What is your diagnosis?
Case for diagnosis. Pregnant woman in the 3rd trimester with pruritic papules and pustules on the trunk. Pruritic folliculitis of pregnancy
Maria Rita Carvalho de Freitas Amorim
, Flavia Amorim Meira Cavaliere, Esther Oliveira Xavier de Brito, Amanda Nascimento Cavalleiro de Macedo Mota
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Service of Dermatology, Hospital Central da Aeronáutica, Rio de Janeiro, RJ, Brazil
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Gestante no 3° trimestre com quadro de pápulas e pústulas pruriginosas no tronco" "tienePdf" => "pt" "tieneTextoCompleto" => "pt" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "102" "paginaFinal" => "104" ] ] "contieneTextoCompleto" => array:1 [ "pt" => true ] "contienePdf" => array:1 [ "pt" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figura 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 810 "Ancho" => 750 "Tamanyo" => 135755 ] ] "descripcion" => array:1 [ "pt" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Folículo piloso permeado por infiltrado inflamatório constituído predominantemente por neutrófilos levando à destruição da estrutura folicular (Hematoxilina & eosina, 400×).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Maria Rita Carvalho de 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Pregnant woman in the 3<span class="elsevierStyleSup">rd</span> trimester with pruritic papules and pustules on the trunk. Pruritic folliculitis of pregnancy" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "102" "paginaFinal" => "104" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Maria Rita Carvalho de Freitas Amorim, Flavia Amorim Meira Cavaliere, Esther Oliveira Xavier de Brito, Amanda Nascimento Cavalleiro de Macedo Mota" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Maria Rita Carvalho de Freitas" "apellidos" => "Amorim" "email" => array:1 [ 0 => "dep.hca@fab.mil.br" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Flavia Amorim Meira" "apellidos" => "Cavaliere" ] 2 => array:2 [ "nombre" => "Esther Oliveira Xavier de" "apellidos" => "Brito" ] 3 => array:2 [ "nombre" => "Amanda Nascimento Cavalleiro de Macedo" "apellidos" => "Mota" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Service of Dermatology, Hospital Central da Aeronáutica, Rio de Janeiro, RJ, Brazil" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2232 "Ancho" => 1674 "Tamanyo" => 450594 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Perivascular infiltrate predominantly consisting of lymphocytes is observed in the dermis (Hematoxylin & eosin, ×40).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Case report</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 26-year-old primiparous female, at her 31<span class="elsevierStyleSup">st</span> week of gestation, reported the onset of pruritic skin lesions on the trunk, with two months of evolution. On physical examination, erythematous papules and pustules were observed on the abdomen (especially on the <span class="elsevierStyleItalic">linea nigra</span>), on the sternum, the back, and the lateral surface of the buttocks (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>). Laboratory tests were requested and a biopsy of the dorsal pustule was performed. Laboratory tests did not disclose any abnormalities and the histopathological analysis showed a lymphocytic perivascular infiltrate, predominantly in the dermis, in addition to a hair follicle permeated by an inflammatory infiltrate with a predominance of neutrophils and destruction of the follicular structure (<a class="elsevierStyleCrossRefs" href="#fig0015">Figs. 3 and 4</a>). The patient was treated with 5% benzoyl peroxide gel, with complete regression of the lesions in the first week of postpartum.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">What is your diagnosis?</span><p id="par0010" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">a)</span><p id="par0015" class="elsevierStylePara elsevierViewall">Pruritic folliculitis of pregnancy</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">b)</span><p id="par0020" class="elsevierStylePara elsevierViewall">Polymorphic eruption of pregnancy</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">c)</span><p id="par0025" class="elsevierStylePara elsevierViewall">Bacterial folliculitis</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">d)</span><p id="par0030" class="elsevierStylePara elsevierViewall">Acneiform eruption</p></li></ul></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">Pruritic folliculitis of pregnancy (PFP) was originally described in 1981 by Zoberman and Farmer.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4</span></a> The authors reported an erythematous-papular, pruritic eruption in six pregnant women between the fourth and ninth months of pregnancy.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a> Lesions spontaneously regressed within one month after delivery.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">This is the least common pregnancy-specific pruritic dermatosis.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Since its description, few case reports have been published. The prospective study carried out by Roger et al. in 1994, which followed 3,192 pregnant women, identified 51 cases associated with pruritus (1.6%), with only one (0.03%) being associated with sterile follicular papules and pustules on the trunk, consistent with the diagnosis of PFP.