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Xie F, Agrawal S, Johnson EF, Wieland CN, Davis DMR, Theiler RN, Lehman JS. Updates on the dermatopathology of pregnancy-associated skin conditions. Hum Pathol 2023; 140:173-195. [PMID: 37209919 DOI: 10.1016/j.humpath.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 05/15/2023] [Indexed: 05/22/2023]
Abstract
Pathologists provide valuable input in the dermatological care of pregnant patients in various contexts. This article provides dermatopathology updates on cutaneous changes associated with pregnancy, organized based on the following classification system: physiological skin changes in pregnancy, specific dermatoses of pregnancy, dermatoses modified in pregnancy, and skin neoplasms in pregnancy. Awareness of the impact of pregnancy on the skin by pathologists is important, as this is an opportunity to contribute to diagnostic precision in this patient population.
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Affiliation(s)
- Fangyi Xie
- Department of Dermatology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Shruti Agrawal
- Department of Dermatology, Mayo Clinic, Rochester, MN, 55905, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Emma F Johnson
- Department of Dermatology, Mayo Clinic, Rochester, MN, 55905, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Carilyn N Wieland
- Department of Dermatology, Mayo Clinic, Rochester, MN, 55905, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Dawn Marie R Davis
- Department of Dermatology, Mayo Clinic, Rochester, MN, 55905, USA; Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Regan N Theiler
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Julia S Lehman
- Department of Dermatology, Mayo Clinic, Rochester, MN, 55905, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, 55905, USA.
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Recognizing, Diagnosing, and Managing Pregnancy Dermatoses. Obstet Gynecol 2022; 140:679-695. [PMID: 36075066 DOI: 10.1097/aog.0000000000004938] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 05/26/2022] [Indexed: 01/05/2023]
Abstract
Pregnancy dermatoses are inflammatory skin disorders that occur during pregnancy or immediately postpartum. This heterogenous group of disorders includes pemphigoid gestationis, polymorphic eruption of pregnancy, intrahepatic cholestasis of pregnancy, atopic eruption of pregnancy, and pustular psoriasis of pregnancy. In this article, we provide a comprehensive literature review of each condition focusing on nomenclature, epidemiology, pathogenesis, clinical presentation, diagnosis, differential diagnosis, maternal risk, fetal risk, and treatment. We aim to increase awareness and help clinicians recognize, diagnose, and manage these unique conditions.
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Diagnostic Pitfall in Atypical Febrile Presentation in a Patient with a Pregnancy-Specific Dermatosis—Case Report and Literature Review. Medicina (B Aires) 2022; 58:medicina58070847. [PMID: 35888566 PMCID: PMC9315689 DOI: 10.3390/medicina58070847] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 06/22/2022] [Accepted: 06/24/2022] [Indexed: 12/04/2022] Open
Abstract
Pruritic urticarial papules and plaques of pregnancy (PUPPP) usually occurs in the third trimester of pregnancy in primiparous women. It is a self-limiting inflammatory disorder with a still unknown pathogenic mechanism. The abdominal wall overdistension, with a subsequent inflammatory response due to damage to the connective tissue, represents a pathogenesis explanation. Clinical features involve intensely pruritic urticarial rash with edematous, erythematous papules and plaques. The clinical picture and dermal biopsy establish the diagnosis. Topical corticosteroids and oral antihistamines are usually sufficient, but sometimes systemic corticosteroids are necessary. Maternal and fetal prognosis is excellent, and the lesions resolve after birth with no scarring or pigmentary change. We present a case of a 36-year-old patient with a 32-week pregnancy who was admitted with a generalized pruritic rash accompanied by fever. The final diagnosis was decided after multiple pathology exclusions. Treatment consisted of systemic corticoid therapy. The patient gave birth by cesarean section to a healthy newborn without dermatological lesions or other conditions. Adding more PUPPP cases to the literature portfolio will bring more awareness to this under-recognized and under-reported skin disorder. We trust this case will encourage other physicians to publish more cases of pregnancy-specific dermatoses.
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Ogura Y, Inuzuka M, Morimoto H, Otsuka M, Tokura Y. Postpartum polymorphic eruption of pregnancy prominently occurring on striae distensae. JOURNAL OF CUTANEOUS IMMUNOLOGY AND ALLERGY 2021. [DOI: 10.1002/cia2.12204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Yasuaki Ogura
- Department of Dermatology & Skin Oncology Allergic Disease Research Center Chutoen General Medical Center Kakegawa Japan
- Allergic Disease Research Center Chutoen General Medical Center Kakegawa Japan
| | | | - Hiroki Morimoto
- Department of Dermatology & Skin Oncology Allergic Disease Research Center Chutoen General Medical Center Kakegawa Japan
| | - Masaki Otsuka
- Department of Dermatology & Skin Oncology Allergic Disease Research Center Chutoen General Medical Center Kakegawa Japan
| | - Yoshiki Tokura
- Department of Dermatology & Skin Oncology Allergic Disease Research Center Chutoen General Medical Center Kakegawa Japan
- Allergic Disease Research Center Chutoen General Medical Center Kakegawa Japan
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Ishikawa-Nishimura M, Kondo M, Matsushima Y, Habe K, Yamanaka K. A Case of Pruritic Urticarial Papules and Plaques of Pregnancy: Pathophysiology and Serum Cytokine Profile. Case Rep Dermatol 2021; 13:18-22. [PMID: 33613229 PMCID: PMC7879330 DOI: 10.1159/000511494] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 09/08/2020] [Indexed: 01/22/2023] Open
Abstract
We report a case of pruritic urticarial papules and plaques of pregnancy (PUPPP) starting with target lesions on both forearms at the end of second pregnancy. The patient's target lesions became generalized itchy edematous eczema lesions especially on her abdomen extended by pregnancy, which immediately disappeared postpartum. The mechanism PUPPP has not been elucidated so far; however, the typical target lesion was the initial phenotype in the current case. To approach the pathophysiology of PUPPP, we examined the cytokine profile in the patient's serum before and after delivery. The upregulated Th2 cytokine profile including IL-9 and IL-33, and the reaction against skin-resident bacteria and fungus might be involved in PUPPP.
