Question of the Week # 205

205) A 27 year old woman, primigravida at 35 week gestation is evaluated in your office for extreme itching associated with rash. The rash and itching first started on her abdomen but now spread to her buttocks and legs as well. She denies similar complaints in any of her family members. On physical examination, an eruption consisting of small erythematous wheals is noted mostly in the abdominal striae with sparing of the peri-umbilical skin. Some rash is also noted on her lower extremities.  There is no involvement of palms and soles. A picture of her abdomen is shown below:

Most likely diagnosis:

A)           Scabies

B)            Pemphigoid Gestationis

C)            Intahepatic Cholestasis of Pregnancy (ICP)

D)            Pruritic Urticarial Papules of Pregnancy (PUPP)

E)            Pruritic folliculitis of Pregnancy

5 Responses

  1. D pruritic urticarial plaques of pregnancy, spares the peri umbilical skin

  2. Correct answer is D PUPP (Pruritic Urticarial Papules of Pregnancy) also known as polymorphic eruption of pregnancy is the most common rash in pregnant women. It normally occurs in first pregnancies during the third trimester with an average onset of 35 weeks. Recurrence in subsequent pregnancies is uncommon. The classic rash begins as papules or wheals in the abdominal striae and coalesces to form plaques. Assocaited with severe pruritis. There is sparing of peri-umbilical skin which helps in clinically distinguishing it from Pemphigoid Gestationis. Rx is with topical corticosteroid.

    Presence of typical rash starting in abdominal striae helps in differentiating it from ICP. ICP is characterized by pruritis without any rash and increased serum bile acids. Excoriations may be present due to scratching but not the typical rash as described in the question.
    Pemphigoid Gestationis can occur in second or third trimester and is associated with urticarial papules or plaques. It may later develop in to bullae. In the early stages, it may closely resemble PUPP. However, the rash in Pemphigoid Gestationis often begins in the peri-umbilical area where as in PUPP; the rash begins in the abdominal straie and often, spares the peri-umbilical area.

    The clinical presentation is not consistent with scabies. There is a history of affected family members in scabies and the distribution of rash is often, in the finger webs, palms and soles.

    Pruritic folliculitis of pregnancy is a rare atopic dermatitis of pregnancy and is characterized by intensely itchy, sterile eruption with follicular distribution.

  3. D:)

  4. Answer is D

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