Pruritic urticarial papules and plaques of pregnancy (PUPPP)

Pruritic urticarial papules and plaques of pregnancy (PUPPP), also known as polymorphic eruption of pregnancy, is a common dermatological condition of pregnancy that typically presents in the third trimester and resolves spontaneously after delivery. Lesions usually present around the striae gravidarum of the abdomen, with subsequent spread to the lower limbs. We report a case of PUPPP in a postpartum patient who presented with a pruritic rash affecting the buttocks and lower limbs, with abdominal sparing. The patient's clinical course, histological and lab findings, and response to treatment are discussed. This case contributes to the limited literature on the occurrence of PUPPP in postpartum patients and also PUPPP presenting without involvement of the abdomen. We aim to increase awareness of this atypical presentation and emphasise the need for a comprehensive evaluation in patients presenting with rashes in pregnancy and post partum.

Pregnancy induces significant hormonal and immunological changes that can alter the skin. Pregnancy-specificdermatoses include, polymorphic eruption of pregnancy, pemphigoid gestationis, intrahepatic cholestasis ofpregnancy, and atopic eruption of pregnancy, some of which are associated with adverse fetal outcomes, such aspreterm birth or low birth weight. In addition, common skin diseases, such as atopic dermatitis, psoriasis, acne,and urticaria, may follow a different clinical course during pregnancy. Management is primarily symptomatic,with topical corticosteroids, antihistamines, and narrowband ultraviolet B phototherapy, which are consideredto be relatively safe options, whereas systemic therapies require careful evaluation of fetal safety. This reviewsummarizes the classification, clinical features, and treatment strategies for pregnancy-related dermatoses, aimingto provide practical guidance for clinicians to optimize maternal and fetal care.

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

Background: Pregnancy induces hormonal, immunologic, and vascular changes that profoundly affect dermatologic health. This systematic review aimed to assess the impact of pregnancy on dermatological disorders in terms of disease incidence, severity, maternal-fetal outcomes, and optimal management strategies. Methods: A systematic search was performed in PubMed, MEDLINE, and Web of Science databases, following PRISMA guidelines. Studies evaluating pregnant women with dermatological disorders, pregnancy-related dermatoses, and pre-existing morbidities, were included. The collaboratively extracted data included patient demographics, disease severity, treatment approaches, and pregnancy outcomes. Results: A total of 8490 pregnant cases with dermatologic changes and conditions caused by pregnancy were studied. The dermatological conditions were divided into physiological changes, pregnancy-related exacerbation of pre-existing skin conditions, and pregnancy-specific dermatoses. Intrahepatic cholestasis of pregnancy and pemphigoid gestationis were associated with increased rates of adverse fetal outcomes in patients with specific dermatoses, including increased preterm birth and fetal distress rates. The atopic eruption of pregnancy and polymorphic eruption of pregnancy were highly relevant, but their effect on fetal health was minimal. The efficacy and safety of treatment modalities, including corticosteroids, antihistamines, and ursodeoxycholic acid, were variable. Conclusions: Pregnancy drastically affects dermatological health, but the nature of the impact depends on the condition. Optimal maternal and fetal outcomes rely on early diagnosis and individualized management strategies. More randomized controlled trials are required to develop standardized diagnostic and treatment guidelines to enhance the quality of dermatologic care during pregnancy.

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.

Introduction and purpose: Pregnancy-specific dermatoses are a group of pruritic skin disorders that arise exclusively during pregnancy or the postpartum period. They encompass four primary conditions: atopic eruption of pregnancy (AEP), polymorphic eruption of pregnancy (PEP), intrahepatic cholestasis of pregnancy (ICP), and pemphigoid gestationis (PG). This review aims to provide a comprehensive analysis of their prevalence, clinical characteristics, underlying mechanisms, therapeutic strategies, and potential fetal risks. Results: These dermatoses often present with overlapping clinical features, making accurate differential diagnosis crucial. While some pose minimal risk to the fetus, others, such as ICP and PG, are associated with significant complications, including preterm birth and stillbirth. The underlying pathophysiology remains incompletely understood, with hormonal, immunological, genetic, and environmental factors playing key roles. Treatment strategies focus primarily on symptomatic relief, with topical corticosteroids and oral antihistamines being the mainstay of therapy, while ursodeoxycholic acid is the treatment of choice for ICP. Conclusions: A multidisciplinary approach is essential for optimal maternal and fetal outcomes. Further research is needed to better understand the mechanisms and develop more effective treatment options for these conditions.

