Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP)

Introduction

• Description: Pruritic urticarial papules and plaques of pregnancy (PUPPP) is the most common dermatosis specific to pregnancy. It is also called polymorphic eruption of pregnancy (PEP), Bourne toxemic rash of pregnancy, linear immunoglobulin M (IgM) dermatosis of pregnancy, or toxic erythema of pregnancy. It typically manifests as itchy, erythematous papules within striae on the abdominal wall, which then may spread to the extremities, coalescing into urticarial plaques.

• Prevalence: 1/160–300 pregnancies.

• Predominant Age: Reproductive age; late in the third trimester (mean 35 weeks) but may occur postpartum.

• Genetics: No genetic pattern.

Etiology and Pathogenesis

• Causes: Unknown. Proposed—skin stretching may cause connective tissue damage, resulting in exposure of dermal antigens triggering an inflammatory response, or there may be an immunologic response to circulating fetal antigens.

• Risk Factors: Nulliparity (75% of cases), multiple gestation (8- to 12-fold increased risk), excessive skin stretch (polyhydramnios).

Signs and Symptoms

• Erythematous papules within striae on the abdominal wall, sparing the umbilical area, the face, palms, and soles.

• White halos surround the erythematous papules; target-like, with three distinct rings/color changes

• Progression to urticarial plaques and the extremities

• Face, palms, and soles are generally spared

• Intense itching

Diagnostic Approach