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Pruritic Urticarial Papules and Plaques of Pregnancy

(Polymorphic Eruption of Pregnancy; PUPPP)

By

Antonette T. Dulay

, MD, Main Line Health System

Last full review/revision Oct 2020| Content last modified Oct 2020
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Pruritic urticarial papules and plaques of pregnancy are pruritic eruptions of unknown cause that develop during pregnancy.

Most cases of pruritic urticarial papules and plaques of pregnancy occur during a first pregnancy. Overall incidence is 1/160 to 300 pregnancies; however, with multiple gestation, risk is 8 to 12 times higher.

Symptoms and Signs

Lesions are intensely itchy, erythematous, solid, superficial, and elevated; some are surrounded by blanching, and some have minute vesicles in the center. Itching keeps most patients awake, but excoriation is uncommon. Lesions begin on the abdomen, frequently on striae atrophicae (stretch marks), and spread to the thighs, buttocks, and occasionally the arms. The palms, soles, and face are usually spared. Most patients have hundreds of lesions.

Lesions develop during the 3rd trimester, most often in the last 2 to 3 weeks and occasionally in the last few days or postpartum. They usually resolve within 15 days after delivery but can take longer. They may recur in up to 5% of subsequent pregnancies.

Diagnosis

  • Clinical evaluation

Diagnosis of pruritic urticarial papules and plaques of pregnancy is clinical. Differentiation from other pruritic eruptions may be difficult. Early lesions of pruritic urticarial papules and plaques of pregnancy usually start in striae on the abdomen; in pemphigoid gestationis, early lesions are usually periumbilical.

Treatment

  • Corticosteroids

  • Nonsedating oral antihistamines

  • Supportive care

Mild symptoms are treated with topical corticosteroids (eg, 0.1% triamcinolone acetonide cream up to 6 times a day). Rarely, more severe symptoms require systemic corticosteroids (eg, prednisone 40 mg orally once a day, tapered as tolerated). Short courses of systemic corticosteroids given late in pregnancy do not seem to have adverse effects on the fetus.

Nonsedating oral antihistamines can also be used to relieve pruritus.

Key Points

  • Pruritic urticarial papules and plaques of pregnancy consist of intensely itchy lesions that usually develop during the last 2 to 3 weeks of pregnancy and resolve within 15 days after delivery.

  • Differentiating these lesions from others may be difficult.

  • Treat with topical corticosteroids for mild symptoms and oral corticosteroids for more severe symptoms.

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