Polymorphic eruption of pregnancy
Alerts and Notices
Synopsis
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.
Codes
ICD10CM:O26.86 – Pruritic urticarial papules and plaques of pregnancy (PUPPP)
SNOMEDCT:
88697005 – Pruritic urticarial papules and plaques of pregnancy
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Differential Diagnosis & Pitfalls
- Impetigo herpetiformis has distinct pustules.
- Pemphigoid (herpes) 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.
- Intrahepatic 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
- Insect bites
- Contact dermatitis (irritant, allergic)
- Seabather's eruption
- 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
Last Updated:02/28/2021
Patient Information for Polymorphic eruption of pregnancy
Overview
Pruritic urticarial papules and plaques of pregnancy (PUPPP) is the most common skin condition of pregnancy. Typically, women affected by PUPPP develop red, itchy bumps on the belly near stretch marks (striae) during their third trimester. PUPPP usually gets better within a few weeks after delivery, does not affect the health of your baby, and has no long-term consequences for you.Who’s At Risk
PUPPP is common in pregnant women, occurring in approximately 1 in every 200 pregnant women. The cause is unknown but has been thought to be due to increasing hormones, skin stretching (distention), and various reactions of the immune system. PUPPP usually appears in the third trimester, most often during a woman's first pregnancy and in women expecting multiple babies. PUPPP typically does not occur in woman in second or later pregnancies.Signs & Symptoms
The earliest signs of PUPPP are red, itchy bumps near areas of stretch marks. These bumps may spread to other parts of the body, usually to the chest, arms, and legs. It is uncommon for the rash to appear on the face, palms, or soles of the feet. The individual bumps may get larger and form raised, red areas that look like hives. Blisters filled with liquid may also be seen. Although the appearance of the rash can vary and change over time, most women's main concern is the intense itching that is a key component of this condition. PUPPP usually goes away about 1 week after delivery (postpartum) but can disappear anywhere from a week before delivery to up to 6 weeks postpartum.Self-Care Guidelines
Thick moisturizers can be applied to the rash throughout the day to prevent dryness and relieve itching. An over-the-counter topical steroid such as hydrocortisone (0.5 or 1%) may be applied to affect areas. An over-the-counter antihistamine such as diphenhydramine is safe to take during pregnancy and can decrease the itching, but it may make you sleepy. Loratadine and cetirizine are other antihistamines that are less sedating and may help during the day.When to Seek Medical Care
The most common treatment your doctor will give you is a steroid cream - either prescription-strength or something available over the counter - to be applied directly to the affected areas. Only in severe cases are oral steroids required to control the itching. Rarely, if your doctor is unsure of the diagnosis of PUPPP, he or she may recommend a skin biopsy to confirm the diagnosis.Treatments
Your doctor may give you a prescription for a topical corticosteroid. In rare cases, you may need oral corticosteroids.References
Broza Z, Kasperska-Zajac A, Oles E, Rogala B. Pruritic urticarial papules and plaques of pregnancy. J Midwifery Womens Health. 2007;52(1):44-48. PMID: 17207750.
Thurston A, Grau RH. An update on the dermatoses of pregnancy. J Okla State Med Assoc. 2008;101(1):7-11. PMID: 18390233.
Tunzi M, Gray GR. Common skin conditions during pregnancy. Am Fam Physician. 2007;75(2):211-218. PMID: 17263216.
Polymorphic eruption of pregnancy