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Month: April 2020

Pregnancy Rash – Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP)

Pruritic urticarial papules and plaques of pregnancy (PUPPP), also known as polymorphic eruption of pregnancy, is the most common skin disease of pregnancy. This polymorphic (i.e., different shapes and forms) skin eruption occurs in approximately 0.5% or 1 in 200 pregnancies. The cause of this condition is generally unknown.

Individuals with this condition exhibit a very itchy (i.e., pruritus) rash that usually begins in the last trimester, but can began earlier in the pregnancy. The rash usually begins in stretch marks on the abdomen, but spares the area around the umbilicus (i.e., belly button) and within a few days begins to spread to the legs, feet, arms, neck, and/or chest. It tends to spare the face, palms, and soles. Skin distension (i.e., stretching) is thought to be a possible trigger for this condition.

It is more common to occur in a first pregnancy than in subsequent pregnancies. Likewise, it is more common to occur in pregnant women who are carrying a male fetus, pregnant with multiple births (e.g., triplets more than twins), and/or who have gained excessive weight during their pregnancy.

Initially the rash presents as red, hive-like (i.e., urticarial) bumps (i.e., papules) and later may develop into larger red, swollen patches (i.e., plaques). In lighter-skinned individuals, the rash may appear to be surrounded by a thin, white halo.



The exact cause of pruritic urticarial papules and plaques of pregnancy is not exactly known.

One theory hypothesizes that when the skin of a pregnant woman is stressed or stretched, the connective tissues can be damaged. This damage causes inflammation which can result in a red, swollen rash.

Another theory of the cause of PUPPP is that it is due to an immune response to fetal cells. During pregnancy, some cells from the fetus migrate throughout the mother’s body. It is these fetal cells that can trigger an immune response in the mother, which in turn causes the rash.


The diagnosis is usually established by the history and appearance of the rash and its association with intense itching. There are no specific diagnostic tests and skin biopsy usually reveals non-specific findings. A skin biopsy is sometimes done in order to differentiate the rash from similar rashes caused by herpes gestationis, prurigo of pregnancy, and atopic dermatitis (i.e., eczema).

Rarely, the baby can be born with a mild form of the rash of pruritic urticarial papules and plaques of pregnancy, but this rash soon fades. It should be noted that PUPPP does not cause any other problem for the baby.


Pruritic urticarial papules and plaques of pregnancy continues until delivery then usually resolves within 1–3 weeks. Rarely, it may persist for longer. In some cases, this relates to retained placental products.

There is no curative treatment for PUPPP, apart from delivery. Symptoms can be controlled using the following:
⦁ Emollients (i.e., moisturizers) applied liberally and frequently as required
⦁ Topical steroids applied thinly once or twice daily to the red itchy patches
⦁ A short course of systemic steroids (e.g., prednisone) in severe PUPPP
⦁ Antihistamine tablets appear safe in late pregnancy, although they may make the baby drowsy upon delivery

It is very uncommon for pruritic urticarial papules and plaques of pregnancy to recur. If it recurs, it is likely to be a milder case. It should also be noted that there is no long-term risk for either the mother or unborn child despite frequently severe itching.

The board certified allergists at Black and Kletz Allergy have over 5 decades of experience in diagnosing and treating all types of allergic skin conditions.  We treat both pediatric and adult patients, and of course pregnant patients.  Black & Kletz Allergy has 3 convenient locations with on-site parking located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  The Washington, DC and McLean, VA offices are Metro accessible and we offer a free shuttle that runs between the McLean, VA office and the Spring Hill metro station on the silver line.  To schedule an appointment, please call any of our offices or you may click Request an Appointment and we will respond within 24 hours by the next business day.  We have been servicing the Washington, DC, Maryland, and Northern Virginia metropolitan area for many years and we look forward to providing you with the utmost state-of-the-art allergy care in a warm and pleasant environment.