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Affiliation(s)
| | - Makoto Kondo
- Department of Dermatology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Yoshiaki Matsushima
- Department of Dermatology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Koji Habe
- Department of Dermatology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Keiichi Yamanaka
- Department of Dermatology, Mie University Graduate School of Medicine, Tsu, Japan
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Payton A, Woo BKP. Instagram Content Addressing Pruritic Urticarial Papules and Plaques of Pregnancy: Observational Study. JMIR DERMATOLOGY 2021; 4:e26200. [PMID: 37632847 PMCID: PMC10501520 DOI: 10.2196/26200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 12/09/2020] [Accepted: 01/20/2021] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Pruritic urticarial papules and plaques of pregnancy (PUPPP) is the most commonly diagnosed pregnancy-specific dermatosis. It presents with intense pruritus and can be difficult to manage, which encourages mothers to look to social media for camaraderie and advice. OBJECTIVE This study aimed to characterize the sources and thematic content of Instagram posts in order to define influential groups of users. Our goal was to determine the status of online discourse surrounding PUPPP and elucidate any potential space for health care provider intervention via creation of Instagram accounts dedicated to information dissemination for patient populations. METHODS Three hashtag categories were selected (#PUPPP, #PUPPPs, and #PUPPPrash), and the top public posts from each were analyzed and organized by source and by thematic content. The numbers of likes and comments were also recorded. RESULTS Among the top 150 posts in each hashtag category, only 428 posts in total were eligible for this analysis. Majority (316/428, 73.8%) of posts were created by mothers who experienced PUPPP. These posts were testimonial accounts in nature. A small fraction of posts (14/428, 3.3%) were generated by physician accounts. Posts from blogs with extensive followings garnered the most attention in the form of likes and comments. CONCLUSIONS Mothers experiencing PUPPP comprised the majority of accounts posting under the hashtags selected. The most common themes included pictures of the rash and personal testimonies. Posts under blog posts received the most likes and comments on average. There is space for physician and health care specialists to improve their social media presence when it comes to discourse surrounding PUPPP. Patients are seeking out communities on social media, like Instagram, in order to have questions answered and obtain advice on management. Accounts with large followings tend to have more likes and more comments, which encourages information dissemination and awareness. Thus, we suggest that physicians create content and potentially partner with blog-type accounts to improve outreach.
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Affiliation(s)
- Ashley Payton
- Department of Psychiatry, Olive View Medical Center, University of California Los Angeles Medical Center, Sylmar, CA, United States
- College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA, United States
| | - Benjamin K P Woo
- Department of Psychiatry, Olive View Medical Center, University of California Los Angeles Medical Center, Sylmar, CA, United States
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Dokuzeylul Gungor N, Gurbuz T, Ture T. Prolonged luteal phase support with progesterone may increase papules and plaques of pregnancy frequency in pregnancies through in vitro fertilization. An Bras Dermatol 2021; 96:171-175. [PMID: 33573870 PMCID: PMC8007486 DOI: 10.1016/j.abd.2020.09.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 09/08/2020] [Accepted: 09/22/2020] [Indexed: 11/30/2022] Open
Abstract
Background Pruritic urticarial papules and plaques of pregnancy development may have a strong relationship with hormone treatments during in vitro fertilization and hormonal changes during pregnancy. Objectives The aim of this study was to evaluate and compare the frequency of papules and plaques of pregnancy and related factors in in vitro fertilization pregnancies and spontaneous pregnancies. Methods In this study, 517 in vitro fertilization pregnancies and 1253 spontaneous pregnancies were retrospectively reviewed for papules and plaques of pregnancy frequency. The diagnosis of papules and plaques of pregnancy was performed by referral to the dermatology department and according to the typical clinical manifestations of the disease. Results The papules and plaques of pregnancy was more common in all in vitro fertilization pregnancies (including single pregnancies) than in spontaneous pregnancies. Age, Rh positivity, mother weight gain, onset of disease during gestation, duration of disease, birth weight and the frequency of male fetus were similar between the two groups (p > 0.05). The rate of multiple pregnancies was higher in in vitro fertilization pregnancies with papules and plaques of pregnancy than in vitro fertilization pregnancies without papules and plaques of pregnancy (p < 0.001). Duration of progesterone treatment was also significantly longer in in vitro fertilization pregnancies with papules and plaques of pregnancy compared to in vitro fertilization pregnancies without papules and plaques of pregnancy (p < 0.001). Study limitations The limitations of the study were the retrospective and single-centered design. Conclusion The results of this study indicate that increased progesterone dosage or prolonged treatment may play a role in the pathogenesis papules and plaques of pregnancy.
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Affiliation(s)
- Nur Dokuzeylul Gungor
- Department of Reproductive Medicine and IVF, Goztepe Medical Park Hospital, Istanbul, Turkey.
| | - Tugba Gurbuz
- Department of Obstetrics and Gynecology, Nisantasi University and Private Medistate Hospital, Istanbul, Turkey
| | - Tugba Ture
- Department of Dermatology, Private Clinic, Istanbul, Turkey
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Abstract
We have explored the rash that appears as target lesions, with the central and dominant diseases belonging to the Stevens-Johnson syndrome/toxic epidermal necrolysis group. After presenting the clinical patterns of an individual target lesion and classifying them into different types of lesions, the contribution has been organized with groups characterized by such specific findings according to the type of lesion: flat or raised, typical or atypical, presence or absence of fever, presence or absence of mucosal ulcerations, presence or absence of arthralgias, and/or internal organ involvement. Other specific features, such as histologic appearance, immunofluorescence findings, and laboratory changes, are considered. We provide clinicians with an algorithmic, systematic, and logical approach to diagnose the condition of the patients who present with targetoid lesions, and enable them to differentiate between those with serious systemic and life-threatening diseases from others with ordinary skin ailments.
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Affiliation(s)
- Ronni Wolf
- The School of Medicine, Hebrew University, Jerusalem, Israel; Hadassah Medical Center, Jerusalem, Israel.
| | - Jennifer L Parish
- Department of Dermatology and Cutaneous Biology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA; Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Lawrence Charles Parish
- Department of Dermatology and Cutaneous Biology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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9
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Patel P, Ashack KA, Aronson IK. Postpartum polymorphic eruption of pregnancy: an unusual presentation. Int J Dermatol 2018; 58:357-359. [PMID: 29907959 DOI: 10.1111/ijd.14084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 02/25/2018] [Accepted: 05/22/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Priyanka Patel
- Department of Dermatology, University of Illinois at Chicago College of Medicine, Chicago, IL, USA
| | - Kurt A Ashack
- Department of Dermatology, University of Illinois at Chicago College of Medicine, Chicago, IL, USA
| | - Iris K Aronson
- Department of Dermatology, University of Illinois at Chicago College of Medicine, Chicago, IL, USA
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Jeon C, Agbai O, Butler D, Murase J. Dermatologic conditions in patients of color who are pregnant. Int J Womens Dermatol 2017; 3:30-36. [PMID: 28492052 PMCID: PMC5418956 DOI: 10.1016/j.ijwd.2017.02.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 02/06/2017] [Accepted: 02/08/2017] [Indexed: 01/16/2023] Open
Abstract
Certain dermatoses that present during pregnancy have a predilection for populations with skin of color (SOC). Additionally, certain systemic diseases such as systemic lupus erythematosus tend to be more aggressive during pregnancy and confer worse prognoses in women with SOC. The purpose of this review is to highlight the unique implications of selected diseases during pregnancy as it relates to SOC. Dermatologists should be vigilant for the unique clinical variations of dermatological conditions in patients of color who are pregnant to ensure correct diagnoses and optimize treatment outcomes.
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11
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Brandão P, Sousa-Faria B, Marinho C, Vieira-Enes P, Melo A, Mota L. Polymorphic eruption of pregnancy: Review of literature. J OBSTET GYNAECOL 2016; 37:137-140. [PMID: 27960565 DOI: 10.1080/01443615.2016.1225019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Polymorphic Eruption of Pregnancy (PEP) is one of the most common dermatosis related to pregnancy. PEP usually consists of pruritic papules and plaques appearing in the third trimester of pregnancy. It is more common in primigravidae and twin pregnancies. Although not associated with poorer foetal or maternal outcomes, it may be hard for pregnant women to endure. The diagnosis is easy if suspected, though sometimes it may be hard to distinguish from other dermatosis such as atopic eczema of pregnancy, pemphigoid gestationis or dermatitis. Topical treatment with emollients and low-medium potency steroids is usually effective but systemic steroid treatment may be required. PEP is self-limiting and resolves days or weeks after the first appearance or after delivery. In this article, the authors aim to review the literature published from 2000 onwards regarding the subject, either in English or Portuguese.
