Delayed Presentation of Pruritic Urticarial Papules and Plaques of Pregnancy in the Postpartum Period: A Case Report

Pruritic urticarial papules and plaques of pregnancy (PUPPP), also known as polymorphic eruption of pregnancy, is a benign inflammatory dermatosis that typically presents in primigravid women during the third trimester of pregnancy. Postpartum onset is rare and often underrecognized. We report a case of a 29-year-old primigravida with a BMI of 38 kg/m²who delivered a healthy 4 kg male infant via emergency cesarean section for fetal distress. On postpartum day five, she developed a pruritic rash on the abdomen, initially suspected to be a drug reaction to low-molecular-weight heparin. Given the short duration of low molecular weight heparin (LMWH) exposure and persistence of symptoms after discontinuation, a drug-induced eruption was deemed unlikely. The rash progressed to the thighs and buttocks. Dermatologic examination revealed erythematous papules and urticarial plaques over abdominal striae with periumbilical sparing, typical of PUPPP. Laboratory evaluation was unremarkable, apart from a mildly elevated C-reactive protein (CRP), which was measured to assess for systemic inflammation or infection, neither of which was clinically evident. A clinical diagnosis of postpartum-onset PUPPP was made. Treatment with oral antihistamines resulted in a rapid resolution within two weeks. The patient was followed for four weeks after resolution, with no recurrence of symptoms. Although rare in the postpartum period, PUPPP should be considered in the differential diagnosis of pruritic eruptions following delivery. Classic distribution patterns, periumbilical sparing, and absence of systemic involvement are key diagnostic features. Risk factors for PUPPP include primigravidity, multiple gestation, excessive maternal weight gain, and high BMI; in this case, obesity was the primary risk factor identified. Conservative treatment is typically effective. This case underscores the importance of recognizing postpartum-onset PUPPP and differentiating it from drug reactions or other dermatoses. Awareness of its clinical presentation allows for timely diagnosis, appropriate reassurance, and effective symptom management.