Specific Pregnancy Dermatoses

Maria-Magdalena Roth, MD, PhD


Dermatology Nursing. 2009;21(2):70-74, 81. 

In This Article

Pruritic Urticarial Papules and Plaques of Pregnancy

Pruritic urticarial papules and plaques of pregnancy (PUPPP) is a benign, self-limited pruritic inflammatory disorder of pregnancy that usually affects the primigravida in the last trimester of pregnancy or immediate postpartum period. Clinically it is characterized by the presence of urticarial papules and plaques. In 1979, Lawley, Hertz, Wade, Ackerman, and Katz introduced the term pruritic urticarial papules and plaques of pregnancy (PUPPP). In 1983, Holmes and Black proposed the term polymorphic eruption of pregnancy (PEP) in order to encompass the entire clinical spectrum. This term has been widely accepted; therefore, PEP and PUPPP are identical dermatoses.

The pathogenesis of PUPPP remains unclear and obscure, despite the high incidence of this condition (see Table 2 ). This condition usually appears in primiparous women with excessive maternal weight gain. Women with multiple gestation pregnancies (twins or triplets) seem more susceptible to this condition (Petropoulou, Georgala, & Katsambas, 2006). Almost 2.9% of the patients with twin pregnancies and 14% with triplet pregnancies developed PUPPP (Ahmadi & Powell, 2005). The main theories proposed now focus on abdominal distension, hormonal, autoimmune, and paternal factors (such as the change in life partner, explained by the implication of paternal antigens), as well as on the role of fetal DNA deposition in maternal skin (Ahmadi & Powell, 2005; Petropoulou et al., 2006).

Patient education. The patient should be informed that the disease is related to pregnancy. Therefore, the lesions will disappear towards the end of pregnancy or in the postpartum period, usually within days or weeks (4-6 weeks) after delivery, with no post-inflammatory pigment changes or scarring of the skin (Rudolph et al., 2006).

The prognosis is usually good because PUPPP is a benign and selflimited disorder. Also, the condition does not recur in subsequent pregnancies except for multiple pregnancies (twins, triplets) (Black, 2002b). If there is a recurrence, it will be less severe than the first episode with a mild clinical picture. The only annoying symptom is pruritus, which sometimes can be severe and disturb sleep. Even in severe cases that need systemic corticosteroid treatment, the prognosis is always excellent.

A normal delivery is possible and a caesarean section is not recommended for PUPPP. In severe cases, an early elective induction of labor should be considered. Monitoring the pregnancy by obstetricians and dermatologists is necessary with regular scheduled check-ups in the prenatal clinic. In severe cases with administration of oral steroids, complications of treatment (diabetes, hypertension) are rare because the duration of the treatment is very short. Women with PUPPP may breast-feed, even when taking oral steroids, as only small quantities of steroid get into breast milk (the maternal-fetal gradient of prednisolone is only 10:1) (Gabbe, 1987). Fetal prognosis is also good without cutaneous lesions at birth (Black, 2002b).


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