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Affiliation(s)
- Pedro Brandão
- a Department of Obstetrics and Gynaecology , Centro Hospitalar Tâmega e Sousa, Hospital Padre Américo , Penafiel , Portugal
| | - Bárbara Sousa-Faria
- a Department of Obstetrics and Gynaecology , Centro Hospitalar Tâmega e Sousa, Hospital Padre Américo , Penafiel , Portugal
| | - Carla Marinho
- a Department of Obstetrics and Gynaecology , Centro Hospitalar Tâmega e Sousa, Hospital Padre Américo , Penafiel , Portugal
| | - Pedro Vieira-Enes
- a Department of Obstetrics and Gynaecology , Centro Hospitalar Tâmega e Sousa, Hospital Padre Américo , Penafiel , Portugal
| | - Anabela Melo
- a Department of Obstetrics and Gynaecology , Centro Hospitalar Tâmega e Sousa, Hospital Padre Américo , Penafiel , Portugal
| | - Lurdes Mota
- a Department of Obstetrics and Gynaecology , Centro Hospitalar Tâmega e Sousa, Hospital Padre Américo , Penafiel , Portugal
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12
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Kroumpouzos G. Advances in obstetric dermatology: A better understanding of skin disease in pregnancy. Clin Dermatol 2016; 34:311-3. [PMID: 27265067 DOI: 10.1016/j.clindermatol.2016.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- George Kroumpouzos
- Department of Dermatology, The Warren Alpert Medical School of Brown University, Providence, RI 02903, USA.
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14
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Abstract
Pregnancy is associated with complex of endocrinological, immunological, metabolic, and vascular changes that may influence the skin and other organs in various ways. Pregnancy is a period in which more than 90% women have significant and complex skin changes that may have great impact on the woman's life. The dermatoses of pregnancy represent a heterogeneous group of skin diseases related to pregnancy and/or the postpartum period. The dermatoses of pregnancy can be classified into the following three groups: Physiologic skin changes in pregnancy, pre-existing dermatoses affected by pregnancy, and specific dermatoses of pregnancy. Though most of these skin dermatoses are benign and resolve in postpartum period, a few can risk fetal life and require antenatal surveillance. Most of the dermatoses of pregnancy can be treated conservatively but a few require intervention in the form of termination of pregnancy. Correct diagnosis is essential for the treatment of these disorders. This article discusses the current knowledge of various skin changes during pregnancy and the evaluation of the patient with pregnancy dermatoses with special emphasis on clinical features, diagnostic tests, maternal and fetal prognosis, therapy, and management.
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Affiliation(s)
- Rita V Vora
- Department of Skin and VD, Pramukhswami Medical College and Shree Krishna Hospital, Gujarat, India
| | - Rajat Gupta
- Department of Skin and VD, Pramukhswami Medical College and Shree Krishna Hospital, Gujarat, India
| | - Malay J Mehta
- Department of Skin and VD, Pramukhswami Medical College and Shree Krishna Hospital, Gujarat, India
| | - Arvind H Chaudhari
- Department of Skin and VD, Pramukhswami Medical College and Shree Krishna Hospital, Gujarat, India
| | - Abhishek P Pilani
- Department of Skin and VD, Pramukhswami Medical College and Shree Krishna Hospital, Gujarat, India
| | - Nidhi Patel
- Department of Skin and VD, Pramukhswami Medical College and Shree Krishna Hospital, Gujarat, India
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Hassan I, Bashir S, Taing S. A clinical study of the skin changes in pregnancy in kashmir valley of north India: a hospital based study. Indian J Dermatol 2015; 60:28-32. [PMID: 25657393 PMCID: PMC4318058 DOI: 10.4103/0019-5154.147782] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Background: Pregnancy is associated with multiple skin changes, most of which are physiological in nature, being the direct result of expected modifications of the hormonal, vascular, metabolic or immunologic status in pregnant females. Pregnancy however is also associated with certain pruritic eruptions, which not only cause distress to the pregnant female, but may influence the fetal outcome as well. Objective: The objective of this study was to determine the pattern of skin changes associated with pregnancy and to identify the various clinical types of pregnancy specific dermatoses (PSDs). Materials and Methods: The study was a cross sectional study carried out at the out-patient Department of Gynecology and obstetrics of our hospital. A total of 650 pregnant females, irrespective of their parity and gestational age were screened for the presence of any dermatological complaint. Results: The age of the study population ranged from 17 to 39 years (mean age: 24 years). The study population included 272 (42%) primigravidae and 378 (58%) multigravidae. Physiological skin changes of pregnancy were seen in all patients, out of which linea nigra was the most common change, seen in 520 (80%) cases. Specific dermatoses of pregnancy were seen in 32 (4.9%) cases, which included (in the decreasing order of frequency) prurigo of pregnancy (50% cases), intrahepatic cholestasis of pregnancy (25% cases), polymorphic eruption of pregnancy (22% cases) and pemphigus gestationis (3% cases). Conclusion: Skin changes were seen in 100% of pregnant females in this study, the major proportion being formed by physiological skin changes of pregnancy though PSDs were also seen in a significant number.
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Affiliation(s)
- Iffat Hassan
- Department of Dermatology, STD, Leprosy, Government Medical College, Srinagar (University of Kashmir), Jammu and Kashmir, India ; Department of Gynaecology and Obstetrics, Government Medical College, Srinagar (University of Kashmir), Jammu and Kashmir, India
| | - Safia Bashir
- Department of Dermatology, STD, Leprosy, Government Medical College, Srinagar (University of Kashmir), Jammu and Kashmir, India ; Department of Gynaecology and Obstetrics, Government Medical College, Srinagar (University of Kashmir), Jammu and Kashmir, India
| | - Shahnaaz Taing
- Department of Dermatology, STD, Leprosy, Government Medical College, Srinagar (University of Kashmir), Jammu and Kashmir, India ; Department of Gynaecology and Obstetrics, Government Medical College, Srinagar (University of Kashmir), Jammu and Kashmir, India
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The utility of C4d immunohistochemistry on formalin-fixed paraffin-embedded tissue in the distinction of polymorphic eruption of pregnancy from pemphigoid gestationis. Am J Dermatopathol 2014; 35:787-91. [PMID: 24061402 DOI: 10.1097/dad.0b013e3182a6b6cc] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Polymorphic eruption of pregnancy (PEP), formerly known as pruritic urticarial papules and plaques of pregnancy, is a dermatosis of pregnancy that must be distinguished from pemphigoid gestationis (PG). Although this differential diagnosis may be possible on routine histology, an additional biopsy for direct immunofluorescence (DIF) is often needed. Recent studies have demonstrated the utility of anti-C4d or anti-C3d antibodies in the diagnosis of bullous pemphigoid (BP) in formalin-fixed paraffin-embedded tissue (FFPE). We investigated the utility of routine immunohistochemistry (IHC) for anti-C4d in FFPE tissue in the specific differential diagnosis of PEP versus PG in known, DIF-proven cases. We performed C4d IHC on PEP (n = 11), PG (n = 8), DIF-proven BP (n = 12), and other common dermatoses (n = 12) that are typically DIF negative. None of the PEP cases (0/11) or the other common dermatoses (0/12) demonstrated C4d positivity at the basement membrane zone. In comparison, 100% of PG cases (8/8) and 83.3% of BP cases (10/12) showed linear C4d immunoreactant deposition along the basement membrane zone. The results demonstrate the potential utility of C4d IHC in FFPE tissue for distinguishing PEP from PG, thus potentially obviating the need of a repeat biopsy for DIF, particularly in C4d-negative cases where there is a low suspicion of PG on both clinical and histological grounds. Also, patients with positive C4d-positive immunoreactivity may also potentially proceed directly to less invasive serological confirmatory testing, such as BP180 NC16a enzyme-linked immunoabsorbent assay.