Introduction and purpose: Pregnancy is a remarkable and delicate period in a woman's life, marked by significant physiological adaptations to accommodate the growing fetus. These changes affect every organ system, including the skin. The aim of this review paper is to raise awareness and assist clinicians in recognizing, diagnosing, and effectively managing these distinct skin conditions associated with pregnancy. Material and methods: An extensive examination of articles published in scientific journals was carried out through online research platforms PubMed and Google Scholar. We searched articles by entering keywords in appropriate configuration: “pregnancy dermatoses”, “pemphigoid gestationis”, “ polymorphic eruption of pregnancy”, “intrahepatic cholestasis of pregnancy”, “pustular psoriasis of pregnancy”, “atopic eruption of pregnancy”. Description of the state of knowledge: This diverse set of pregnancy-related skin conditions includes pemphigoid gestationis, polymorphic eruption of pregnancy, intrahepatic cholestasis of pregnancy, atopic eruption of pregnancy, and pustular psoriasis of pregnancy. Summary: Early diagnosis and treatment are crucial to mitigate maternal and fetal complications, and in some conditions, prevent fatalities. Improving clinicians' in-depth understanding of these disease processes can enhance patient safety and quality of life during and after pregnancy.

ABSTRACT A primiparous patient, 30 days postpartum, presented to the clinic with a chief complaint of an itchy red rash on her mid to lower abdomen. It started 2 days ago. The rash had spread to her upper thighs. Past medical history was negative for skin disease or atopy. Her examination exposed pruritic erythematous polymorphous papules, with subsequent coalescence of larger urticarial plaques on the mid to lower abdomen and upper thighs. The patient was diagnosed with pruritic urticarial papules and plaques of pregnancy (PUPPP). PUPPP is the most common dermatosis affecting about one in 200 pregnant women. It has no tendency to recur in subsequent pregnancies. The elevated differential diagnosis included pemphigoid gestationis and eczema. Drug eruptions, urticaria, and viral exanthems were also considered. The primary goal of PUPPP treatment is to alleviate pruritus and discomfort. Antihistamines and topical corticosteroids are often prescribed along with skin care recommendations. Patients frequently have limited relief from topical treatments or skin care strategies. The extent of patient discomfort mandates competent evaluation because treatment is symptomatic and PUPPP can be difficult to manage. Despite the discomfort related to severe pruritus, PUPPP is not harmful to the mother or baby.

Pruritic urticarial papules and plaques of pregnancy (PUPPP) present as a benign condition, which is a self- limiting inflammatory reaction that typically affects primigravida within the third trimester of pregnancy. Cases of PUPPP are also seen in the postpartum period. The majority of risk factors are those associated with significant skin stretching, as seen in rapid and excessive weight gain, or multiple pregnancies (such as twins). A preliminary narrative review was conducted to summarize and critically assess the prior literature focusing on the association between PUPPP and multiple gestation. A literature search was carried out in electronic databases using controlled vocabulary. According to current studies, the rapid stretching of the skin is responsible for causing an inflammatory reaction, which causes damage to connective tissue, hence forming urticarial or hive-like lesions. Other risk factors include in-vitro fertilization, hormonal therapy, and a primigravida or nulliparous condition. Moreover, multiple gestations are linked with increased levels of estrogen and progesterone. The lesions are elevated with edematous areas of small papules joining to form bigger plaques. The affected area usually includes the upper and lower abdomen, particularly the area within or next to Striae gravidarum, followed by expansion to proximal limbs, primarily thighs, back, and buttocks. Histopathological findings suggest the presence of perivascular lymphohistiocytic infiltrates of Eosinophils, mononuclear cells, and skin oedema in the dermis, which is mainly composed of T- helper lymphocytes. Women still often seek treatment for symptomatic relief due to the intense itching. Conservative treatments are suitable to control the manifestations during gestation, and the lesions usually resolve shortly after pregnancy. Symptomatic relief can be provided by antihistamines given orally, emollients, and topical steroids.

