The aim of this leaflet
This leaflet is designed to tell you more about Polymorphic Eruption of Pregnancy (PEP). It tells you what the condition is, what causes it, what can be done about it and where to find out more about it.

What is Polymorphic Eruption of Pregnancy?
Polymorphic eruption of pregnancy is a relatively common skin disorder that occurs in women of childbearing age. It usually presents in women during their first pregnancy and recurrence in subsequent pregnancies is unusual.

It is characterised by an itchy rash that commonly begins on the abdomen, particularly within stretch marks (striae). It most usually develops during late pregnancy (third trimester) but can also start immediately after the baby is born. It was previously known as PUPPP (pruritic urticarial papules and plaques of pregnancy) but this name has been abandoned as it caused confusion.

What causes Polymorphic Eruption of Pregnancy?
The true cause of PEP is unknown although there have been many theories as to its aetiology. Previous studies have suggested a link with increased maternal weight gain during pregnancy, increased birthweight, sex hormones and the sex of the baby but none of these have been proven. It more commonly occurs with multiple pregnancy (twins or triplets). There are no specific tests for PEP and it can be confused with other skin conditions presenting in pregnancy, such as eczema, drug rashes or even scabies.

Does Polymorphic Eruption of Pregnancy run in families?
No

What are the symptoms of PEP and what does it look like?
Itching is common and often starts on the abdomen often sparing the umbilicus (belly button) during late pregnancy (3rd trimester). If stretch marks (striae) are present the itching may start within them. Itching may then be followed by a rash with wheals (like hives from nettles), small raised lumps in the skin (papules) and large red inflamed areas of skin (plaques). It commonly spreads on the trunk, lower abdomen, under the breasts and limbs. The face, scalp and mucous membranes (mouth and genital area) are hardly ever affected.  Small blisters are sometimes present and if these are scratched then straw-coloured fluid may leak out and cause crusts to form. 

How will Polymorphic Eruption of Pregnancy be diagnosed?
Diagnosis is usually based on the typical appearance and distribution of the rash but this can be confirmed by taking a sample of skin (skin biopsy). Usually the appearance and behaviour of the rash is very typical but in some cases the rash can look reminiscent of other skin diseases such as eczema or a drug eruption. In some cases differentiation from the rarer skin disease of pregnancy (Pemphigoid Gestationis) can be difficult and a special test can be done on blood and a skin biopsy (immunofluorescence) to confirm the diagnosis of Pemphigoid Gestationis.

Can Polymorphic Eruption of Pregnancy be cured?
In most cases this condition is self-limiting and will disappear towards the end of pregnancy or immediately following delivery. It can be suppressed with treatment. In most cases symptoms resolve days or weeks after giving birth.

How can Polymorphic Eruption of Pregnancy be treated?
The primary aim of treatment is to relieve itching and to reduce inflammation and redness in the skin. It is also important during pregnancy to use treatments that are entirely safe for both mother and baby.

Topical steroid creams can be used in mild cases if only a limited area of skin is affected. Even if the rash is quite extensive a trial of a strong steroid cream may be worthwhile before steroid tablets are given, as creams are much less likely to cause side effects. The majority of cases will respond to topical treatment, and the disease is self-limiting.

Emollient creams or ointments can also be applied to reduce itching and soothe sore areas. Bath emollients and soap substitutes are also helpful in many cases.

Oral antihistamines (only those suitable for use during pregnancy) can be used to relieve itching.

Treatment with high doses of steroid tablets may be required for more severe disease. Alternatively early elective induction of labour can be considered, depending on maternal and foetal health. This needs careful monitoring and should involve the obstetricians as well. The dose of steroid tablets can usually be reduced quickly (within 3-5 days) after delivery once the skin lesions disappear.

It is unusual for PEP to recur in subsequent pregnancies. Women who do experience a recurrence normally have milder form of the disease in their second pregnancy.

Will the baby be affected?
No. There have been no reports of the baby being affected.
It has been suggested that PEP occurs more commonly in women who gain more weight during the third trimester of pregnancy, have larger babies and in women with multiple pregnancies (twins or triplets). 

Is normal delivery possible?
Yes. Caesarean section is not recommended for this condition.

Are the treatments safe for the baby and mother?
Mild to moderately potent topical steroids appear to be safe during pregnancy and can be used. With oral steroids there is an increased risk in the mother of developing diabetes (raised sugar levels) and hypertension (raised blood pressure) but as already indicated the duration of oral steroid therapy is very short. Careful observation of blood pressure and urine checks are therefore essential at antenatal clinic, while ultrasound scans can look for any changes in the baby’s growth .

Can women with Polymorphic Eruption of Pregnancy still breastfeed?
Yes. Breastfeeding does not appear to affect PEP. Even while taking oral steroid tablets women should still be encouraged to breastfeed as only negligible amounts of steroid get into breast milk.

Is any special monitoring required?
Yes, regular review at an antenatal clinic is important to monitor foetal size. Maternal blood tests, urine tests, blood pressure checks with ultrasound scans are all extremely important to monitor the mother and baby’s wellbeing.

Where can I get more information about Polymorphic Eruption of Pregnancy?
Web links to detailed leaflets:
www.dermnetnz.org/reactions/puppp.html
www.emedicine.com/derm/topic351.htm

This leaflet has been prepared by the EADV task force “skin disease in pregnancy”, it does not necessarily reflect the official opinion of the EADV. July 2007