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Woidacki K, Zenclussen AC, Siebenhaar F. Mast cell-mediated and associated disorders in pregnancy: a risky game with an uncertain outcome? Front Immunol 2014; 5:231. [PMID: 24904581 PMCID: PMC4033021 DOI: 10.3389/fimmu.2014.00231] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Accepted: 05/05/2014] [Indexed: 11/13/2022] Open
Abstract
During pregnancy, the maternal organism is under the influence of tremendous endocrine as well as immunological changes as an adaptation to the implanted and developing fetus. In most cases, the maternal adaptations to pregnancy ensure both, the protection against harmful pathogens and the tolerance toward the growing semi-allogeneic fetus. However, under certain circumstances the unique hormonal milieu during pregnancy is causative of a shift into an unfavorable direction. Of particular importance are cellular disorders previous to pregnancy that involve cell types known for their susceptibility to hormones. One interesting cell type is the mast cell (MC), one of the key figures in allergic disorders. While physiological numbers of MCs were shown to positively influence pregnancy outcome, at least in mouse models, uncontrolled augmentations in quantity, and/or activation can lead to pregnancy complications. Women that have the desire of getting pregnant and been diagnosed with MC mediated disorders such as urticaria and mastocytosis or chronic inflammatory diseases in which MCs are involved, including atopic dermatitis, asthma, or psoriasis, may benefit from specialized medical assistance to ensure a positive pregnancy outcome. In the present review, we address the course of pregnancy in women affected by MC mediated or associated disorders.
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Affiliation(s)
- Katja Woidacki
- Experimental Obstetrics and Gynecology, Medical Faculty, Otto-von-Guericke University , Magdeburg , Germany
| | - Ana Claudia Zenclussen
- Experimental Obstetrics and Gynecology, Medical Faculty, Otto-von-Guericke University , Magdeburg , Germany
| | - Frank Siebenhaar
- Department of Dermatology and Allergy, Allergie-Centrum-Charité, Charité-Universitätsmedizin Berlin , Berlin , Germany
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18
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Abstract
The specific dermatoses of pregnancy represent a diverse group of intensely pruritic dermatoses, occurring only in the puerperal state. The relative rarity of these conditions, the often variable clinical appearance, and the lack of definitive diagnostic tests have led to confusion regarding the appropriate diagnosis and management of the specific dermatoses of pregnancy. Herein we review the clinical characteristics, diagnosis and treatment of five dermatoses occurring during pregnancy: pruritic urticarial papules and plaques of pregnancy, atopic eruption of pregnancy, pemphigoid gestationis, intrahepatic cholestasis of pregnancy, and pustular psoriasis of pregnancy.
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Affiliation(s)
- Stephanie Lehrhoff
- The Ronald O. Perelman Department of Dermatology, New York University, New York, New York 10016, USA.
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19
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Kroumpouzos G. Specific dermatoses of pregnancy: advances and controversies. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/edm.10.59] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Sirikudta W, Silpa-Archa N. Polymorphic eruption of pregnancy presented with targetoid lesions: a report of two cases. Case Rep Dermatol 2013; 5:138-43. [PMID: 23741213 PMCID: PMC3670623 DOI: 10.1159/000351259] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background Skin lesions in pregnant women could be caused by physiologic or pathologic changes. Polymorphic eruption of pregnancy (PEP), which manifests as various types of skin lesions, is the most common pregnancy dermatosis. Thus, PEP could mimic other skin diseases related to unfavorable maternal and fetal outcomes. Main Observations Two PEP patients with targetoid lesions are presented here. One of them was a primigravida, whereas the other was a secundigravida. Both patients had singleton pregnancies and skin rash which started during the third trimester. The lesions began on the abdomen and then spread to the trunk and extremities. The face, palms, soles, and mucosa were not affected. Pruritus was observed but no other systemic symptoms were reported. Both patients delivered healthy, term infants without complications. Conclusion Targetoid lesions in PEP are an uncommon presentation, and the differential diagnosis of PEP along with other dermatoses should be considered. However, the prognosis for this type of PEP is not different from that for classic PEP.
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Affiliation(s)
- Wararat Sirikudta
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Ghazeeri G, Kibbi AG, Abbas O. Pruritic urticarial papules and plaques of pregnancy: epidemiological, clinical, and histopathological study of 18 cases from Lebanon. Int J Dermatol 2013; 51:1047-53. [PMID: 22909357 DOI: 10.1111/j.1365-4632.2011.05203.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Pruritic urticarial papules and plaques of pregnancy (PUPPP) is a benign pruritic inflammatory skin disorder that usually affects primigravidae in their third trimester of pregnancy. Studies on this condition from our area are lacking. OBJECTIVE AND METHODS To describe the epidemiological, clinical, and histopathological findings of all patients diagnosed with PUPPP at the American University of Beirut Medical Center (AUB-MC) between 1998 and 2009 and compare our findings with those published in the literature. RESULTS PUPPP mainly affected primigravidae (72%) in the third trimester of pregnancy (89%). Multiple gestation pregnancies were observed in 50% of cases. The abdomen and proximal thighs were the most commonly involved sites (67%), with exclusive involvement of the extremities in four cases. Although pruritic urticarial papules and plaques were the main morphological feature of PUPPP observed (98%), five cases had additional features, and one case presented exclusively with papulovesicular lesions. Microscopically, all cases biopsied showed the typical features of PUPPP, including negative direct immunofluorescence findings. Emollients, topical corticosteroids, and/or oral antihistamines were generally adequate to control symptoms in all cases, in which skin lesions resolved in an average of three weeks. CONCLUSION This study showed a lower incidence of PUPPP in our population compared with its incidence in other populations. It also confirmed the previously described clinical features, benign course, and excellent outcome of the condition, although variations may occur. Significant associations mainly included multiple gestation pregnancies, excessive maternal weight, and Rh-positive blood type, while fetal gender and weight gain did not contribute.