Asthma – What You Need to Know

Asthma is a fairly common disease in the U.S. Asthma is a chronic disease that causes inflammation of the bronchial tubes (i.e., breathing tubes) resulting is symptoms that may include chest tightness, wheezing, shortness of breath, and/or coughing. According to the Centers for Disease Control and Prevention (CDC), approximately 25 million people in the U.S. have asthma which equates to 1 in every 13 individuals or 7.7% of the population. Note that 7.5% of children in the U.S. have asthma. Asthma is more common in adult women (9.1%) compared with adult men (6.2%), however, in children, boys are affected more than girls (8.3% vs. 6.7% respectively). Regarding race and ethnicity, asthma prevalence in the U.S. decreases in the following order: Native American (10.5%) > African American (9.6%) > White (8.2%) > Hispanic (6.0%) > Asian (4.7%). The fatality rate per million in individuals with asthma in the U.S. decreases in the following order: African American (21.8%) > Native American (11.3%) > White (9.5%) > Asian or Pacific Islander (8.5%) > Hispanic (6.3%). From the above statistics, one can see that the fatality rate is not based on the prevalence. It should also be noted that the asthma prevalence has been increasing over the last few decades even though there are more treatment modalities available now than ever before.

Asthma is characterized by the class it is designated. Asthma is categorized as follows: mild intermittent, mild persistent, moderate persistent, and severe persistent. The classification depends on how often one experiences symptoms, how often symptoms are causing nighttime awakenings, if the symptoms are disrupting normal activities, and how often one uses their rescue inhalers. In addition to these categories, asthma can also be classified as exercise-induced asthma, cough-variant asthma, nocturnal asthma, occupational asthma, asthma with associated COPD (i.e., chronic obstructive pulmonary disease), cardiac asthma (i.e., not actually asthma but congestive heart failure and other heart disease that masquerades as asthma since the symptoms are very similar to asthma), allergic asthma (i.e., an older classification which is not used anymore), nonallergic asthma (i.e., an older classification which is not used anymore).

In addition to asthma, there are several conditions that mimic asthma in its presentation and some of them are as follows: cardiac asthma (mentioned above), vocal cord dysfunction and/or paralysis, GERD (i.e., gastroesophageal reflux disease), sinusitis, upper respiratory tract infections (i.e., URI’s), COPD (e.g., chronic bronchitis, emphysema), bronchiectasis, cystic fibrosis, thyroid gland tumors, lung or chest tumors, pulmonary embolism, anxiety, pneumonia, and food aspiration.

The diagnosis of asthma requires a comprehensive history and physical examination in conjunction with a pulmonary function test. Additional measures may be needed depending on the history and physical examination and may include allergy skin or blood tests, chest X-ray, other types of bloodwork, sweat chloride test, CT scans, and others. The treatment of asthma is catered to each specific patient based on the frequency and severity of their symptoms. A host of medications may be utilized and range from just a rescue inhaler (i.e., short acting beta 2 inhalers) for intermittent asthma to biologicals (i.e., Xolair, Fasenra, Nucala) for more moderate-to-severe cases. Other therapeutics utilized to treat asthma may include inhaled corticosteroids, long acting beta 2 inhalers, combination inhalers of corticosteroids and long acting beta 2 inhalers, leukotriene antagonists (e.g., Singulair, Accolate, Zyflo), methylxanthines (e.g., theophylline), and oral corticosteroids. The prevention of asthma symptoms can usually be achieved through allergy immunotherapy (i.e., allergy shots, allergy injections, allergy hyposensitization, allergy desensitization) as well as to attempt to avoid triggers that can exacerbate one’s asthma.

The board certified allergists at Black & Kletz Allergy have had more than 50 years of experience in diagnosing and treating asthma in the Washington, DC, Northern Virginia, and Maryland metropolitan area. We treat both children and adults and have office locations in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. We offer on-site parking at all of our office locations. The Washington, DC and McLean, VA offices are also Metro accessible. We offer a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line.  To schedule an appointment, please call one of our offices or alternatively you may click Request an Appointment and we will respond within 24 hours by the next business day. The allergy doctors at Black & Kletz Allergy are happy to help you diagnose and treat your asthma as well as any other allergy-related or immunological condition that you might have.