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Polymorphic Eruption of Pregnancy

Polymorphic Eruption of Pregnancy

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Polymorphic eruption of pregnancy (PEP), first described as pruritic urticarial papules and plaques of pregnancy (PUPPP), refers to a benign dermatosis that usually arises late in the third trimester of a first pregnancy. [1] The entity previously had been reported as toxemic rash of pregnancy, [2] toxemic erythema of pregnancy, and late-onset prurigo of pregnancy. See the image below.

See Diagnosing Dermatoses in Pregnant Patients: 8 Cases to Test Your Skills, a Critical Images slideshow, for help identifying cutaneous eruptions associated with pregnancy.

Following atopic eruption of pregnancy, which occurs earlier in gestation, PEP is the second most common pruritic dermatosis of pregnancy. [3] (See DDx.) One European author proposes that early gestational papular dermatoses (usually atopic eruption of pregnancy) be referred to as “early-onset PEP,” distinguished from “late-onset PEP”. [4]

Polymorphic eruption of pregnancy (PEP) occurs in 1 out of 160 pregnancies. [4, 5]  The condition may be less common in blacks.

The cause and pathogenesis of polymorphic eruption of pregnancy (PEP) are not known. A meta-analysis revealed that 11.7% of patients with PEP had multiple gestation pregnancies. [6] Within that group, a higher PEP risk for triplet (14%) over twin (2.9%) pregnancies was found, [7] suggesting a relationship between skin distention and the development of PEP. Most studies have revealed increased maternal weight gain in patients with PEP when compared with normal pregnancies, further supporting the role of increased skin distention. [5]

A study from Israel also found maternal hypertension and induction of labor to be significantly associated with the condition. [8] One large series [9] of cases revealed a male-to-female infant ratio of 2:1.

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] Finally, a case-control study from France confirmed previously documented associations with multiple gestations, cesarean deliveries, and male fetuses, although no relationship to maternal or fetal weight gain was noted. [11]

The prognoses for the affected woman and her newborn are excellent in polymorphic eruption of pregnancy (PEP). It typically resolves within 4-6 weeks, independent of delivery, [5] and the condition does not tend to recur in subsequent pregnancies. Only 7% of multiparous PEP patients described a similar rash with prior pregnancies. [3] Patients who have had PEP will not precipitate a return of the condition through the subsequent use of oral contraceptives.

No mortality is associated with PEP. The mere appearance of an unusual skin eruption in pregnancy can provoke anxiety, but the pruritus is the most distressing feature. The later weeks of pregnancy can be associated with many physical symptoms, and the severe itching of PEP may further debilitate and aggravate sleep loss in the weeks prior to delivery. No known systemic complications exist for affected females, and fetal mortality or morbidity do not increase.

The patient should understand that PEP is a benign disorder and has not been shown to have adverse consequences for the fetus. Fully explain the side effects of corticosteroids and antihistamines (which are used in the treatment of PEP). Reassure the affected patient that PEP does not usually recur with subsequent pregnancies and will not be triggered by future use of oral contraceptives. (See Prognosis, Treatment, and Medication.)

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):305-8. [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].

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

Kanj RV, Gerber D, Frey MK, Rahmanou F, Hardy C. Anaplastic Large Cell Lymphoma in Pregnancy. A Case Report. J Reprod Med. 2015 May-Jun. 60 (5-6):265-8. [Medline].

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. 2005 Jun. 141(6):705-10. [Medline].

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

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. 2008 Nov 15. 14(11):4. [Medline].

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. 1992 Feb. 26(2 Pt 1):266-7. [Medline].

Jeon IK, On HR, Oh SH, Hann SK. Three cases of pruritic urticarial papules and plaques of pregnancy (PUPPP) treated with intramuscular injection of autologous whole blood. J Eur Acad Dermatol Venereol. 2015 Apr. 29 (4):797-800. [Medline].

Joseph C Pierson, MD Dermatology Residency Program Director, University of Vermont College of Medicine

Joseph C Pierson, MD is a member of the following medical societies: Association of Professors of Dermatology, New England Dermatological Society, American Academy of Dermatology

Disclosure: Nothing to disclose.

Christine C Tam, MD Managing Member, Certified Dermatologists

Christine C Tam, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

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, Society for Investigative Dermatology

Disclosure: Received income in an amount equal to or greater than $250 from: Elsevier; WebMD.

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.

Polymorphic Eruption of Pregnancy

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