Pruritic Urticarial Papules and Plaques of Pregnancy Clinical Presentation

  • Author: Joseph C Pierson, MD; Chief Editor: William D James, MD   more...
 
Updated: May 23, 2012
 

History

Pruritic urticarial papules and plaques of pregnancy (PUPPP) typically begins with intensely pruritic papules arising within striae distensae late in the third trimester of a first pregnancy. Of all cases, 73% are seen in primigravidae pregnancies.[3] Additionally, 11.7 % of affected females are multiple-gestation pregnancies.[5]

As many as 15% of PUPPP cases arise in the immediate postpartum period.[3] In a few days, the eruption spreads to the buttocks and proximal thighs and may generalize. Patients present for a diagnosis of their unusual skin eruption and seek relief from the intense itching.

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Physical Examination

In classic pruritic urticarial papules and plaques of pregnancy (PUPPP), papules occur within prominent striae distensae, as shown in the images below.

Papules within prominent striae distensae. CourtesPapules within prominent striae distensae. Courtesy of Jeffrey P. Callen, MD of Louisville, Kentucky. Papules within prominent striae distensae. CourtesPapules within prominent striae distensae. Courtesy of Jeffrey P. Callen, MD of Louisville, Kentucky.

Similar lesions are often found on the buttocks and proximal thighs and may generalize elsewhere over the trunk and extremities, although the periumbilical area is characteristically spared. Small vesicles often are noted, but larger bullae, though documented in one case, typically do not occur and would suggest the possibility of herpes gestationis.[12, 13] Less commonly, target lesions and annular and polycyclic wheals may be present. PUPPP usually does not affect the face, palms, or soles.

Although the eruption is intensely pruritic, excoriations rarely are found. One report described a case of PUPPP that progressed to involve the neck, arms, and legs in a photosensitive distribution as the initial abdominal involvement settled.[14]

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Contributor Information and Disclosures
Author

Joseph C Pierson, MD  Chief of Dermatology Service, Guthrie Army Clinic, Fort Drum; Assistant Professor of Dermatology, University of Vermont College of Medicine

Joseph C Pierson, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Coauthor(s)

Christine C Tam, MD  Staff Physician, Dermatology Office of David A Spott, MD

Christine C Tam, MD is a member of the following medical societies: American Medical Association

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD  Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology and Society for Investigative Dermatology

Disclosure: Elsevier Royalty Other

Additional Contributors

David F Butler, MD Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Edward F Chan, MD Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania School of Medicine

Edward F Chan, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Abdul-Ghani Kibbi, MD Professor and Chair, Department of Dermatology, American University of Beirut Medical Center, Lebanon

Disclosure: Nothing to disclose.

References

  1. Lawley TJ, Hertz KC, Wade TR, Ackerman AB, Katz SI. Pruritic urticarial papules and plaques of pregnancy. JAMA. Apr 20 1979;241(16):1696-9. [Medline].

  2. Bourne G. Toxaemic rash of pregnancy. Proc R Soc Med. Jun 1962;55:462-4. [Medline].

  3. 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. Mar 2006;54(3):395-404. [Medline].

  4. Roth MM. Pregnancy dermatoses: diagnosis, management, and controversies. Am J Clin Dermatol. Feb 1 2011;12(1):25-41. [Medline].

  5. Kroumpouzos G, Cohen LM. Specific dermatoses of pregnancy: an evidence-based systematic review. Am J Obstet Gynecol. Apr 2003;188(4):1083-92. [Medline].

  6. Elling SV, McKenna P, Powell FC. Pruritic urticarial papules and plaques of pregnancy in twin and triplet pregnancies. J Eur Acad Dermatol Venereol. Sep 2000;14(5):378-81. [Medline].

  7. 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. Jan 2006;154(1):54-60. [Medline].

  8. 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. May 2006;19(5):305-8. [Medline].

  9. 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. Jul 1999;141(1):71-81. [Medline].

  10. Aractingi S, Berkane N, Bertheau P, et al. Fetal DNA in skin of polymorphic eruptions of pregnancy. Lancet. Dec 12 1998;352(9144):1898-901. [Medline].

  11. Regnier S, Fermand V, Levy P, Uzan S, Aractingi S. A case-control study of polymorphic eruption of pregnancy. J Am Acad Dermatol. Jan 2008;58(1):63-7. [Medline].

  12. Sherley-Dale AC, Carr RA, Charles-Holmes R. Polymorphic eruption of pregnancy with bullous lesions: a previously unreported association. Br J Dermatol. Nov 3 2009;[Medline].

  13. Roger D, Vaillant L, Fignon A, et al. Specific pruritic diseases of pregnancy. A prospective study of 3192 pregnant women. Arch Dermatol. Jun 1994;130(6):734-9. [Medline].

  14. Goolamali SI, Salisbury JR, Higgins EM. Polymorphic eruption of pregnancy in a photodistribution: a potentially new association?. Clin Exp Dermatol. Oct 2009;34(7):e381-2. [Medline].

  15. Powell AM, Sakuma-Oyama Y, Oyama N, et al. Usefulness of BP180 NC16a enzyme-linked immunosorbent assay in the serodiagnosis of pemphigoid gestationis and in differentiating between pemphigoid gestationis and pruritic urticarial papules and plaques of pregnancy. Arch Dermatol. Jun 2005;141(6):705-10. [Medline].

  16. Ahmadi S, Powell FC. Pruritic urticarial papules and plaques of pregnancy: current status. Australas J Dermatol. May 2005;46(2):53-8; quiz 59. [Medline].

  17. Scheinfeld N. Pruritic urticarial papules and plaques of pregnancy wholly abated with one week twice daily application of fluticasone propionate lotion: a case report and review of the literature. Dermatol Online J. Nov 15 2008;14(11):4. [Medline].

  18. Beltrani VP, Beltrani VS. Pruritic urticarial papules and plaques of pregnancy: a severe case requiring early delivery for relief of symptoms. J Am Acad Dermatol. Feb 1992;26(2 Pt 1):266-7. [Medline].

 
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Papules within prominent striae distensae. Courtesy of Jeffrey P. Callen, MD of Louisville, Kentucky.
Papules within prominent striae distensae. Courtesy of Jeffrey P. Callen, MD of Louisville, Kentucky.
 
 
 
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