A erupção polimórfica específica da gravidez é uma dermatose específica da gestação de desconhecida etiologia, mecanicamente induzida, mais comum em multíparas, primigestas e no terceiro trimestre da gestação. Apresenta ampla gama de diagnósticos diferenciais de dermatoses gestacionais, sendo necessário seu conhecimento clínico para correta investigação e diagnóstico oportuno. O presente trabalho é um relato de caso de gestante primigesta, de 34 semanas, com feto feminino, o que apresenta algumas diferenças na clássica epidemiologia da doença. Descritores: PUPP, erupção polimórfica específica da gestação, dermatose, dermatologia, gestaçã

Pruritic urticarial papules and plaques of pregnancy (PUPPP) is a rare dermatitis of unknown etiology first diagnosed in 1979. It occurs most commonly in the 3rd trimester of pregnancy. Postpartum presentation is extremely rare. Treatment modalities mostly involve the relief of symptoms. We are going to report here one case of a 24-year-old primigravid female who presented in the 9th month of the gestational period with generalized pruritic eruptions in a tertiary care hospital in the Eastern part of India. These eruptions were erythematous, hyperpigmented, and papular, which began within the striae distensae of the abdomen and progressively spread on the skin of upper and lower limbs, trunk, and buttocks. After the delivery of a full-term male child, there was an aggravation of the symptoms such as itching and disturbed sleep. There was also increased spread of the lesions over the skins of the mentioned areas, which persisted for 6 weeks of the postpartum period. The lesions and associated symptoms gradually subsided with topical application of corticosteroids and hydroquinone along with oral antihistaminic for prolonged periods. Our objective behind reporting this case is to make clinicians aware of PUPPP as a differential diagnosis of peripartum and postpartum pruritic eruptions for prolonged periods.

Pruritic urticarial papules and plaques of pregnancy (PUPPP) is a rare dermatitis of unknown etiology first diagnosed in 1979. It occurs most commonly in the 3rd trimester of pregnancy. Postpartum presentation is extremely rare. Treatment modalities mostly involve the relief of symptoms. We are going to report here one case of a 24-year-old primigravid female who presented in the 9th month of the gestational period with generalized pruritic eruptions in a tertiary care hospital in the Eastern part of India. These eruptions were erythematous, hyperpigmented, and papular, which began within the striae distensae of the abdomen and progressively spread on the skin of upper and lower limbs, trunk, and buttocks. After the delivery of a full-term male child, there was an aggravation of the symptoms such as itching and disturbed sleep. There was also increased spread of the lesions over the skins of the mentioned areas, which persisted for 6 weeks of the postpartum period. The lesions and associated symptoms gradually subsided with topical application of corticosteroids and hydroquinone along with oral antihistaminic for prolonged periods. Our objective behind reporting this case is to make clinicians aware of PUPPP as a differential diagnosis of peripartum and postpartum pruritic eruptions for prolonged periods.

Hormonal, vascular, immunological and metabolic changes in pregnancy can cause many changes in body systems. This condition has an impact on skin changes associated specifically with pregnancy (dermatoses in pregnancy). These changes can be physiological or pathological. This condition is usually considered normal and ignored by health workers but can affect the quality of life in pregnant women. This study was conducted to determine the prevalence of both physiological and pathological skin changes in pregnancy. In this systematic review, literature was reviewed through three databases in accordance with the 2020 PRISMA guidelines. Inclusion criteria were primary literature or journals, full text, in English or Indonesian, published in 2013-2023, examined the prevalence of skin disorders in pregnancy, cross-sectional study design sectionals, cohorts. The study that cannot be accessed in full text and in the form of a review is excluded from the literature review. Most skin disorder changes in pregnant women are in the form of physiological disorders with the type of hyperpigmentation. While the most pathological changes are Atopic Eruption of Pregnancy (AEP) and Polymorphic Eruption of Pregnancy (PEP).

