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Two Cases of Pruritic Urticarial Papules and Plaques of Pregnancy

Two Cases of Pruritic Urticarial Papules and Plaques of Pregnancy

Severely pruritic rash. Approximately
2 weeks earlier, a pruritic,
papular eruption had developed over
the abdomen of a 33-year-old woman
who was 34 weeks' pregnant. The
rash was confined mainly to the striae
distensae (Figure 3). Because the
site was severely pruritic, the patient
was unable to sleep. Based on the
clinical presentation, pruritic urticarial
papules and plaques of pregnancy
(PUPPP) was diagnosed.

PUPPP is a distinct eruption of
pregnancy that occurs most often in
the primigravida and usually begins
in the third trimester. The incidence
is higher in women who have a multiple
pregnancy. Recurrence in subsequent
pregnancies is rare. Erythematous
plaques, papules, vesicles,
purpura, or erythema multiforme-
like lesions usually begin on the abdomen
within the striae distensae
and subsequently spread to the
breasts, upper thighs, and arms; the
face is spared.

Consider herpes gestationis
in the differential. This disease can
be ruled out by the absence of
circulating complement-binding HG
factor in the serum; also, direct immunofluorescence
of a patient with
PUPPP will show no consistent findings
of immunoreactants in lesional
or perilesional skin and no linear
deposition of C3 at the basement
membrane zone.

Treatment of patients who
have PUPPP includes application of
a high-potency topical corticosteroid,
which is tapered after 1 week. Antihistamines,
antipruritics, and emollients may also be helpful. Systemic
corticosteroids are used in severe
disease; often, relief of symptoms is
obtained in 24 hours. Early delivery
may be induced when the symptoms
are extremely severe and other treatments
have failed.

Spreading pruritic rash in a
primigravida.
During the eighth
month of her first pregnancy, a
28-year-old woman presented with an
intensely pruritic, slightly elevated
eruption (Figure 4). The rash began
on her abdomen and quickly spread
to her arms and legs.

Initially, another practitioner had
diagnosed this eruption as hives and
then as scabies. Treatment with an
oral antihistamine and, subsequently,
permethrin was unsuccessful. PUPPP
was diagnosed based on the history
and clinical appearance.

Unlike herpes gestationis, a less
common dermatosis of pregnancy in
which the HG factor can cross the
placenta and may cause a transient
rash in the neonate, PUPPP has no
effect on the fetus. PUPPP usually
resolves spontaneously shortly after
delivery; postpartum episodes are
very rare and outbreaks during subsequent
pregnancies are unusual.

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