Pruritic urticarial papules and plaques of pregnancy

Chronic rash that occurs during pregnancy

Pruritic urticarial papules and plaques of pregnancy (PUPPP), known in United Kingdom as polymorphic eruption of pregnancy (PEP), is a chronic hives like rash that strikes some women during pregnancy. Some skin changes are known to occur in people who are pregnant while other skin conditions, or dermatoses, that people have prior to getting pregnant will become altered or symptoms will increase. Pruritic urticarial papules and plaques of pregnancy (PUPPP) is one of many skin conditions that is specific to pregnancy and occurs in about 1 in every 160 (0.625%) of pregnancies. It presents no long term risk for either the woman or fetus as there is no statistical increase of risk of premature labor or fetal loss, despite frequently severe pruritus. PUPPP usually first appears on the abdomen and often spreads to the legs, feet, arms, chest, and neck. The face is usually not affected. Skin distension (stretching) is thought to be a possible trigger for PUPPP as it most commonly affects primigravida (women in their first pregnancy), those with large fundal measurements (distance from the pubic bone to the top of the uterus) and/or those who are carrying large babies or multiples. The papules and plaques often first appear within stretch marks before changing appearance and spreading to other areas of the body. For those who may be experiencing signs and symptoms of PUPPP, it is strongly recommended they speak with their primary care physician and receive a consult from a dermatologist regarding skin changes during pregnancy. Over time, individual segments of this rash can join to form one whole, larger rash with the same characteristics. As this happens, people report noticing the skin surrounding the rash to appear white in color (blanched) and in the shape of "halos". Multiple features of the disease can continue with time and have been reported as widespread erythema (a red skin rash due to damage of underlying capillaries) and patches of inflamed, itchy, rough, and cracked patches of skin that appear similarly to eczema. The timeline of onset for these symptoms has been reported with some variability. However, most people report experiencing symptoms during the third trimester (last few weeks of pregnancy) where 15% of the women who have PUPPP reported that symptoms actually began immediately after delivery of the baby.

PUPPP is the most common dermatosis of pregnancy and is the most frequent in pregnant women habitating a male fetus, women who had quick and conspicuous weight gain during a short period, and women who ultimately deliver by a c section. Estimated 75% of people with typical PUPPP people have never given birth. Occasionally, this condition may also occur postpartum, but rarely does this ever occur in the first and second trimester. Other than additional associations with hypertension and induction of labour, there are no observed difference in the outcome of the pregnancy for mothers or babies.

During pregnancy as the abdominal wall rapid stretching, it is hypothesized that there is an inflammatory reaction that occurs due to the exposure of collagen.

Throughout pregnancy, there are hormonal changes that occur where it has been hypothesized that these changes may contribute to the onset of PUPPP. Although current research is low on this hypothesis, it has been seen that those who have had multiple gestations can exhibit an increased level of progesterone. With this increase in progesterone, it causes there to be an increased level of progesterone receptors present eliciting an immune reaction seen by skin lesions in PUPPP. With multiple gestations, there is an increase in sex hormones that has been seen those with the condition such as an increase in progesterone as previously discussed but also higher levels of estradiol. It has been hypothesized that PUPPP appears in response to fetal antigens that circulate throughout the body. For example, a study showed that fetal male DNA was found within the lesions of the mother's skin which was thought to be caused by the fetal cells seen in the mother's blood throughout pregnancy.

Although this condition has not been determined as an autoimmune condition, from a single study it has been seen that Immunoglobulin M (IgM) deposition at the dermal epidermal membrane has been associated with a variety of dermatosis including PUPPP. The problem with the hypothesis that has been proposed is that this condition does not reoccur and it does not progressively worsen.

It is important to note that diagnosis should be conducted by a trusted medical professional. In the case that a woman is experiencing symptoms of PUPPP, it is recommended that they contact their primary care physician for referral to a dermatologist for treatment guidance and should not self treat. However, a few women continue to experience symptoms long into the postpartum period. One of the most recent forms of treatment suggested is the intramuscular injection of autologous whole blood as an alternative treatment option for people affected by PUPPP right after childbirth, as it seems to have both subjective and objective improvements of the symptoms. This is a very good option for the people who are worried about taking medications during pregnancy or breastfeeding

Antihistamine tablets may be prescribed to provide relief from the itch, although they are generally considered much less effective than corticosteroid treatments, Second generation antihistamines such as loratadine and cetirizine are non sedating and may also be effective in controlling pruritus in pregnant people. Knowing that oral antihistamines are generally ineffective, high potency topical steroids are used to treat PUPPP, and ideally tapering it off after 7 days of therapy. Class I or II corticosteroid creams and ointments are used in more aggressive cases, and oral (systemic) corticosteroids can be used to treat very severe cases—although the benefits of a pregnant woman's ingesting high potency corticosteroids must be weighed carefully against possible (and mostly unknown) risks to the developing fetus or fetuses. The use of high potency topical corticosteroids over 300 grams throughout the pregnancy may increase the risk of low birth weight for the baby. Rarely, in unusually persistent and distressing cases, some women have had their labor induced as soon as they are considered to be at term (37 weeks). When the pruritus is unbearable to the patient with PUPPP, oral prednisone in doses of 10 to 40 mg/day has been generally used for these type of severe cases. With this treatment, symptoms are usually relieved after 24 hours of the oral treatment. Sometimes, if the cases are too severe and the symptoms are extremely unbearable, early delivery can be discussed with the patient if the other treatments are ineffective. However, early delivery of the baby still does not guarantee that the symptoms will be gone. Luckily, in most cases, steroid treatment works efficiently and symptoms are generally greatly improved within several days. As with most steroid treatments, the usage of it is a controversial topic. Nonetheless, short term or one time use is advisable, and tends to be safer while using it during the third trimester compared to the first trimester. Pine tar soap/body wash can also bring relief as can keeping the skin chilled such as through a cold shower or iced cloths.