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A primigravid 24-year-old woman at 34-weeks gestation comes to the clinic because of a pruritic rash that has been developing on her abdomen over the last week. She is otherwise well and has had normal prenatal visits and blood work. She lives with her husband who does not appear to be affected. Physical examination shows numerous 1-2 mm erythematous, edematous vesicular papules along the periumbilical striae distensae but sparing the umbilicus. There is an extension of similar lesions to her upper medial thighs. No pustules, bullae, or burrows are appreciated. The remainder of the physical examination is unremarkable. A biochemical profile is normal. She should be told that she has
A. a form of pustular psoriasis and should be started on systemic corticosteroid
B. Herpes gestationis and will most likely develop similar lesions in subsequent pregnancies
C. prurigo gravidarum and will be at increased risk for postpartum hemorrhage
D. pruritic urticarial papules and plaques of pregnancy and it typically will resolve postpartum without treatment
E. scabies and needs to be treated with permethrin
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can't be E, C or B. i would say D ???
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how can it be herpes ? both thighs ?
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B. Herpes gestationis and will most likely develop similar lesions in subsequent pregnancies
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The correct answer is D. Pruritic urticarial papules and plaques of pregnancy (PUPPP) is a relatively common, intense pruritic dermatosis of pregnancy that typically occurs in the third trimester in primigravidas. PUPPP typically develops on the abdomen, especially with periumbilical striae distensae, while the umbilicus is usually spared in contrast to patients with Herpes gestationis. PUPPP is characterized by 1-2 mm erythematous papules that coalesce to form urticarial plaques that may involve a large portion of the abdomen. PUPPP usually responds to topical corticosteroid for symptomatic relief and remits postpartum. It does not recur in subsequent pregnancies, flares with ingestion of oral contraceptives, and is not associated with increased fetal morbidity and mortality.
Impetigo herpetiformis, a rare form of pustular psoriasis (choice A) in pregnant females, is marked by acute, febrile onset with development of grouped erythematous plaques that are rimmed with small sterile pustules. Lesional plaques predominate in flexural areas and expand peripherally. It is usually associated with significant constitutional symptoms and hypocalcemia with secondary delirium, seizures, and tetany. It usually promptly remits after delivery but may recur in subsequent pregnancies.
Herpes gestationis (choice B), also known as pemphigoid gestationis, is a rare autoimmune disease that occurs exclusively during the second or third trimester of pregnancy, or during the immediate postpartum period. It is characterized by intense pruritic papules and tense blisters. Classically, Herpes gestationis presents as urticarial eruption on the abdomen that usually evolves into a pemphigoid like eruption, sparing the face, mucous membranes, palms, and soles. The umbilicus is usually involved, in contrast to PUPPP. The disease tends to recur during subsequent gestations and one quarter of women experience flare-ups with use of oral contraceptives.
Prurigo gravidarum (choice C) is a hepatic condition that usually occurs late in pregnancy. The initial cutaneous manifestation is pruritus, which usually precedes onset of jaundice by 2-4 weeks. It tends to remit soon after delivery but typically recurs in subsequent gestations. It may recur in susceptible individuals after exposure to oral contraceptives. Some reports suggested increased incidence of prematurity, stillbirth, and postpartum hemorrhage.
Scabies (choice E) is infestation with the human itch mite Sarcoptes scabiei, which is spread primarily by person-to-person contact. The chief symptom is pruritus, which can occur on any part of the body but most commonly occurs on the hands, waist, and genital area. The most diagnostic lesions are burrows, which are small, crooked lines 4-6 mm in length that are most common in the web spaces of the fingers, sides of hands, flexor surfaces of wrist, and lateral and medial surfaces of the foot nearest the heel. Mainstay of therapy include permethrin 5% and lindane. Ivermectin single oral dose has been reported to be effective for severe scabies.
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D. pruritic urticarial papules and plaques of pregnancy and it typically will resolve postpartum without treatment
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