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Affiliation(s)
- Ghina Ghazeeri
- Department of Obstetrics, American University of Beirut-Medical Center, Beirut, Lebanon
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Sánchez-Borges M, Asero R, Ansotegui IJ, Baiardini I, Bernstein JA, Canonica GW, Gower R, Kahn DA, Kaplan AP, Katelaris C, Maurer M, Park HS, Potter P, Saini S, Tassinari P, Tedeschi A, Ye YM, Zuberbier T. Diagnosis and treatment of urticaria and angioedema: a worldwide perspective. World Allergy Organ J 2012; 5:125-47. [PMID: 23282382 PMCID: PMC3651155 DOI: 10.1097/wox.0b013e3182758d6c] [Citation(s) in RCA: 126] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
: Urticaria and angioedema are common clinical conditions representing a major concern for physicians and patients alike. The World Allergy Organization (WAO), recognizing the importance of these diseases, has contributed to previous guidelines for the diagnosis and management of urticaria. The Scientific and Clinical Issues Council of WAO proposed the development of this global Position Paper to further enhance the clinical management of these disorders through the participation of renowned experts from all WAO regions of the world. Sections on definition and classification, prevalence, etiology and pathogenesis, diagnosis, treatment, and prognosis are based on the best scientific evidence presently available. Additional sections devoted to urticaria and angioedema in children and pregnant women, quality of life and patient-reported outcomes, and physical urticarias have been incorporated into this document. It is expected that this article will supplement recent international guidelines with the contribution of an expert panel designated by the WAO, increasing awareness of the importance of urticaria and angioedema in medical practice and will become a useful source of information for optimum patient management worldwide.
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Affiliation(s)
- Mario Sánchez-Borges
- Department of Allergy and Clinical Immunology, Centro Médico-Docente La Trinidad, Caracas, Venezuela
| | - Riccardo Asero
- Ambulatorio di Allergologia, Clinica San Carlo, Paderno-Dugnano, Milan, Italy
| | - Ignacio J Ansotegui
- Department of Allergy and Immunology, Hospital Quirón Bizkaia, Bilbao, Spain
| | - Ilaria Baiardini
- Allergy and Respiratory Disease Clinic, University of Genova, Ospedale S.Martino di Genova, Genoa, Italy
| | - Jonathan A Bernstein
- Department of Internal Medicine, Division of Immunology/Allergy Section University of Cincinnati, Cincinnati, OH
| | - G Walter Canonica
- Allergy and Respiratory Disease Clinic, University of Genova, Ospedale S.Martino di Genova, Genoa, Italy
| | - Richard Gower
- Department of Medicine, University of Washington, Spokane, WA
| | - David A Kahn
- Division of Allergy and Immunology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Allen P Kaplan
- Division of Pulmonary and Critical Care Medicine and Allergy and Immunology, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Connie Katelaris
- Department of Allergy and Immunology, University of Western Sydney and Campbelltown Hospital, Sydney, Australia
| | - Marcus Maurer
- Universitätsmedizin Berlin. Allergie-Centrum-Charité, Berlin, Germany
| | - Hae Sim Park
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, South Korea
| | - Paul Potter
- Allergy Diagnostic & Clinical Research Unit, University of Cape Town Lung Institute, Groote Schuur, South Africa
| | - Sarbjit Saini
- Division of Allergy and Clinical Immunology, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Paolo Tassinari
- Immunology Institute, Faculty of Medicine, Universidad Central de Venezuela, Caracas, Venezuela
| | - Alberto Tedeschi
- U.O. Allergologia e Immunologia Clinica, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - Young Min Ye
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, South Korea
| | - Torsten Zuberbier
- Universitätsmedizin Berlin. Allergie-Centrum-Charité, Berlin, Germany
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Kar S, Krishnan A, Shivkumar PV. Pregnancy and skin. J Obstet Gynaecol India 2012; 62:268-75. [PMID: 23730028 DOI: 10.1007/s13224-012-0179-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Accepted: 04/08/2012] [Indexed: 10/27/2022] Open
Abstract
INTRODUCTION Skin changes occur in about 90 % pregnant women in one form or the other. The various skin changes maybe either physiological (hormonal), changes in pre-existing skin diseases or development of new pregnancy-specific dermatoses. All of these dermatoses can be attributed to the profound hormonal, vascular, metabolic, and immunological changes occurring during pregnancy. CLASSIFICATION Pregnancy-specific dermatoses have now been classified into dermatoses which are definitively associated and dermatoses with uncertain association with pregnancy. Though most of these skin dermatoses are benign and resolve in postpartum period, a few can risk fetal life and require antenatal surveillance. Most of the dermatoses of pregnancy can be treated conservatively but a few require intervention in the form of termination of pregnancy. CONCLUSION Careful history taking and examination will help us to identify each condition clinically and appropriate management can be instituted for the well-being of the mother and the fetus.
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Affiliation(s)
- Sumit Kar
- Department of Dermatology, Venereology & Leprosy, Mahatma Gandhi Institute of Medical Sciences (MGIMS), Sevagram, Wardha, Maharashtra 442012 India
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Giugliano E, Cagnazzo E, Servello T, Mossuto E, Marci R, Patella A. Pruritic urticarial papules and plaques of pregnancy. J OBSTET GYNAECOL 2012; 32:301-2. [PMID: 22369410 DOI: 10.3109/01443615.2011.652704] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- E Giugliano
- Department of Biomedical Sciences, University of Ferrara, Ferrara, Italy.
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Abstract
What is probably the first description of targetoid or iris lesions, as they appear in erythema multiforme (EM), can be found in Thomas Bateman's 1836 textbook "Practical Synopsis of Cutaneous Diseases According to the Arrangement of Dr. Willan." EM was initially described by Bateman and later by von Hebra as an acute self-limiting skin disease, symmetrically distributed on the extremities with typical concentric "targetoid" or "iris" lesions, and often recurrent. Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) were added to this syndrome later. A newer classification has created two disease spectra: EM consisting of EM minor and EM major (or bullous EM), and SJS and TEN. EM minor and EM major are often recurrent, postinfectious (especially after herpes and mycoplasma) disorders with low morbidity and almost no mortality. SJS and TEN are usually severe drug-induced reactions with high morbidity and poor prognosis. The target lesions found in each form of the disease are described and defined. Although the term "target lesion" originated from the description of EM and despite its being the dominant lesion in this disease, it is not pathognomonic for EM, and these lesions can sometimes appear in other diseases. Short descriptions of these other diseases are presented.
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MESH Headings
- Dermatitis, Allergic Contact/classification
- Dermatitis, Allergic Contact/pathology
- Erythema Multiforme/classification
- Erythema Multiforme/history
- Erythema Multiforme/pathology
- Hemangioma/classification
- Hemangioma/pathology
- History, 19th Century
- History, 20th Century
- History, 21st Century
- Humans
- Lupus Erythematosus, Systemic/classification
- Lupus Erythematosus, Systemic/pathology
- Pemphigus/classification
- Pemphigus/pathology
- Pregnancy Complications/classification
- Pregnancy Complications/pathology
- Pruritus/classification
- Pruritus/pathology
- Skin Diseases/classification
- Skin Diseases/history
- Skin Diseases/pathology
- Skin Diseases, Vesiculobullous/classification
- Skin Diseases, Vesiculobullous/pathology
- Syphilis/classification
- Syphilis/pathology
- Vasculitis, Leukocytoclastic, Cutaneous/classification
- Vasculitis, Leukocytoclastic, Cutaneous/pathology
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Affiliation(s)
- Ronni Wolf
- Dermatology Unit, Kaplan Medical Center, 76100 Rechovot, Israel (affiliated to the Hebrew University-Hadassah Medical School, Jerusalem, Israel).
