Document 6478022

Recurrence of Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP) and different approach to management
Miss Aparna Gumma,Mr Ramesh Appiahanna , Mr Haytham Adel Fardoun
Peterborough and Stamford Hospitals NHS Foundation Trust
BACKGROUND
TREATMENT
DIFFERENTIAL DIAGNOSIS
 Conventional:
 Moisturisers such as Dermol 500 to wash with plus Diprobase cream as
moisturiser
 Mild topical steroids such as Eumovate cream 100g applied topically twice a
day
 Antihistamines such as Chlorphenamine as required
 1% Menthol in Aqueous cream 500g as required.
 Balneum Plus cream which also has a topical anaesthetic effect which may be
helpful.
 Over the counter/ on internet:
 Coal Tar Soap
 PUPPP is common in Primigravida and rarely re-occurs. We report a case
where it has not only occurred, but was quite significant and similar to earlier
presentation.
 The patient has elected to use the coal tar soap/cream which we believe
might have contributed to almost complete resolution of the condition
antenatally.
 Important points to remember :
 First, PUPPP does re-occur and it should be considered in the
differential diagnosis.
 Second, over the counter methods could be as efficient as
clinical treatment in these non-specific skin conditions.
OUTCOME AND FOLLOW UP
 This lady’s PUPPP has responded very well to the Coal Tar Soap and her rash
has completely resolved.
CASE PRESENTATION
 This patient has been treated in her first pregnancy for severe PUPPP
involving the trunk area and neck and limbs.
 Apart from being overweight and developing Gestational diabetes in
both pregnancies and having large for gestational age babies, she is fit
and healthy.
 PUPP was treated by multiple agents including dermol, deprobase,
Eumovate, chlorphenamine, 1% Menthol in aqueous cream, and Balneum
Plus in no particular order.
 The extent of the rash was quite significant as it covered the entire trunk
as well as neck and limbs.
 The traditional approach towards PUPPP in her first pregnancy has
managed to give her some relief from her symptoms.
 Around 28weeks gestation in her second pregnancy, she devoloped
PUPPP again with significant presentation also which is quite unusual.
 The lead consultant for her antenatal care has sought dermatology
opinion and we have been informed there were no new
recommendations for treatment apart from what she tried in her first
pregnancy.
 The patient at this stage has researched the internet and elected to try
Coal Tar Soap which has given her gradual release and near full resolution
of her rash antenatally.
DISCUSSION
 The importance of the case is that it highlights in a very practical way the
importance of considering differential diagnosis.
 Using over the counter/internet management options has worked particularly
well for this patient and should always be considered especially if the
conventional management has failed to improve.
 Coal tar has been used for a long time mainly for psoriasis. In British National
Formulary, pregnancy is not a contraindication for use of Tars. In addition to
that, Medscape information on Coal tars recommends using it with caution if
benefits outweigh risk due to possible lack of information
LEARNING
POINTS




Uncommon scenarios should still be included in differential diagnosis
Patient’s wishes and experience makes a very valid contribution to the management
Over the counter treatment could work really well in some cases and they should be explored.
Safety of over the counter preparations should be checked before any recommendations could be
made.
REFERENCES
1.Maharajan A, Aye C, Ratnavel R, Burova E. Skin eruptions specific to pregnancy: an overview. The Obstetrician & Gynaecologist
2013;
DOI: 10.1111/tog.12051.
2.Kroumpouzos George, MD, PhD. Specific Dermatoses of Pregnancy: Advances and Controversies: Polymorphic Eruption of
Pregnancy (Pruritic Urticarial Papules & Plaques of Pregnancy). Medscape 11/24/2010