Polymorphic Eruption Of Pregnancy Research Articles

Pruritic Urticarial Papules and Plaques of Pregnancy With Unusual and Extensive Palmoplantar Involvement

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.

Pruritus in pregnancy

Pruritus is the leading dermatological symptom during pregnancy. Besides preexisting or acquired dermatoses, there are a number of pregnancy-specific dermatological diseases such as PEP (polymorphic eruption of pregnancy, previously named PUPPP), pemphigoid (herpes) gestationis, and pruritus gravidarum that are accompanied by severe itching and scratching. Because of potential effects on the fetus, the treatment of pruritus in pregnancy requires prudent consideration. The use of topical and systemic treatments depends on the underlying aetiology of pruritus and the stage and status of the skin. In general, emollients, topical anti-pruritics and topical corticosteroids appear to be the safest options for localised forms of pruritus in pregnancy whereas systemic treatments and/or UV phototherapy are adequate for generalized pruritus. Systemic corticosteroids and a restricted number of antihistamines may be administered in severe cases. This paper highlights the major aetiologies of pruritus during pregnancy and points out the cornerstones of antipruritic therapy in recognition of our own clinical experiences and the current literature.

Biological implications of bi-directional fetomaternal cell traffic: a summary of a National Institute of Child Health and Human Development-sponsored conference

Objective: The National Institute of Child Health and Human Development (NICHD) held a workshop on 27-28 July 2000 to bring together investigators working in the field of fetomaternal cellular and nucleic acid trafficking with the hope that this would stimulate further research into the biological implications of such phenomena. Methods: Invited speakers from all over the world presented their latest (unpublished) data. The conference proceedings were delayed until the present time to allow independent publication of the primary data. Results and conclusions: Bi-directional fetomaternal trafficking of cells and nucleic acids during pregnancy is now well established, through the use of molecular techniques including conventional and real-time polymerase chain reaction, as well as fluorescence in situ hybridization. In addition, human leukocyte antigen (HLA) is deposited in the skin of pregnant women. Feto-maternal trafficking is increased in some complications of pregnancy, such as pre-eclampsia, polyhydramnios, polymorphic eruption of pregnancy, preterm labor and specific fetal chromosome aneuploidies. Maternal cells and nucleic acids have been documented in umbilical cord blood and in autopsy tissue of non-transfused neonates. Fetal cells persist postpartum and may be associated with the development of disorders such as scleroderma, lichen planus, lupus and thyroid disease. The extent of fetomaternal trafficking may be affected by three generational HLA relationships. Thus, the consequences of pregnancy extend beyond gestation.

Connubial Contact Dermatitis: An Unusual Pregnancy Dermatosis

Sir, Pregnancy is frequently complicated by skin abnormalities, which is a cause of concern for the obstetrician and dermatologist because some pregnancy dermatoses can cause severe illness and even be life-threatening. Most common dermatoses are eczema, polymorphic eruption of pregnancy, pruritic folliculitis, prurigo and pemphigoid gestationis, but no cases of contact dermatitis were noted in a review of 200 patients (1). We report a 28-year-old and 7-month pregnant primi-gravida who presented with an acute inflammatory, erythematous, confluent macular skin eruption affecting her legs, lower back and lower abdomen, and ending in a clear-cut line above the umbilicus. Flexure sites such as groins, rima ani and popliteal fossae were spared (Fig. 1). She complained of severe itch, and a pregnancy-related dermatosis was suspected. The rash had started shortly after she had been wearing her husband’s dungarees, which because of her increasing waistline were comfortable to wear. It emerged that her husband, a psoriasis sufferer, had been started on home treatment with a short contact dithranol regime. It turned out, however, that he had been only partially compliant with the instructions and at times had failed to wash off the dithranol after 30 min in accordance with the instructions before putting on his dungarees. Dithranol residue found its way onto the inner layer of his trousers and had caused an irritating reaction in his wife. She stopped wearing her husband’s trousers and thus halted her involuntary exposure to the irritant. The symptoms settled quickly. Dithranol is an effective treatment for plaque psoriasis, but also a well-known irritant, with an evaluated irritation dose (ID 50) of 0.046% in 100 psoriatic patients and 0.057% in 100 controls, the difference being statistically not significant (2). For short contact dithranol treatment, concentrations of dithranol between 0.1% and 1% are usually used and therefore have a high potential to cause irritancy. Connubial contact dermatitis in which contact dermatitis occurs to a substance used by the partner has been described for various substances, most commonly fragrances and hair dye materials, and in these cases an allergic contact dermatitis was reported in the husband of a woman using these substances (3 – 5). To our knowledge, this is not only the first case of connubial contact dermatitis in which the causative agent is an irritant, it is also the first case in which the patient affected by contact dermatitis is the female partner. This case once again emphasizes the importance of a thorough clinical history not just in dermatology but in all medical specialities.

