Pregnancy dermatosis polymorphic O26.4

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 17.12.2020

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Synonym(s)

Late onset prurigo of pregnancy; Late-onset prurigo of pregnancy; Nurse's "late onset prurigo" of pregnanacy; Papules and plaques pruritic urticarial in pregnancy; PEP; Polymorphic eruption of pregnancy; Polymorphic pregnancy dermatosis; Pruritic urticarial papules and plaques during pregnancy; Pruritic urticarial papules and plaques of pregnancy; PUPP; Toxemic rash of pregnancy; Toxic erythema of pregnancy

History
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Lawley, 1979; Holmes and Black 1983

Definition
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Non-recurrent, very multiform, most frequent specific pregnancy dermatosis with highly itchy, urticarial papules, plaques and vesicles with self-limiting course. Symptoms typically occur in the last weeks of pregnancy or immediately postpartum (15%). Striking association with first-time mothers, multiple pregnancies and excessive maternal weight gain.

Occurrence/Epidemiology
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The frequency is estimated at 1/60- 1/200 pregnancies. Thus PUPPP is by far the most frequent pregnancy dermatosis (see below pregnancy, skin changes).

Etiopathogenesis
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Unknown. A connection with damage to collagen due to overstretching is suspected, whereby previously "inert structures" are supposed to acquire antigenic character and thereby trigger the exanthema (Ambros-Rudolph CM et al. 2017). This would explain that the disease starts in the striae distensae and manifests at the time of the highest abdominal distension. The role of peripheral microchimerism with deposition of fetal DNA in maternal skin is unclear.

Manifestation
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Mostly occurring in the last trimester; also directly postportal (15%). Association with first-time mothers, multiple pregnancies, excessive maternal weight gain (Murase JE et al 2014).

Localization
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Initially, the HVs are mainly found on the abdomen, leaving out the navel region; also on the back, buttocks, thighs and upper arms

Clinical features
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Very diverse clinical picture. Beginning with a papular or urticarial, violently itchy exanthema (nodules, plaques) on the abdomen which spreads rapidly to the thighs, buttocks, arms and lateral parts of the trunk. Note: HV often start in the striae cutis distensae! In most cases (but not always) the umbilical region is left out! With increasing duration of the disease, there are not only urticarial papules, but also targetoid surface-smooth and eczema-like plaques; in addition, there are blisters (never blisters), also"prurigo-like" skin changes.

Histology
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Perivascular lymphohistiocyte infiltration. Severe edema of the dermis. Less specific pattern! Only evaluable in connection with the clinic and immunohistology (negative findings)!

Direct Immunofluorescence
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Obligation negative.

Differential diagnosis
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External therapy
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Initially try with pale lotio alba, ethanolic zinc oxide shaking mixture R292, emulsions or gels free of active ingredients. Cooling gels free of active agents temporarily alleviate the itching R039.

Cool showers, "cool packs" or moist compresses, e.g. with 0.9% NaCL solution, also have a soothing effect.

If not sufficient, application of tannin 3-5% in lotio alba or of menthol(menthol cream 5%) - or polidocanol-containing topical preparations (e.g. R200, R197, Optiderm®).

Next step are glucocorticoid-containing emulsions (e.g. Hydrogalen, R123) or 0.5% hydrocortisone cream (see glucocorticoids pregnancy).

Internal therapy
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  • In cases of severe and intolerable itching with considerable sleep disturbances glucocorticoids, e.g. prednisone (e.g. Decortin®) 50 mg/day p.o. are indicated for 3 days. Gradual dose reduction according to clinical findings (see glucocorticoids, pregnancy). Alternatively 25mg p.o for another 3 days (Ambros-Rudolph et al. 2017).
  • In severe cases and in the last weeks of pregnancy additional administration of diphenhydramine HCl(e.g. Vivinox 25 to 50 mg/day) or benzodiazepines (e.g. diazepam 2-5 mg/day).
  • The administration of antihistamines during pregnancy is assessed differently in the literature. At most, however, first-generation preparations such as clemastine (e.g. Tavegil 2 times/day 1 tbl. p.o. or 2 times/day 1 amp. i.v.) or hydroxyzine (e.g. Atarax 1-3 tbl./day) come into question (see also pemphigoid gestationis).

Progression/forecast
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Spontaneous healing of the eruptions within 4-6 weeks. Healing is independent of the time of delivery. Rare is a protracted course with persistence of the skin lesions over several months. Recurrences are a rarity. There are no skin lesions in the newborn.

Note(s)
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There are associations with multiple pregnancies and excessive weight gain of the mother.

Literature
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  1. Ambros-Rudolph CM (2017) Specific pregnancy dermatoses. Dermatologist 68: 87-94
  2. Ambros-Rudolph CM (2010) Specific pregnancy dermatoses. Dermatologist 61: 1014-1020
  3. Cohen LM et al (1989) Pruritic urticarial papules and plaques of pregnancy and its relationship to maternal-fetal weigt gain and twin pregnancy. Arch Dermatol 125: 1534-1536
  4. Dietz H et al (1995) Pruriginous urticarial papules and plaques in pregnancy (PUPP). Z Hautkr 70: 429-431
  5. Elling SV et al (2000) Pruritic urticarial papules and plaques of pregnancy in twin and triplet pregnancies. J Eur Acad Dermatol Venereol 14: 378-381
  6. Kannambal K et al (2017) A Screening Study on Dermatoses in Pregnancy. J Clin Diagn Res 11:WC01-WC05.
  7. Murase JE et al (2014) Safety of dermatologic medications in pregnancy and lactation: Part I. Pregnancy. J Am Acad Dermatol 70:401.e1-14
  8. Nilles M et al (1989) The PUPPP dermatosis. Dermatologist 40: 586-588
  9. Ohlinger R et al (2003) Pruritic urticarial papules and plaques of pregnancy (PUPPP)--a case report. Z Obstetrics Neonatol 207: 107-109

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Last updated on: 17.12.2020