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Polymorphic eruption of pregnancy
Other Resources UpToDate PubMed

Polymorphic eruption of pregnancy

Contributors: Jordana Gilman MD, Vivian Wong MD, PhD, Susan Burgin MD, Mitchell Linder MD
Other Resources UpToDate PubMed


Polymorphic eruption of pregnancy (PEP), also known as pruritic urticarial papules and plaques of pregnancy (PUPPP), is the most common specific eruption of pregnancy. The etiology is unknown, but it may be related to skin distension. It is a benign condition that almost always begins in the third trimester of a first pregnancy or in the immediate postpartum period. This pruritic eruption develops in and around the abdominal striae and it may then spread to the extremities, chest, and back. It presents as erythematous or urticarial papules and plaques. Polymorphic clinical features are seen in around half of patients, including the development of eczematous papules and plaques, vesicles, and target lesions. Pruritus can be severe, leading to sleep disturbance.

PEP occurs in about 0.5% of pregnancies and is associated with a higher frequency of multiple gestation and significant intrapartum weight gain (with a higher degree of stretching of abdominal skin). Other risk factors include primiparity and Northern European descent. It is important to note that there is no association with adverse fetal or maternal outcomes. PEP is self-limiting and typically resolves within 4 weeks of rash onset, usually 2 weeks postpartum. Recurrence with subsequent pregnancies is uncommon.


O26.86 – Pruritic urticarial papules and plaques of pregnancy (PUPPP)

88697005 – Pruritic urticarial papules and plaques of pregnancy

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Differential Diagnosis & Pitfalls

  • Impetigo herpetiformis has distinct pustules.
  • Pemphigoid gestationis is an autoimmune blistering disease that occurs in pregnancy. Vesicles and bullae are diagnostic hallmarks but may be absent early on. A positive direct immunofluoresence (DIF) can help to differentiate early cases of pemphigoid gestationis from PEP.
  • Cholestasis of pregnancy also presents with intense itching. There are no primary lesions, but secondary lesions such as excoriations and pruriginous lesions may be seen. Itching starts on the palms and soles, rather than spares them, as in PEP. Bile acids and liver function tests may be ordered to further differentiate, if needed.
  • The target lesions of PEP may be confused with Erythema multiforme. Differentiate with history, clinical presentation, and histology.
  • Exanthematous drug eruption
  • Atopic eruption of pregnancy
  • Urticaria
  • Arthropod bite or sting
  • Contact dermatitis (Irritant contact dermatitis, Allergic contact dermatitis)
  • Seabather
  • Scabies
  • Viral syndromes may also present with red papules similar to PEP. See Viral exanthem.

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Last Reviewed:02/21/2021
Last Updated:02/28/2021
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Polymorphic eruption of pregnancy
A medical illustration showing key findings of Polymorphic eruption of pregnancy : Abdomen, Pruritus, Striae, Maculopapular erythema
Clinical image of Polymorphic eruption of pregnancy - imageId=24163. Click to open in gallery.  caption: 'A close-up of urticarial plaques arising within striae.'
A close-up of urticarial plaques arising within striae.
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