Polymorphic eruption of pregnancy

What are the aims 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 can occur in women during pregnancy. If present it usually appears during a woman’s first pregnancy and is characterised by an itchy rash that commonly begins on the abdomen, particularly within stretch marks (striae). It usually develops during third trimester, especially in the last few weeks, but can also occur immediately after the baby is born.

It was previously known as PUPPP (pruritic and urticarial papules and plaques of pregnancy).

What causes PEP?

The cause of PEP is unknown. It is thought to occur due to the stretching of the skin on the abdomen, and hormonal changes within the pregnancy. It occurs more commonly with multiple pregnancy (twins or triplets). Previous studies have suggested a link with increased maternal weight gain during pregnancy, increased birthweight, and sex hormones, but these are not proven.

Does PEP run in families?


What are the symptoms of PEP and what does it look like?

Itching is common and often starts on the abdomen, usually sparing the umbilicus (belly button). 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 / darkened inflamed areas of skin (plaques). It can often spread on the trunk, lower abdomen, under the breasts and limbs. The face, scalp, mouth, genital area, palms and soles are hardly ever affected. Small blisters are occasionally present and if these are scratched then straw-coloured fluid may leak out and cause crusts to form. Sometimes the rash may develop into eczema or target like lesions (dusky red / dark centre with surrounding paler area).

It is important to seek advice from your dermatologist if you develop several blisters as PEP can resemble an early form of another skin condition in pregnancy called Pemphigoid gestastionis. This condition may require different treatment and monitoring for you and the baby.

How will PEP be diagnosed?

Diagnosis is usually made by a dermatologist or another doctor based on the typical appearance and distribution of the rash. However, if the appearance is not typical your dermatologist may take a skin biopsy (sample of skin under local anaesthetic) and a blood test to help make the diagnosis. Although there are no tests that can accurately diagnose this condition, these help to rule out other conditions that can occur in pregnancy.

Can PEP be cured?

In most cases this condition is self-resolving and will get better towards the end of pregnancy or immediately following delivery. It can be controlled with treatment. In most cases symptoms resolve within a few weeks after giving birth.

How can PEP be treated?

The aim of treatment is to relieve itching and reduce inflammation in the skin.

Soothing agents can help to relieve itching and soreness. These include cool baths, wet soaks and wearing cotton clothes. Bath moisturisers and soap substitutes followed by moisturising creams or ointments will help to moisturise the skin. Menthol in aqueous cream can be particularly helpful in relieving itch.

CAUTION: This leaflet mentions ‘emollients’ (moisturisers). Emollients, creams, lotions and ointments contain oils which can catch fire. When emollient products get in contact with dressings, clothing, bed linen or hair, there is a danger that a naked flame or cigarette smoking could cause these to catch fire. To reduce the fire risk, patients using skincare or haircare products are advised to be very careful near naked flames to reduce the risk of clothing, hair or bedding catching fire. In particular smoking cigarettes should be avoided and being near people who are smoking or using naked flames, especially in bed. Candles may also risk fire. It is advisable to wash clothing daily which is in contact with emollients and bed linen regularly.

Topical steroid creams or ointments are often prescribed to reduce the inflammation in the skin and are safe to use during pregnancy.

Oral antihistamines (only those suitable for use during pregnancy) can be used to relieve itching. Ask your pharmacist, midwife, or GP for further advice.

Rarely, if the condition is severe, a short course of steroids by mouth may be prescribed.

Will the baby be affected?

No. There have been no reports of the baby being affected.

Is normal delivery possible?

Yes. Caesarean section is not required for this condition.

Can women with PEP still breastfeed?

Yes. Breastfeeding does not appear to affect PEP. It is safe to breast feed your baby even if you are taking steroid tablets as only a tiny amount of steroid gets into breast milk.

Is any special monitoring required?

No, but regular attendance at the antenatal clinic is important. It is recommended that your midwife and/or obstetrician is informed of this diagnosis.

Will PEP reoccur in subsequent pregnancies?

The condition tends not to reoccur, except in future pregnancies with more than one foetus

Where can I get more information about PEP?

Web links to detailed leaflets:

www.dermnetnz.org/reactions/puppp.html (includes photographs)

Jargon Buster: https://www.skinhealthinfo.org.uk/support-resources/jargon-buster/

Please note that the BAD provides web links to additional resources to help people access a range of information about their treatment or skin condition. The views expressed in these external resources may not be shared by the BAD or its members. The BAD has no control of and does not endorse the content of external links.

This leaflet aims to provide accurate information about the subject and is a consensus of the views held by representatives of the British Association of Dermatologists: individual patient circumstances may differ, which might alter both the advice and course of therapy given to you by your doctor.

This leaflet has been assessed for readability by the British Association of Dermatologists’ Patient Information Lay Review Panel


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