Puppp

PUPPP-Pruritic Urticarial Papules and Plaques of Pregnancy Dr Sandip Vaddoriya MBBS,DGO Other names  PEP (Polymorphic Eruption of Pregnancy)  late-onset prurigo of pregnancy Epidemiology  (PEP) occurs in 1 out of 160 pregnancies. [4, 5] The condition may be less common in blacks.

Etiology  There is no known cause of PEP, but there is some similarities in cases: 1. Women carrying boys (male-to-female infant ratio of 2:1) 2. First pregnancy 3. Multiple gestation pregnacy(11.7% of patients) 4. Increased maternal weight gain

- Investigators identified fetal deoxyribonucleic acid (DNA) in the skin of mothers with PEP, suggesting that chimerism may be relevant to the pathogenesis of this disorder. [10] - It mostly happens to women during their first pregnancy, and generally when they are carrying either multiples or males.

Clinical Presentation History  Polymorphic eruption of pregnancy (PEP) typically begins with intensely pruritic papules arising within striae distensae late in the third trimester of a first pregnancy(73%).  As many as 15% of PEP cases arise in the immediate postpartum period, [3] and in one case report 2 weeks postpartum.[12

Physical Examination

 Itching to be the worst part of PUPPP. Although PUPPP does cause distinctive red marks on the abdomen, there are other details a woman should pay attention to before diagnosis that may indicate whether she is suffering from this condition.  Very itchy rash  Redness  Small blisters  Eczema-like lesions  Appears on abdomen first  Is not found on the belly button  Stretching of the skin, stretch marks are generally the first sign

 The appearance of PUPPP has been described as bumpy, itchy papules that turn to red, scalded skin with welts over time. At first they look like stretch marks, but as time passes, the rash grows larger in area and becomes bumpy and red. Oddly, there is never a rash on the belly button, only around it on the abdomen. From the abdomen, the rash will begin to spread to all parts of the body, including the chest, legs, feet, neck, armpits, and face of the expectant mother.

Differential Diagnoses  Atopic eruption of pregnancy - Includes eczema of pregnancy, prurigo of pregnancy, pruritic folliculitis of pregnancy  Pemphigoid gestationis (herpes gestationis)  Intrahepatic cholestasis of pregnancy  Impetigo herpetiformis  Viral exanthem  Scabies - Check for scabies if the history and physical examination findings are suggestive  Anaplastic large cell lymphoma - Consider this in a pregnant patient who presents with cutaneous symptoms[17] Treatment & Management  topical moisturizing creams or aqueous ointments to treat mild cases.  Corticosteroid creams and ointments (High-potency topical -class I or II) are usually used when the condition has reached extreme severity.  And if the condition is too out of control, the doctor will treat the patient with oral corticosteroids. Antihistamine tablets may be prescribed to provide relief from the itchiness.  General treatment measures include the use of cool, soothing baths; emollients; wet soaks; and light cotton clothing. PEP tends to resolve spontaneously shortly after delivery Medication Summary  Antihistamines have a sedative effect that may improve sleep.  Diphenhydramine (Benadryl, Diphenhist, Allerdryl) -Diphenhydramine is used for the symptomatic relief of pruritus caused by the release of histamine in inflammatory reactions.  Hydroxyzine (Vistaril)

-Hydroxyzine antagonizes H1 receptors in the periphery. It may suppress histamine activity and subsequently cause relieve of pruritus.  Corticosteroids have anti-inflammatory properties and cause profound and varied metabolic effects. In addition, these agents modify the body's immune response to diverse stimuli. Use systemic steroids for severe, refractory cases only.  Fluocinonide (Vanos) -Fluocinonide is a class II, high-potency, topical corticosteroid that inhibits cell proliferation. It is immunosuppressive and anti-inflammatory.  Fluticasone (Cutivate) -Fluticasone is a high-potency, topical corticosteroid that inhibits cell proliferation. It is immunosuppressive and anti-inflammatory.  Prednisone -Prednisone may decrease inflammation by reversing increased capillary permeability and suppressing polymorphonuclear leukocyte activity.

References  Lawley TJ, Hertz KC, Wade TR, Ackerman AB, Katz SI. Pruritic urticarial papules and plaques of pregnancy. JAMA. 1979 Apr 20. 241(16):1696-9. [Medline].  Bourne G. Toxaemic rash of pregnancy. Proc R Soc Med. 1962 Jun. 55:462-4. [Medline].  Ambros-Rudolph CM, Mullegger RR, Vaughan-Jones SA, Kerl H, Black MM. The specific dermatoses of pregnancy revisited and reclassified: results of a retrospective two-center study on 505 pregnant patients. J Am Acad Dermatol. 2006 Mar. 54(3):395-404. [Medline].  Roth MM. Pregnancy dermatoses: diagnosis, management, and controversies. Am J Clin Dermatol. 2011 Feb 1. 12(1):25-41. [Medline].  Rudolph CM, Al-Fares S, Vaughan-Jones SA, Mullegger RR, Kerl H, Black MM. Polymorphic eruption of pregnancy: clinicopathology and potential trigger factors in 181 patients. Br J Dermatol. 2006 Jan. 154(1):54-60. [Medline].  Kroumpouzos G, Cohen LM. Specific dermatoses of pregnancy: an evidence-based systematic review. Am J Obstet Gynecol. 2003 Apr. 188(4):1083-92. [Medline].  Elling SV, McKenna P, Powell FC. Pruritic urticarial papules and plaques of pregnancy in twin and triplet pregnancies. J Eur Acad Dermatol Venereol. 2000 Sep. 14(5):378-81. [Medline].

 Ohel I, Levy A, Silberstein T, Holcberg G, Sheiner E. Pregnancy outcome of patients with pruritic urticarial papules and plaques of pregnancy. J Matern Fetal Neonatal Med. 2006 May. 19(5):3058. [Medline].  Vaughan Jones SA, Hern S, Nelson-Piercy C, Seed PT, Black MM. A prospective study of 200 women with dermatoses of pregnancy correlating clinical findings with hormonal and immunopathological profiles. Br J Dermatol. 1999 Jul. 141(1):71-81. [Medline].  Aractingi S, Berkane N, Bertheau P, et al. Fetal DNA in skin of polymorphic eruptions of pregnancy. Lancet. 1998 Dec 12. 352(9144):1898-901. [Medline].  Regnier S, Fermand V, Levy P, Uzan S, Aractingi S. A case-control study of polymorphic eruption of pregnancy. J Am Acad Dermatol. 2008 Jan. 58(1):63-7. [Medline].  Dehdashti AL, Wikas SM. Pruritic urticarial papules and plaques of pregnancy occurring postpartum. Cutis. 2015 Jun. 95 (6):344-7. [Medline].  Sherley-Dale AC, Carr RA, Charles-Holmes R. Polymorphic eruption of pregnancy with bullous lesions: a previously unreported association. Br J Dermatol. 2009 Nov 3. [Medline].  Roger D, Vaillant L, Fignon A, et al. Specific pruritic diseases of pregnancy. A prospective study of 3192 pregnant women. Arch Dermatol. 1994 Jun. 130(6):734-9. [Medline].  Sirikudta W, Silpa-Archa N. Polymorphic eruption of pregnancy presented with targetoid lesions: a report of two cases. Case Rep Dermatol. 2013 May. 5 (2):138-43. [Medline].