DR [page 22] [Dermatology Reports 2012; 4:e7] Polymorphic eruption of pregnancy developing postpartum: 2 case reports Ellen Cathrine Pritzier, Carsten Sauer Mikkelsen Department of Dermato-venerology, Stavanger University Hospital, Stavanger, Norway Abstract Polymorphic eruption of pregnancy (PEP), also known as pruritic urticarial papules and plaques of pregnancy, is a common benign der- matosis of pregnancy mainly affecting primi- gravidae and multiple pregnancies. We report here two cases of PEP with typical clinical and histological features presenting in the postpar- tum period. Introduction Polymorphic eruption of pregnancy (PEP), also known as pruritic urticarial papules and plaques of pregnancy (PUPPP) is a common benign dermatosis of pregnancy mainly affect- ing primigravidae and multiple pregnancies. PEP usually evolves in the third trimester and resolves rapidly postpartum (Table 1). We describe two cases of PEP with typical clinical and histological features presenting in the postpartum period. Only few cases of PEP developing postpar- tum have been described in the literature. However, a rash appearing in the mother shortly after delivery still can be a specific der- matosis of pregnancy. Case Report #1 A 21-year-old woman was referred to our Department of Dermatology complaining of an intense pruritic rash starting 12 days postpar- tum. The eruption initially developed in and around the abdominal striae distensae with a periumbilical sparing (Figure 1). The urticari- al plaques and erythematous papules spread to the buttocks, thighs and lower lumbar region. On the abdomen tiny vesicles were observed. No facial involvement or hand and foot lesions were observed. The patient was successfully treated with prednisolone 20 mg daily for five days combined with high potency topical corti- costeroids tapered over four weeks. A punch biopsy showed slight dermal edema and a pre- dominantly perivascular infiltrate of lympho- cytes and eosinophilic granulocytes (Figure 2). There were no epidermal alterations, no blis- ters and no vasculitis. Direct immunfluo- rescens study was negative. Case Report #2 A 26-year old primigravida woman was referred 5 days after giving birth with an itchy rash on the abdomen spreading to the proxi- mal thighs. In the last week of her pregnancy, she had noticed some itchiness on her abdomen but no visible changes besides well- marked striae gravidarum. Objectively erythe- matous urticarial plaques and confluent papules were seen with a periumbilical spar- ing. High potency topical corticosteroids were initiated in combination with oral antihista- mines and the itchy eruption subsided in the following 3 weeks. A 4 mm punch biopsy from the skin of the buttock showed a slight dermal edema and perivascular lymphocytic infiltrates with scattered perivascular and interstitial eosinophils. The patient was otherwise healthy apart from a tendency to depression treated with citalopram. Discussion In pregnancy, complex endocrinologic, immunologic, metabolic and vascular changes influence the skin in various ways. The multi- ple alterations of the skin during pregnancy can be classified as physiological skin changes, alterations in pre-existing skin dis- eases and specific dermatoses of pregnancy.1 The specific dermatoses of pregnancy repre- sent a unique group of disease processes caused or exacerbated by the pregnancy state and include gestational pemphigoid (herpes gestationis), prurigo of pregnancy, intrahepat- ic cholestasis of pregnancy, impetigo herpeti- formis and PEP/PUPPP. PEP is a common distinct clinical entity with an estimated incidence in a single pregnancy of one in 130-300 pregnancies.2-4 It is generally considered as a benign dermatosis almost exclusive in primigravidae. The condition is more common in multiple pregnancies, where both earlier presentation and recurrence in second pregnancy are seen.5-7 The etiology is still unknown. It has been postulated that excessive abdominal disten- sion and weight gain may act as a trigger for the skin changes due to connective tissue damage caused by overstretching.1,4 Rudolph et al. found a high frequency of atopy (55%) among their patients, especially in those with longer disease duration. PEP usually evolves in the third trimester at the average gestational week of 35 and resolves rapidly postpartum and only excep- tionally does it appear in the postpartum peri- od.2,4 The lesions start in the abdominal striae in two thirds of the patients with a periumbili- cal sparing distinguishing PEP from other common rashes of pregnancy.8 The rash con- sists of very itchy small erythematous papules in the stretch marks which can coalesce to form larger urticarial abdominal plaques often surrounded by blanched halos. Occasionally eczematous, polycyclic and target lesions can be seen or vesicles (but never bullae) eventu- ally in an acral dyshidrosiform pattern.4,5,6 Over days, the rash can spread over the