Case Reports

Pruritic Urticarial Papules and Plaques of Pregnancy Occurring Postpartum

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References

Classical presentation of PUPPP starts with erythematous papules within the abdominal striae, sparing the periumbilical skin.1 The abdominal striae are most commonly affected, and in some women, it may be the only site affected.10 The lesions then may pro-gress to urticarial plaques involving the extremities, while the face, palms, and soles usually are spared.11 However, clinical manifestations of PUPPP can vary, with reports of targetlike lesions with a surrounding halo resembling erythema multiforme as well as involvement of the face and palmoplantar skin.10-13 Histologic findings are not diagnostic but can help distinguish PUPPP from other pregnancy-associated dermatoses.14 Histologically, PUPPP demonstrates variable epidermal spongiosis and a nonspecific superficial perivascular infiltrate in the dermis composed of lymphocytes with eosinophils or neutrophils, and there may be dermal edema.10,15 Direct immunofluorescence usually is negative in PUPPP; however, 31% of cases have demonstrated deposition of C3 and IgM or IgA, either perivascularly or at the dermoepidermal junction.1,10,15

There are no systemic alterations seen in PUPPP; however, all patients report severe pruritus.12 Pruritic urticarial papules and plaques of pregnancy typically affects women in the third trimester, and delivery is curative in most patients.13 Recurrence of PUPPP usually is not seen with subsequent pregnancies, and the long-term prognosis is excellent.15

The pathogenesis of PUPPP is not well understood and likely is multifactorial. Ohel et al12 found PUPPP to be strongly associated with hypertensive disorders, multiple gestation pregnancies, excessive maternal weight gain, excessive stretching of the abdominal skin, and nulliparity.13 One theory suggests that abdominal skin stretching, if drastic, can damage underlying connective tissue, resulting in the release of antigens that can trigger a reactive inflammatory response.16 The majority of maternal weight gain occurs during the third trimester, which may explain why most cases of PUPPP present in the third trimester.17 Alternative theories have suggested that PUPPP may represent an immunologic response to circulating fetal antigens.18 It is possible, as in our case, that certain nulliparous women who have a healthy weight prior to pregnancy (as determined by a body mass index of 18.5 to 24.9) in combination with excessive weight gain during the third trimester and drastic hormone fluctuations associated with labor and delivery may be at greater risk for developing PUPPP. Another theory may be related to the degree of skin stretching during the third trimester and the abrupt decrease in the stretching of the skin that occurs with delivery.16

Conclusion

Pruritic urticarial papules and plaques of pregnancy can present in a variety of ways, most commonly in the third trimester but also in the postpartum period. When a patient presents in the postpartum period with a pruritic eruption, PUPPP should be included in the differential diagnosis. The pathogenesis of PUPPP is multifactorial and not well understood, and additional research in the field may lead to improved prediction of who may be at risk and what we can do to prevent it.

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