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Özcan D, Özçakmak B, Aydoğan FÇ. Polymorphic eruption of pregnancy with palmoplantar involvement that developed after delivery. J Obstet Gynaecol Res 2011; 37:1158-61. [DOI: 10.1111/j.1447-0756.2010.01492.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
Some aspects regarding the etiology and the nosologic classification of various pregnancy dermatoses are highly controversial. While some authors highlight the existence of premises allowing several skin disorders to be re-grouped within broader disease concepts, others underline the absence of clear, undisputed etiopathogenetic data that could support such classifications. This review exhaustively analyzes the various pregnancy dermatoses (pemphigoid gestationis, intrahepatic cholestasis of pregnancy, impetigo herpetiformis, polymorphic eruption of pregnancy, and the papular dermatoses of pregnancy [prurigo of pregnancy, pruritic folliculitis of pregnancy, and the new classification, atopic eruption of pregnancy]) in an attempt to shed light over this confusing and disputed domain, while subsequently offering an algorithmic approach to their diagnosis and management. While for pemphigus gestationis, intrahepatic cholestasis of pregnancy, and impetigo herpetiformis, specific diagnostic tests such as histopathology, immunofluorescence, or laboratory investigations will confirm the diagnosis, the identification of the other types of pregnancy dermatoses is based only on clinical criteria. In this context, the review argues for the inclusion of the whole group represented by the papular dermatoses of pregnancy within the broad spectrum of polymorphic eruption of pregnancy, separating each of these entities by focusing on their onset: early-onset polymorphic eruption of pregnancy (comprising prurigo of pregnancy, pruritic folliculitis of pregnancy, and atopic eruption of pregnancy) and late-onset polymorphic eruption of pregnancy. In light of the same practical approach guiding it, the review provides updated treatment strategies for each of these conditions.
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Affiliation(s)
- Maria-Magdalena Roth
- Department of Dermatology, "Elias" University Emergency Hospital, Bucharest, Romania.
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Regnier S, Fermand V, Levy P, Uzan S, Aractingi S. A case-control study of polymorphic eruption of pregnancy. J Am Acad Dermatol 2007; 58:63-7. [PMID: 17884242 DOI: 10.1016/j.jaad.2007.08.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2006] [Revised: 08/01/2007] [Accepted: 08/09/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND Polymorphic eruption of pregnancy (PEP) is a pruritic disease that usually occurs in primiparous women, most commonly in the last trimester of pregnancy. The origin and pathomechanisms still remain unknown. OBJECTIVES We attempted to determine the parameters that may be associated with or complicate the course of PEP. METHODS Data of 200 pregnant women (40 PEP and 160 control) were studied retrospectively and compared statistically using univariable and multivariable analysis. RESULTS In multivariate analysis, pregnancy with male fetuses (P = .02) and delivery by cesarean section (P = .012) were overrepresented in the PEP group. A tendency toward more multiple gestation pregnancy in PEP was found (P = .07). The risk of PEP was not related to excessive maternal or fetal weight gain. LIMITATIONS This was a retrospective study. CONCLUSION This large case-control study confirms the already suspected association of PEP with male fetuses and cesarean deliveries in multivariate analysis. The higher rate of multiple gestation pregnancy was also established.
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Affiliation(s)
- Stephanie Regnier
- Department of Dermatology, Hôpital Tenon (Assistance Publique-Hôpitaux de Paris), Unité de Formation et de Recherche Pierre et Marie Curie, Paris 6, Université Pierre et Marie Curie, Paris, France.
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Brzoza Z, Kasperska-Zajac A, Oleś E, Rogala B. Pruritic urticarial papules and plaques of pregnancy. J Midwifery Womens Health 2007; 52:44-8. [PMID: 17207750 DOI: 10.1016/j.jmwh.2006.09.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Pruritic urticarial papules and plaques of pregnancy (PUPPP) are among the most common pruritic dermatoses observed in pregnant women. PUPPP appears most frequently in the third trimester, in primigravidas, and in multiple gestation pregnancies. The eruption of changes occurs initially on the abdomen and extends over the thighs, legs, back, buttocks, arms, and breasts. Skin changes typical for PUPPP are erythematous, urticarial plaques, and papules. Rash regression is usually observed within 6 weeks postpartum. Immunologic mechanisms, hormonal abnormalities, and abdominal skin distension have been suggested as etiologic mechanisms. PUPPP is thought to be harmless for the mother and fetus and usually requires intervention only for symptom relief. In some cases, laboratory investigation, histologic examination, and immunologic study should be performed to exclude more serious disorders of pregnancy, such as herpes gestationis or intrahepatic cholestasis of pregnancy. This article reviews the epidemiology, clinical manifestation, etiology, differential diagnosis, and treatment of PUPPP.
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Affiliation(s)
- Zenon Brzoza
- Clinical Department of Internal Diseases, Allergology and Clinical Immunology, Medical University of Silesia, Katowice, ul. 3 Maja 13-15, 41-800 Zabrze, Poland.
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Abstract
Polymorphic eruption of pregnancy (PEP) is a benign, self-limiting, pruritic disorder of pregnancy, which usually affects the primigravida during the last trimester or immediately postpartum. Its pathogenesis is unclear and its clinical manifestations are variable, leading frequently to an incorrect diagnosis. In cases of PEP the histological findings are nonspecific and the laboratory results, including direct immunofluorescence (DIF) and indirect immunofluorescence (IIF), are negative. Polymorphic eruption of pregnancy is not associated with any fetal risk and symptomatic treatment is all that is usually required. In this review we present the clinical presentation of PEP and a differential diagnosis which defines PEP as a separate entity. We will also review all current data of possible etiologic factors, histologic and immunologic findings, prognosis and therapy.
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Affiliation(s)
- Haritini Petropoulou
- Department of Dermatology, University of Athens School of Medicine, Andreas Sygros Hospital for Skin and Venereal Diseases, Athens, Greece
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Castro LA, Lundell RB, Krause PK, Gibson LE. Clinical experience in pemphigoid gestationis: Report of 10 cases. J Am Acad Dermatol 2006; 55:823-8. [PMID: 17052488 DOI: 10.1016/j.jaad.2006.07.015] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2006] [Revised: 07/11/2006] [Accepted: 07/18/2006] [Indexed: 12/01/2022]
Abstract
BACKGROUND Pemphigoid gestationis is a rare autoimmune blistering disease that occurs during pregnancy. OBJECTIVE This study reviewed our clinical experience with pemphigoid gestationis. METHODS We reviewed medical records of 10 patients with pemphigoid gestationis seen at Mayo Clinic, Rochester, Minnesota, between 1976 and 2004. RESULTS Urticarial papules were the most frequent clinical presentation followed by blisters and rash. Pruritus was the cardinal symptom. Lesions presented initially on the legs, thighs, back, and chest. Direct immunofluorescence had the highest diagnostic test sensitivity. Systemic corticosteroids were the mainstay of treatment. Fetal and maternal outcome was good in all cases. LIMITATIONS This was a retrospective, single-institution study. CONCLUSIONS This condition can be easily confused with other dermatoses of pregnancy, for example, pruritic urticarial papules of pregnancy. Biopsy for direct immunofluorescence is the preferred test for confirmation of diagnosis. On the basis of good patient outcomes, conservative treatment seems warranted.