thighs, but- tocks, breasts, and arms with infrequent facial, hand and foot lesions.4 In spite of the severe pruritus, the absence of excoriations on the skin is a striking feature in contrast to excori- ations related to cholestasis of pregnancy. The condition is harmless to the mother but can be very annoying because of the severe itching.4,6 The average duration of healing is 4- 6 weeks. There are no cutaneous manifesta- tions in the newborn and the fetal prognosis is excellent.1 The diagnosis of PEP can be made clinically in typical cases based on the appear- ance of the rash. There are no specific labora- tory abnormalities and only nonspecific histopathology with a perivascular lymphohis- tiocytic infiltrate with some edema and eosinophils in the dermis.4 Direct immunoflu- orescence studies of the skin are by definition negative.4 Skin biopsies are only performed to rule out other differential diagnoses such as pemphigoid gestationis, atopic dermatitis, contact dermatitis, drug eruptions, viral erup- tions and scabies. PEP is a self-limiting disor- Dermatology Reports 2012; volume 4:e7 Correspondence: Ellen Cathrine Pritzier, Depar- ment of Dermato-venerology, Stavanger Univer- sity Hospital, Postboks 8100, 4068 Stavanger, Norway. Tel. +47.515.130.10. E-mail: elnc@sus.no Key words: pruritic urticarial papules and plaques of pregnancy, polymorphic eruption of pregnancy, dermatosis Conflict of interests: the authors report no poten- tial conflict of interests. Received for publication: 16 April 2012. Accepted for publication: 16 April 2012. This work is licensed under a Creative Commons Attribution NonCommercial 3.0 License (CC BY- NC 3.0). ©Copyright E.C. Pritzier and C.S. Mikkelsen, 2012 Licensee PAGEPress, Italy Dermatology Reports 2012; 4:e7 doi:10.4081/dr.2012.e7 No n- co mm er cia l u se on ly [Dermatology Reports 2012; 4:e7] [page 23] der with resolution shortly after parturition and the treatment is symptomatic.4,6 General measures, such as mild to potent topical steroids can be helpful in treating symptoms from the disease together with systemic anti- histamines. Furthermore application of emol- lients is basic in the treatment.4 In the most severe cases, as seen in one of the cases above, oral steroids may be necessary to con- trol itching.4,5 If systemic corticosteroid treat- ment is necessary during pregnancy non-halo- genated glucocorticosteroids (e.g. pred- nisolone) which are inactivated enzymatically in placenta should be administered as a short time therapy in a dosage of 0.5-2 mg/kg/day depending of the severity of symptoms.1 Conclusions PEP is a frequently occurring pruritic, self- limited inflammatory dermatosis, most often seen in primiparous women and in the last trimester of pregnancy.1 If a rash develops after delivery, specific dermatoses of pregnancy still remains a possible diagnosis. References 1. Ambros-Rudolph CM. Dermatoses of preg- nancy. J Dtsch Dermatol Ges 2006;9:748- 59. 2. Holmes RC, Black MM, Dann J, et al. A comparative study of toxic erythema of pregnancy and herpes gestations. Br J Dermatol 1982;106:499-510. 3. Roger D, Vaillant L, Fignon A, et al. Specific pruritic diseases of pregnancy. A prospective study of 3192 pregnant women. Arch Dermatol 1994;130:734-9. 4. Rudolph CM, Al-Fares S, Vaughan-Jones SA, et al. Polymorphic eruption of pregnan- cy: clinicopathology and potential trigger factors in 181 patients. Br J Dermatol 2006;154:54-60. 5. Powell FC. Pruritic urticarial papules and plaques of pregnancy and multiple preg- nancies. J Am Acad Dermatol 2000;43:730- 1. 6. Cohen LM. Capeless EL, Krusinski PA, Maloney ME. Pruritic urticarial papules and plaques of pregnancy and its relation- ship to maternal-fetal weight gain and twin pregnancy. Arch Dernatol 1989;125:1534-6. 7. Elling SV, McKenna P, Powell FC. Pruritic urticarial papules and plaques of pregnan- cy in twin and triplet pregnancies. J Eur Acad Dermatol Venereol 2000;14:378-81. 8. Matz H, Orion E, Wolf R. Pruritic urticarial papules and plaques of pregnancy: poly- morphic eruption of pregnancy (PUPPP). Clin Dermatol 2006;24:105-8. Case Report Table 1. Clinical features of two patients with postpartum polymorphic eruption of pregnancy. Patient Maternal Primagravida Delivery Outcome Onset Duration of Distribution Morphology Treatment age gestational polymorphic age eruption of pregnancy A 21 12 days Abdomen, Urticarial postpartum thighs plaques B 26 yes Caesarean Healthy 5 days 3 weeks Abdomen, Urticarial Topical Section boy postpartum thighs plaques steroids, ....... antihistamines Figure 2. Skin biopsy showing a predomi- nantly perivascular infiltrate of lympho- cytes and eosinophilic granulocytes. Typical, but not diagnostic for polymor- phic eruption of pregnancy. Figure 1. Erythematous papules and urticarial plaques with periumbilical spar- ing and accentuation in striae in a 21-year old woman with polymorphic eruption of pregnancy. No n- co mm er cia l u se on ly