Two Cases of Pruritic Urticarial Papules and Plaques of Pregnancy

Severely pruritic rash. Approximately2 weeks earlier, a pruritic,papular eruption had developed overthe abdomen of a 33-year-old womanwho was 34 weeks' pregnant. Therash was confined mainly to the striaedistensae (Figure 3). Because thesite was severely pruritic, the patientwas unable to sleep. Based on theclinical presentation, pruritic urticarialpapules and plaques of pregnancy(PUPPP) was diagnosed.

PUPPP is a distinct eruption ofpregnancy that occurs most often inthe primigravida and usually beginsin the third trimester. The incidenceis higher in women who have a multiplepregnancy. Recurrence in subsequentpregnancies is rare. Erythematousplaques, papules, vesicles,purpura, or erythema multiforme-like lesions usually begin on the abdomenwithin the striae distensaeand subsequently spread to thebreasts, upper thighs, and arms; theface is spared.

Consider herpes gestationisin the differential. This disease canbe ruled out by the absence ofcirculating complement-binding HGfactor in the serum; also, direct immunofluorescenceof a patient withPUPPP will show no consistent findingsof immunoreactants in lesionalor perilesional skin and no lineardeposition of C3 at the basementmembrane zone.

Treatment of patients whohave PUPPP includes application ofa high-potency topical corticosteroid,which is tapered after 1 week. Antihistamines,antipruritics, and emollients may also be helpful. Systemiccorticosteroids are used in severedisease; often, relief of symptoms isobtained in 24 hours. Early deliverymay be induced when the symptomsare extremely severe and other treatmentshave failed.

Spreading pruritic rash in aprimigravida. During the eighthmonth of her first pregnancy, a28-year-old woman presented with anintensely pruritic, slightly elevatederuption (Figure 4). The rash beganon her abdomen and quickly spreadto her arms and legs.

Initially, another practitioner haddiagnosed this eruption as hives andthen as scabies. Treatment with anoral antihistamine and, subsequently,permethrin was unsuccessful. PUPPPwas diagnosed based on the historyand clinical appearance.

Unlike herpes gestationis, a lesscommon dermatosis of pregnancy inwhich the HG factor can cross theplacenta and may cause a transientrash in the neonate, PUPPP has noeffect on the fetus. PUPPP usuallyresolves spontaneously shortly afterdelivery; postpartum episodes arevery rare and outbreaks during subsequentpregnancies are unusual.

This woman's rash responded toa topical corticosteroid and an overthe-counter antipruritic lotion.

(First case and photograph courtesy of Drs AmorKhachemoune, C. Lisa Kauffman, Elektra J.Papadopoulos, and Simone McKitty. Second case andphotograph courtesy of Dr David L. Kaplan.)