Polymorphic Eruption of Pregnancy (PEP) und ihre Abgrenzung zu anderen Schwangerschaftsdermatosen

We report on a 29- and a 27-year-old primigravida, which both developed pruritic eruptions in the end of the 6th month of pregnancy. The lesions began in one case on the abdomen and in the other case on the arms and legs. By means of our clinical, histological and immunological investigations we could confirm the diagnosis polymorphic eruptions of pregnancy (PEP) and exclude the other diseases of pregnancy. In one case we found a pemphigus-like-antibody and an elevated titer against the measles-virus, both without pathogenetic meaning. Because of the extreme pruritus and the impairment of quality of life, we gave both patients a therapy with oral corticosteroids with good effect. We excluded other dermatosis of pregnancy because of the typical beginning and the clinical, immunological and histological results.

Biological implications of bi-directional fetomaternal cell traffic: a summary of a National Institute of Child Health and Human Development-sponsored conference

Objective: The National Institute of Child Health and Human Development (NICHD) held a workshop on 27-28 July 2000 to bring together investigators working in the field of fetomaternal cellular andnucleic acid trafficking with the hope that this would stimulate further research into the biological implications of such phenomena.Methods: Invited speakers from all over the world presentedtheir latest (unpublished) data. The conference proceedings were delayed until the present time to allow independent publication of the primary data.Results and conclusions: Bi-directionalfetomaternal trafficking of cells and nucleic acids during pregnancy is now well established, through the use of molecular techniques including conventional and real-time polymerase chain reaction, as wellas fluorescence in situ hybridization. In addition, human leukocyte antigen (HLA) is deposited in the skin of pregnant women. Feto-maternal trafficking is increased in some complications of pregnancy, suchas pre-eclampsia, polyhydramnios, polymorphic eruption of pregnancy, preterm labor and specific fetal chromosome aneuploidies. Maternal cells and nucleic acids have been documented in umbilical cord bloodand in autopsy tissue of non-transfused neonates. Fetal cells persist postpartum and may be associated with the development of disorders such as scleroderma, lichen planus, lupus and thyroid disease. Theextent of fetomaternal trafficking may be affected by three generational HLA relationships. Thus, the consequences of pregnancy extend beyond gestation.

Microchimerism in Human Health and Disease

During pregnancy some cells traffic between the fetus and the mother. Recent investigative work indicates a low level of fetal cells commonly persists in the maternal circulation for years, or even indefinitely, after pregnancy has been completed. The term microchimerism refers to one individual harboring DNA or cells at a low level that derive from another individual. Chronic graft-versus-host disease (cGvHD) shares similarities with some autoimmune diseases and is an iatrogenic form of chimerism, occurring as a complication of hematopoietic stem cell transplantation. The HLA genes of the donor and the host are known to be of central importance to the development of cGvHD. When also considered in light of the female predilection to autoimmunity, these series of observations led to the hypothesis that microchimerism and HLA genes of host and non-host cells are involved in some autoimmune diseases. The hypothesis can also apply to men, children, and women who have not been pregnant because there are other sources of microchimerism. Persistent microchimerism can follow a blood transfusion, or can occur from transfer between twins in utereo. Additionally, maternal cells have recently been found to persist in her immune competent progeny. A number of studies have investigated a potential role of microchimerism in human diseases including systemic sclerosis (SSc), primary biliary cirrhosis (PBC), Sjögren's syndrome, polymorphic eruption of pregnancy, myositis, and thyroid disease. While some studies lend support to the concept that microchimerism is involved in the pathogenesis of selected autoimmune diseases, studies also indicate microchimerism is not uncommon in other human conditions and in healthy individuals.

