Updated: 10/4/2022

Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP)

Review Topic
  • Snapshot
    • A 30-year-old G1P0 woman presents to her obstetrician with a new itchy rash. She is 36 weeks pregnant. The rash has been present for a week now with intense pruritus. She denies any other symptoms, including shortness of breath, swelling of the eyes, or fever. She denies any exposure to new medications or allergens. On physical exam, there are multiple erythematous urticarial plaques within the stretch marks on her abdomen. The umbilicus is spared.
  • Introduction
    • Pruritic urticarial papules and plaques of pregnancy (PUPPP) or polymorphic eruption of pregnancy (PEP)
    • A self-limited pruritic inflammatory disorder of the skin occurring in the last trimester of pregnancy or immediately postpartum
  • Epidemiology
    • Common in primiparous women
    • Common in women with multiple gestation pregnancies
    • Pathogenesis
      • largely unknown
      • degree of skin stretch of abdomen may play a role
  • Presentation
    • Symptoms
      • occurs in late third trimester or postpartum
      • extremely pruritic, erythematous urticarial papules and plaques within striae on abdomen
      • periumbilical sparing of rash
      • can spread to extremities, chest, and back
      • spares palms, soles, and face
      • lasts 4-6 weeks, typically resolving within 2 weeks postpartum
  • Evaluation
    • Diagnosis is usually based on history and physical exam
    • Skin biopsy only if diagnostic uncertainty
      • perivascular and interstitial lymphocytic infiltrate with eosinophils
    • No lab abnormalities
  • Differential Diagnosis
    • Pemphigoid gestationis
    • Erythema multiforme
    • Other drug reaction rash
  • Treatment
    • Initial therapy
      • mid-to-high potency topical steroids
    • If refractory
      • systemic corticosteroids with quick taper
    • Anti-histamines for pruritus
  • Prognosis
    • Resolves typically in 4-6 weeks or within 2 weeks postpartum
    • No risk of fetal or maternal morbidity
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