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Polymorphic eruption of pregnancy (PEP) or PUPPP

Polymorphic eruption of pregnancy (PEP) or PUPPP

Image: https://www.pcds.org.uk/clinical-guidance/polymorphous-eruption-of-pregnancy-syn-pruritic-urticarial-papules-and-pla

It is also called pruritic urticarial papules and plaques of pregnancy (PUPPP)

Urticaria: Transient red swelling of skin. 

Papule: A small solid raised well defined bump on skin that is typically less than 1 centimeter in diameter.

Plaque: A skin plaque is an elevated, solid, superficial lesion that is typically more than 1 centimeter in diameter.

“ Benign, self-limiting, pruritic, inflammatory disorder.”

Usually: First pregnancy 

Mostly: Last three months of pregnancy, mean onset 35 weeks. It can rarely begin after pregnancy

“ Itching tends to be intense.”

Prevalence: 1 in 160 to 300 pregnancies

Streching

It has been hypothesized that stretching may cause damage to connective tissue, which results in exposure of dermal antigens that trigger an inflammatory response.

Lesions

Initial site

– Abdominal striae are the most common initial site with peri umbilical sparing.

– Lesion can spread to the extremities, chest, and back and coalesce to form urticarial plaques.

–  The face, palms, and soles are usually spared.

Character

– Erythematous papules within striae.

– White halos often surround the erythematous papules.

– Over the course of the disease, approximately one-half of the patients develop more polymorphic lesions, including target-like lesions exhibiting three distinct rings/color changes instead of a halo, or erythematous patches and vesicles.

Diagnosis 

– The diagnosis of is usually clinical, based upon history and physical examination.

– A skin biopsy is generally not necessary for diagnosis.

– There are no laboratory abnormalities.

Differential diagnosis 

– Urticaria: pemphigoid gestationis early phase (PEP typically spares the umbilical region) Rarely need biopsy to confirm diagnosis.

– Target-like lesions: erythema multiforme. 

– Erythematous papules: Drug reactions, viral syndromes, and infestations like scabies.

Treatment 

The goal of treatment is relief of symptoms. 

Topical steroids

Mid- to high-potency topical corticosteroids (groups 2 to 4 as initial therapy, applied once or twice daily until improvement occurs. 

The use of potent or superpotent topical corticosteroids exceeding 300 g during the whole pregnancy may be associated with an increased risk of low birth weight, so better avoided.

Systemic corticosteroids

In severe cases, a short course of systemic corticosteroids with a quick taper, such as prednisone or prednisolone 0.5 mg/kg per day for one week, tapered over one to two weeks, may be given for rapid resolution of symptoms.

Anti-histamines

– First-generation oral antihistamine, Chlorpheniramine

– Second-generation nonsedating oral antihistamines, such as loratadine and cetirizine. 

Prognosis 

– PEP generally lasts four to six weeks and resolves within two weeks postpartum, although it may last longer. In some cases, this relates to retained placental products.

– No increased fetal /maternal risk.

– Recurrence is rare.