Dermatosis específicas del embarazo. Actualización

Abstract.—Pregnancy dermatoses are a group of disorders that occur as a consequence of inmunologic and metabolic changes in pregnant women. The terminology has become increasingly confusing with various names in use for analogous clinical entities. During the last 15 years a great effort has been performed to rationalize the nomenclature and a clinical classification is getting to be consolidated. This review summarizes the available data on the topic of pregnancy dermatoses and validates the classification in four definite groups: herpes gestationis, polymorphic eruption of pregnancy, prurigo of pregnancys and pruritic folliculitis of pregnancy.

Pruritic urticarial papules and plaques of pregnancy in twin and triplet pregnancies

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

Abstract Background: Pruritic urticarial papules and plaques of pregnancy (PUPPP) has been described either as a homogeneous or a polymorphic clinical process. Its cause is unknown. Objective: We attempted to characterize the clinical and immunopathologic findings in PUPPP on the basis of long-term clinical and immunopathologic observations. Methods: The clinical and immunopathologic features of 57 patients with PUPPP were evaluated. Results: The clinical features in 57 patients with PUPPP were categorized into three types: mainly urticarial papules and plaques (type I), nonurticarial erythema, papules, or vesicles (type II), and combinations of the two forms (type III). Direct immunofluorescence studies in 48 of the 57 patients showed nonspecific immunoreactants in dermal blood vessels and/or moderate granular deposits at the dermoepidermal junction in 15 patients. Conclusion: Type I PUPPP differed from types II and III in clinical appearance and distribution (absence of face, palm, and sole lesions), but trimester onset, parity, and direct immunofluorescence findings were not significantly different among the three groups. (J Am Acad Dermatol 1998;39:933-9.)

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

Background: Pruritic urticarial papules and plaques of pregnancy (PUPPP) has been described either as a homogeneous or a polymorphic clinical process. Its cause is unknown. Objective: We attempted to characterize the clinical and immunopathologic findings in PUPPP on the basis of long-term clinical and immunopathologic observations. Methods: The clinical and immunopathologic features of 57 patients with PUPPP were evaluated. Results: The clinical features in 57 patients with PUPPP were categorized into three types: mainly urticarial papules and plaques (type I), nonurticarial erythema, papules, or vesicles (type II), and combinations of the two forms (type III). Direct immunofluorescence studies in 48 of the 57 patients showed nonspecific immunoreactants in dermal blood vessels and/or moderate granular deposits at the dermoepidermal junction in 15 patients. Conclusion: Type I PUPPP differed from types II and III in clinical appearance and distribution (absence of face, palm, and sole lesions), but trimester onset, parity, and direct immunofluorescence findings were not significantly different among the three groups. (J Am Acad Dermatol 1998;39:933-9.)

Fetal DNA in skin of polymorphic eruptions of pregnancy

Polymorphic eruptions of pregnancy (PEP) are common cutaneous disorders of unknown origin that occur usually after week 34 of gestation. Since pregnancy is associated with peripheral-blood chimerism, particularly during the third trimester, we studied the role of fetal cells in the development of the skin lesions. We studied samples of skin from ten women with PEP who were carrying male fetuses and 26 women with normal skin or non-PEP skin disorders (13 carrying male and 13 carrying female fetuses). Epidermis and dermis were dissected from the samples, and the DNA was extracted. PCR with primers specific for the SRY gene was used to detect male DNA. Male DNA was detected in dermis or epidermis from skin lesions of six of the ten women with PEP. No male DNA was detected in any of the 26 women without PEP. Fetal cells can migrate to skin during gestation, where they seem to be associated with the development of cutaneous disorders of pregnancy.