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Affiliation(s)
- Luis A Castro
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota 55905, USA
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Caproni M, Giomi B, Berti S, Bianchi B, Fabbri P. Relevance of cellular infiltrate and cytokines in polymorphic eruption of pregnancy (PEP). J Dermatol Sci 2006; 43:67-9. [PMID: 16621452 DOI: 10.1016/j.jdermsci.2006.03.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2005] [Revised: 03/01/2006] [Accepted: 03/06/2006] [Indexed: 10/24/2022]
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Rudolph CM, Al-Fares S, Vaughan-Jones SA, Müllegger RR, Kerl H, Black MM. Polymorphic eruption of pregnancy: clinicopathology and potential trigger factors in 181 patients. Br J Dermatol 2006; 154:54-60. [PMID: 16403094 DOI: 10.1111/j.1365-2133.2005.06856.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Polymorphic eruption of pregnancy (PEP; synonym: pruritic urticarial papules and plaques of pregnancy) is the most common specific dermatosis of pregnancy. However, its clinical characterization is controversial and its pathogenesis uncertain. OBJECTIVES To evaluate clinical characteristics of and potential trigger factors for PEP in a large mixed ethnic population. METHODS A retrospective analysis of epidemiological, clinical, immunopathological and obstetric findings in 181 patients with PEP seen at two university-based dermatological hospitals in Graz, Austria, and London, U.K. RESULTS PEP mainly affected white (88%) primigravidae (70%) in late pregnancy (83%; mean +/- SD onset 34 +/- 5 weeks) or the immediate postpartum period (15%). The most commonly involved sites were the abdomen and proximal thighs (97%). Involvement of the whole skin, including the face, palms and soles, was only rarely observed. While pruritic urticarial papules and plaques were the main morphological features at disease onset (98%), more than one-half of the patients (51%) later developed polymorphous features including erythema, vesicles, and targetoid and eczematous lesions. Topical treatment with corticosteroids and emollients was sufficient to control symptoms in the majority of patients, and skin lesions resolved after a mean +/- SD of 4 +/- 3 weeks. Multiple gestation pregnancies were observed in 13% of cases, excessive maternal weight gain in 78%. CONCLUSIONS Our data confirm the benign, self-limiting nature of PEP and its favourable outcome for both the mother and the fetus. For the first time, we have documented a characteristic change in morphology with disease progression. The evidence of polymorphous clinical features in more than one-half of the patients favours the use of the term PEP. Multiple gestation pregnancies and excessive maternal weight gain, but not fetal weight and sex, were found to be significantly associated with PEP.
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Affiliation(s)
- C M Rudolph
- Department of Dermatology, Medical University Graz, Auenbruggerplatz 8, A-8036 Graz, Austria.
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Matz H, Orion E, Wolf R. Pruritic urticarial papules and plaques of pregnancy: polymorphic eruption of pregnancy (PUPPP). Clin Dermatol 2006; 24:105-8. [PMID: 16487883 DOI: 10.1016/j.clindermatol.2005.10.010] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The most commonly diagnosed pruritic dermatosis of pregnancy has a confusing nomenclature. The most commonly term used in the United States is pruritic urticarial papules and plaques of pregnancy (PUPPP), and in Great Britain, since 1982, polymorphic eruption of pregnancy. The etiology of PUPPP is still unknown. Placental products, hormonal alterations, and damage to connective tissue with subsequent conversion of nonantigenic molecules to antigenic ones, have been proposed as possible causes. The maternal and fetal prognosis is excellent. Treatment consists of topical or oral corticosteroids. Delivery does not usually provide relief of symptoms.
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Affiliation(s)
- Hagit Matz
- Dermatology Unit, Kaplan Medical Center, 76100 Rechovot, Israel
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High WA, Hoang MP, Miller MD. Pruritic Urticarial Papules and Plaques of Pregnancy With Unusual and Extensive Palmoplantar Involvement. Obstet Gynecol 2005; 105:1261-4. [PMID: 15863603 DOI: 10.1097/01.aog.0000159564.69522.f9] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pruritic urticarial papules and plaques of pregnancy (PUPPP) is a specific dermatosis of pregnancy common to primigravid women in the third trimester. The rash usually begins on the lower abdomen within striae and spreads to the proximal extremities. Involvement of face, palms, and soles is unusual. Although intensely pruritic, the fetus is unaffected, and the condition does not usually recur. It can be difficult to distinguish PUPPP from pemphigoid gestationis, an autoimmune bullous disorder with potential fetal consequences that may recur with subsequent pregnancy, menses, or hormonal therapy. CASE A young secundagravida at 36 weeks of gestation with monochorionic twins presented with a 3-week history of a pruritic papular eruption that began on the abdomen and spread to the extremities. She had extensive involvement of the distal extremities, including the palmoplantar surfaces, with small vesicles of 2-4 mm on acral skin. Because of her unusual presentation, she was thought initially to have pemphigoid gestationis. Subsequent dermatological evaluation and a biopsy confirmed the diagnosis of PUPPP. Shortly after admission she delivered 2 healthy male infants, and her rash cleared with conservative management. CONCLUSION Pruritic urticarial papules and plaques of pregnancy often, but not always, spares the face, palms, and soles. Small vesicles can occur in PUPPP, but formation of true bullae is not observed. Careful dermatological examination and cutaneous biopsy can assist in differentiating PUPPP from pemphigoid gestationis, which is essential for treatment and prognosis.
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Affiliation(s)
- Whitney A High
- Department of Dermatology, Pathology, the University of Texas Southwestern Medical Center at Dallas, Texas, USA
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Affiliation(s)
- Uwe Wollina
- Department of Dermatology, Hospital Dresden-Friedrichstadt, Dresden, Germany.
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Affiliation(s)
- Samantha Berti
- The Department of Dermatological Sciences, University of Florence, Via della Pergola 58, 50121 Florence, Italy
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Fabbri P, Caproni M, Berti S, Bianchi B, Amato L, De Pità O, Frezzolini A. The role of T lymphocytes and cytokines in the pathogenesis of pemphigoid gestationis. Br J Dermatol 2003; 148:1141-8. [PMID: 12828741 DOI: 10.1046/j.1365-2133.2003.05265.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Pemphigoid gestationis (PG), also known as herpes gestationis, is a rare autoantibody-mediated bullous disease, usually associated with pregnancy and the postpartum period. However, infiltrating cells have recently been suggested to also contribute to the pathogenesis of cutaneous lesions. OBJECTIVES To evaluate the immunophenotype of T cells infiltrating the PG lesional skin and their prevalent cutaneous cytokine expression, as well as the presence and distribution of mast cells, eosinophils and neutrophils. Methods We performed an immunohistochemical study with a large panel of monoclonal antibodies to CD3, CD4, CD8, HLA-DR, CD25, myeloperoxidase, tryptase, eosinophil cationic protein EG2, human interleukin (IL)-2, -4, -5, -8, interferon (IFN)-gamma, and granulocyte-macrophage colony-stimulating factor using the alkaline phosphatase-antialkaline phosphatase procedure on lesional skin of seven patients with PG. Skin from four subjects with pruritic urticarial papules and plaques of pregnancy and three additional healthy donors were used as controls. RESULTS The findings indicate that there is a T-cell population with a prevalent T-helper (Th) 2 phenotype in the lesional skin of PG subjects. We also found a number of eosinophils and neutrophils with clear signs of activation. CONCLUSIONS These data suggest that an inflammatory infiltrate is involved in the production of PG bullous lesions. In particular, we assume that the Th2 cells might be implicated in the very early stages of autoimmune response and may exercise a broad influence in blister formation in this disease.
