatosis of unknown aetiology. Multiple pregnancies occur frequently in most reported series of PUPPP and increased abdominal distension has been considered a factor in its causation. To determine the frequency of PUPPP in twin and triplet pregnancies. A retrospective review of all the records of patients delivered of twin or triplet pregnancies over an 18-month period at a busy general maternity hospital. One hundred and thirty-eight women delivered twins, four of whom developed PUPPP (2.9%). Fourteen women delivered triplet pregnancies, two of whom developed PUPPP (14%). Four of these six multiple pregnancies were conceived by in vitro fertilization. The reported rate of PUPPP in single pregnancies is 1 in 200 (0.5%). Our findings suggest that multiple pregnancies are at a higher risk of developing this cutaneous eruption with 2.9% of twin and 14% of triplet pregnancies affected in our study.

Pruritic urticarial papules and plaques of pregnancy (PUPPP): A clinicopathologic study