Tropical Dermatological Diseases in Pregnancy

In pregnancy, several dermatoses are seen, some of which may be specifically related to the pregnancy, others which occur coincidentally or may be aggravated by the pregnancy. The changes may be physiological or pathological. This article discusses some of the more interesting skin complaints in pregnant women in a tropical country. In the darker skinned women of the tropics, the most prominent of the physiological changes in the skin is the hyperpigmentation which occurs in the majority of pregnant women. However, the most common cause for dermatological referral is a pruritic dermatosis. Pruritus is associated with such conditions as scabies, cholestasis, pruritus gravidarum, polymorphic eruption of pregnancy and prurigo. The majority of these conditions do not affect the outcome of the pregnancy. In contrast, such immunological diseases as systemic lupus erythematosus can cause increased fetal morbidity and mortality. Herpes gestationis, although rare, is one immunological disease specifically associated with pregnancy and is also discussed. Finally, fungal infections of the skin, while of little or no risk to the fetus, are common and often contribute greatly to the discomfort of the mother.

WS053 PUPPP or polymorphic eruption of pregnancy

WS053 PUPPP or polymorphic eruption of pregnancy

Pruritic urticarial papules and plaques of pregnancy (polymorphic eruption of pregnancy): two unusual cases

We report two unusually florid cases of polymorphic eruption of pregnancy (PEP) or pruritic urticarial papules and plaques of pregnancy, the first occurring in a triplet pregnancy, and the second with some clinical features more suggestive of pemphigoid gestationis (PG). The first case responded to treatment with moderately potent topical steroids while the second case required a short course of systemic steroids. Our first case is the only reported case of PEP occurring during a triplet pregnancy. We discuss the effect of multiple pregnancy on PEP and some distinguishing factors between PEP and PG.

Pruritic urticarial papules and plaques of pregnancy (polymorphic eruption of pregnancy): two unusual cases

Pruritic urticarial papules and plaques of pregnancy (polymorphic eruption of pregnancy): two unusual cases

Pruritic urticarial papules and plaques of pregnancy (PUPPP): a clinicopathological review of 35 patients

AbstractThe clinical features of 35 cases of Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP) seen over an 8 year period were reviewed with regard to age and gestational stage of onset, evolution and severity of disease and response to therapy. The histologic features in biopsies from 15 patients were analysed for pattern and extent of inflammatory change and the composition of the inflammatory cells were studied with a panel of monoclonal antibodies. This study confirmed PUPPP to be a well defined clinical entity mainly occurring in young primagravidas in the third trimester and usually responsive to topical treatments. Histologically, perivascular upper and mid‐dermal inflammatory changes were present in all biopsies with epidermal spongiosis and vesiculation a prominant feature in many cases. The inflammatory infiltrate was composed of an admixture of T lymphocytes and macrophages.

Specific Dermatoses of Pregnancy

THE INFLAMMATORY dermatoses that occur during pregnancy have been reported under a variety of confusing terms,<i>such as erythema multiforme of pregnancy,1 prurigo annularis,2 toxaemic rash of pregnancy,3 prurigo gestationis of Besnier,4 late-onset prurigo of pregnancy (PP),5 pruritic urticarial papules and plaques of pregnancy,6 and papular dermatitis of pregnancy.7</i>Only dermatologists could have so many denominations for clinical situations whose exact pathogenesis and cause are not known and that may in fact belong to the same disease entity! With the exception of pemphigoid (herpes) gestationis (PG), we know of no criteria that can be used to differentiate these conditions.⁸Holmes and Black^9,10came to a similar conclusion and, in an attempt to rationalize the obsolete nomenclature, proposed a classification that included four entities: PG, polymorphic eruption of pregnancy (PEP), PP, and pruritic folliculitis of pregnancy (PFP).¹⁰The hope that this

Parity, polypregnancy, paternity, and PUPPP

Parity, polypregnancy, paternity, and PUPPP

Familial occurrence of pruritic urticarial papules and plaques of pregnancy

The occurrence of pruritic urticarial papules and plaques of pregnancy (PUPPP) was noted in four women with unusual family relationships. The purpose of the study was to document the occurrence of PUPPP in these families and to make observations on their possible relevance. Case reports of the four patients are detailed. Histologic and HLA studies are recorded. In both families, sisters were married to brothers. A common paternal influence is suggested. We postulate that PUPPP may be a maternal response to a circulating paternal factor for which tolerance develops in subsequent pregnancies.