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In the 1999 study by Vaughan Jones et al., a cohort of 200 women with gestational dermatoses (GD) with a two-year follow-up identified PFP in 14 patients (7%).<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> It is noteworthy that, in this article, serum androgen levels were measured and showed no changes when compared to the control group, ruling out the hypothesis of an etiology related to the increase in the levels of these hormones.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In 2006, Ambros-Rudolph et al. carried out a retrospective study by analyzing the medical records of 505 pregnant women. PFP was diagnosed in only one patient (0.2%), with a history of eczema in childhood and a family history of atopy in two first-degree relatives. The authors proposed a new classification of GD, introducing the term atopic eruption of pregnancy (AEP) which encompasses PFP, prurigo of pregnancy, and eczema of pregnancy.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> This term has been criticized because not all pregnant women with AEP have a history of atopy, similarly the patient in this report.</p><p id="par0055" class="elsevierStylePara elsevierViewall">As described in the literature and observed in the present case, patients respond well to topical treatments based on 5% or 10% benzoyl peroxide and 1% hydrocortisone.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,8,9</span></a> Complete spontaneous regression of the lesions is common within weeks after delivery.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Pruritic folliculitis of pregnancy is a rare, benign and self-limited gestational dermatosis that does not interfere with maternal-fetal morbidity and mortality. It is essential that pregnant women be adequately diagnosed and advised, and followed-up with specialized care.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Financial support</span><p id="par0065" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Authors’ contributions</span><p id="par0070" class="elsevierStylePara elsevierViewall">Maria Rita Carvalho de Freitas Amorim: Collection, analysis and interpretation of data; writing of the manuscript; obtaining, analysis and interpretation of data; critical review of the literature and approval of the final version of the manuscript.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Flavia Amorim Meira Cavaliere: Critical review of important intellectual content; effective participation in research orientation; intellectual participation in the propaedeutic and therapeutic conduct and approval of the final version of the manuscript.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Esther Oliveira Xavier de Brito: Critical review of important intellectual content and approval of the final version of the manuscript.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Amanda Nascimento Cavalleiro by M. Mota da Silva: Design and planning of the study; critical review of important intellectual content; intellectual participation in the propaedeutic and therapeutic conduct and approval of the final version of the manuscript.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0090" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case report" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "What is your diagnosis?" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Financial support" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Authors’ contributions" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of interest" ] 6 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2021-05-25" "fechaAceptado" => "2021-07-26" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Study conducted at the Hospital Central da Aeronᵴica, Rio de Janeiro, RJ, Brazil.</p>" ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1345 "Ancho" => 1674 "Tamanyo" => 135315 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Erythematous papules and pustules located on the sternum and abdomen (<span class="elsevierStyleItalic">linea nigra</span>).</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1347 "Ancho" => 1674 "Tamanyo" => 112112 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Erythematous papules located on the back.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2232 "Ancho" => 1674 "Tamanyo" => 450594 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Perivascular infiltrate predominantly consisting of lymphocytes is observed in the dermis (Hematoxylin & eosin, ×40).</p>" ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1807 "Ancho" => 1674 "Tamanyo" => 419089 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Hair follicle permeated by an inflammatory infiltrate consisting predominantly of neutrophils leading to the destruction of the follicular structure (Hematoxylin & eosin, ×400).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pruritic folliculitis of pregnancy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "E. Zoberman" 1 => "E.R. Farmer" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arch Dermatol." "fecha" => "1981" "volumen" => "117" "paginaInicial" => "20" "paginaFinal" => "22" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7458373" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prurigo, pruritic folliculitis, and atopic eruption of pregnancy: facts and controversies" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M.M. Roth" 1 => "P. Cristodor" 2 => "G. Kroumpouzos" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.clindermatol.2016.02.012" "Revista" => array:6 [ "tituloSerie" => "Clin Dermatol." 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