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Affiliation(s)
- P Fabbri
- Department of Dermatological Sciences, University of Florence, Italy.
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Kroumpouzos G, Cohen LM. Specific dermatoses of pregnancy: an evidence-based systematic review. Am J Obstet Gynecol 2003; 188:1083-92. [PMID: 12712115 DOI: 10.1067/mob.2003.129] [Citation(s) in RCA: 110] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE We conducted an evidence-based systematic analysis of the literature on specific dermatoses of pregnancy. STUDY DESIGN The bibliographic databases MEDLINE and EMBASE were screened for studies and reports in all languages about herpes gestationis, pruritic urticarial papules and plaques of pregnancy, pruritic folliculitis of pregnancy, and prurigo of pregnancy from January 1962 to January 2002. As main index terms, including analogs and derivatives, we used the names of specific dermatoses of pregnancy. Intrahepatic cholestasis of pregnancy, not a primary dermatosis, was included herein because this disorder is associated with pregnancy and its secondary skin manifestations must be differentiated from specific dermatoses of pregnancy. Other sources were abstract books of symposia and congresses, theses, textbooks, monographs, reviews, editorials, letters to the editor, free or rapid communications, and the reference lists from all the articles that were retrieved. All articles selected for inclusion in this review were evaluated critically with regard to their impact factor and evidence-based contribution to this field, as measured by their citation index and impact factor of the journal in which they were published. Approximately 39% of articles met the selection criteria. RESULTS The clinical features and prognosis of the specific dermatoses of pregnancy have been delineated through a number of retrospective and cohort studies. The molecular biologic and immunogenetic properties of herpes gestationis, pruritic urticarial papules and plaques of pregnancy, and intrahepatic cholestasis of pregnancy have been further clarified. A meta-analysis in this review reveals a higher prevalence of multiple gestation pregnancy (11.7%) among patients with pruritic urticarial papules and plaques of pregnancy. Several investigations have unraveled the fetal complications in intrahepatic cholestasis of pregnancy and herpes gestationis. New treatment modalities in intrahepatic cholestasis of pregnancy (cholestyramine, ursodeoxycholic acid) and herpes gestationis (cyclosporin, intravenous immunoglobulin, and tetracyclines postpartum) have shown promise and warrant further evaluation. CONCLUSION During the past few decades, a significant amount of new data has provided new insights into the classification, pathogenesis, treatment, prognosis, and fetal risks that are associated with the specific dermatoses of pregnancy.
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Affiliation(s)
- George Kroumpouzos
- Division of Dermatology, Department of Medicine, Saint Vincent Hospital at Worcester Medical Center, Newton
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Bank I, Libourel EJ, Middeldorp S, Van Der Meer J, Büller HR. High rate of skin complications due to low-molecular-weight heparins in pregnant women. J Thromb Haemost 2003; 1:859-61. [PMID: 12871432 DOI: 10.1046/j.1538-7836.2003.t01-7-00115.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Affiliation(s)
- M M Black
- St. John's Institute of Dermatology, St. Thomas' Hospital, London, UK
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Abstract
The dermatoses of pregnancy can be classified into the following 3 groups: physiologic skin changes in pregnancy, dermatoses and cutaneous tumors affected by pregnancy, and specific dermatoses of pregnancy. Correct diagnosis and classification are essential for the treatment of these disorders, when necessary. Laboratory investigations are required when the diagnosis remains in question despite a careful history and thorough physical examination. A discussion with the pregnant woman about the nature of her skin condition, and the possible fetal risks associated with it, is imperative.
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Affiliation(s)
- G Kroumpouzos
- Department of Dermatology, Boston Medical Center, Boston University School of Medicine, Massachusetts, USA
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Abstract
This article reviews the literature that evaluates pruritic urticarial papules and plaques of pregnancy, herpes gestationis, and intrahepatic cholestasis of pregnancy and their impact on the fetus. Using MEDLINE years 1966 to 1999, a literature search was performed using the terms pregnancy, dermatology, pruritic urticarial papules and plaques of pregnancy, herpes gestationis, and intrahepatic cholestasis of pregnancy. References from the selected papers were then reviewed for additional sources. Thirty-seven studies were reviewed. Both original studies and review articles were included in the sources. The results of each study as originally reported are included to provide the reader the finding of each. The available literature reports no risk with pruritic urticarial papules and plaques of pregnancy; however, the current opinion of most was that there is an increased risk with herpes gestationis and intrahepatic papules and plaques of pregnancy. Although much information is known concerning these unique conditions, a consensus regarding their effect on the fetus has yet to be reached. Pregnancies affected by herpes gestationis and cholestasis of pregnancy should be considered high risk until more definitive evidence can be gained.
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Affiliation(s)
- G B Sherard
- Department of Obstetrics and Gynecology, East Carolina University--Brody School of Medicine, Greenville, North Carolina, USA.
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Abstract
UNLABELLED Pregnancy is associated with immunological, endocrine, metabolic and vascular changes that may adversely affect the skin. The specific dermatoses of pregnancy are disease entities almost exclusively related to the pregnancy or the puerperium. LEARNING OBJECTIVE At the conclusion of this learning activity, participants should be aware of the main entities of the specific pregnancy dermatoses, their clinical presentations, the main diagnostic criteria and therapeutic options.
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Affiliation(s)
- S I Al-Fares
- Department of Dermatological Immunopathology, St John's Institute of Dermatology, Guy's King's and St Thomas' School of Medicine, St Thomas' Hospital, London, UK
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DIAGNOSIS AND TREATMENT OF ATOPIC DERMATITIS, URTICARIA, AND ANGIOEDEMA DURING PREGNANCY. Radiol Clin North Am 2000. [DOI: 10.1016/s0033-8389(22)00130-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Boiko S, Zeiger R. DIAGNOSIS AND TREATMENT OF ATOPIC DERMATITIS, URTICARIA, AND ANGIOEDEMA DURING PREGNANCY. Immunol Allergy Clin North Am 2000. [DOI: 10.1016/s0889-8561(05)70186-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Powell FC. Pruritic urticarial papules and plaques of pregnancy and multiple pregnancies. J Am Acad Dermatol 2000; 43:730-1. [PMID: 11004645 DOI: 10.1067/mjd.2000.107742] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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