Introduction: Pregnancy is a physiological state of women which is associated with intricate endocrinological, immunological, metabolic & vascular changes. So pregnancy makes a woman susceptible to various changes in skin & appendages. Alteration to the immune state of the pregnant women is necessary to allow mother to tolerate genetically different tissue during pregnancy. Decrease in cell mediated immunity in normal pregnancy is mainly responsible for the higher frequency and severity of certain infectious diseases. Some of which can also be transmitted to the baby during child birth. Moreover there are marked changes in the levels of sex hormones particularly oestrogen & progesterone and this can lead to profound changes in skin. Objective: To find the prevalence of dermatological manifestations in pregnant patients presenting in a tertiary care hospital Study Design: Descriptive/Cross-sectional Study Setting: The study was done in the Dermatology unit DHQ Hospital Faisalabad. Duration of Study: The study was carried out from 1st October 2016 to 10th March 2017 Subjects and methods: 185 pregnant women presenting at any gestational age in dermatology department and patients referred from Gynae department with dermatological complaints were included in the study. Patients with pre-existing medical conditions such as hypertension and diabetes were excluded. Complete history and clinical features of the patients were accessed and relevant investigations were done to support the diagnosis. Final diagnosis was made on basis of history, clinical examination and laboratory confirmation of disease as per operational definition. LFT’s for intrahepatic cholestasis of pregnancy was done from DHQ laboratory and sample for skin biopsy for pemphigoid gestationis were sent to pathology laboratory FMU. All the data was recorded in a well-structured questionnaire. Results: Age range in this study was from 18 to 40 years with mean age of 30.129±3.26 years and mean duration of disease was 5.864±1.79 week. Majority of the women were with 2nd trimester of pregnancy (67%). 60% of women had no occupation. Striae Gravidarum was seen in 48.1%, Linea Nigra 45.9%, Melasma 25.4%, Hirsutism 16.2%, Palmer Erythema 8.1%, Atopic eruption of Pregnancy 11.9%, Polymorphic eruption of Pregnancy 3.2%, Intrahepatic Cholestasis of Pregnancy 1.6%, Pemphigoid gestationis 1.1%, Acne Vulgaris 9.7%, Vulvovaginal candidosis 8.1%, Urticaria 6.5% and Scabies was 5.4%. Practical Implication: We set out to investigate the prevalence of dermatological manifestations during pregnancy, as well as other clinical characteristics affecting pregnant women in Pakistan. Conclusion: If infections during pregnancy are diagnosed at the earliest stage it may prevent morbidity during and after antenatal period. Keywords: Pregnancy; Dermatological manifestations; Frequency, Clinical Patterns, Pemphigoid Gestationis, Acne Vulgaris, Vulvovaginal Candidosis,

Development and multicenter international validation of a diagnostic tool to differentiate between pemphigoid gestationis and polymorphic eruption of pregnancy

Dermatoses of pregnancy encompass a range of skin disorders that manifest uniquely during the gestational period, characterized by significant itching. This review delves into four primary types: polymorphic eruption of pregnancy, pemphigoid gestationis, atopic eruption of pregnancy, and intrahepatic cholestasis of pregnancy. While atopic eruption and polymorphic eruption are generally benign with no fetal impact, pemphigoid gestationis and intrahepatic cholestasis carry risks for the fetus, including prematurity and stillbirth. Key challenges include the difficulty in early diagnosis of pemphigoid gestationis due to its resemblance to polymorphic eruption and the increased risk of complications like gestational diabetes and pre-eclampsia in intrahepatic cholestasis. Understanding these dermatoses is crucial for prompt diagnosis and effective treatment, to prevent adverse outcomes for mothers and babies and improve the overall pregnancy experience. The review focuses on epidemiology, clinical features, diagnostic methods, maternal and fetal outcomes, treatment options, and comprehensive management strategies for these conditions.

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.

33841 Pregnancy dermatosis clinical scoring system: How to predict between pemphigoid gestationis and polymorphic eruption of pregnancy

Polymorphic eruption of pregnancy (PEP) is a benign self-limiting dermatoses that occursduring pregnancy and/or the postpartum period. Etiology is unknown and evidence suggest arelationship between excessive maternal weight gain, cesarean deliveries, skinoverdistension, multiple gestation and male fetuses. We present a case of PEP in a26-year-old woman with twin pregnancy. We recommend prompt evaluation and diagnosis of apregnant woman with primary skin lesions and pruritus to differentiate between the benignpolymorphic eruption of pregnancy and other dermatosis which are associated with increasedfetal morbidity.