PUPPPs: an Overview of Pruritic Urticarial Papules of Pregnancy

A woman’s immune system is suppressed during pregnancy, meaning she has a greater risk of developing benign conditions that would otherwise not manifest. Small rashes, allergies, and eczema can all flare up during pregnancy. These small, but only slightly bothersome conditions can most likely be handled with home remedies. There are some, however, that can be more troublesome, and may require closer attention. One of these conditions is called pruritic urticarial papules and plaques of pregnancy (PUPPP). Pruritic describes an intense itching sensation, or a strong urge to scratch. Urticarial papules are red bumps, hives, and sometimes lesions that appear on the surface of the skin. When a large area of the skin is covered with urticarial papules, it’s called a plaque.

PUPPPs is a benign chronic rash that occurs in 1 in 200 pregnancies, about 0.5% of all pregnancies. It is the most commonly diagnosed dermatological condition related to pregnancy. PUPPPs is not dangerous to mom or the unborn baby. PUPPPs occurs in the late third trimester, most often just a few weeks before delivery. It also occurs more often in women carrying their first baby or multiples. The PUPPPs rash can be difficult to diagnose. There is no test that can be done to confirm PUPPPs, although it might be tested in order to rule out more dangerous conditions.

Symptoms

Not every rash that occurs late in pregnancy can be diagnosed as PUPPPs. PUPPPs is characterized to be a rash consisting of light to deep red hives and lesions causing intense itching. PUPPPs appears on the areas of the skin that have been under the most stress and have more striations. It starts low on the abdomen, often inside existing stretch marks. It then spreads across the entire lower belly and around to the buttocks, and down to the upper thighs. It can also appear on the arms, legs, armpits, chest, and neck. The rash coalesces, meaning if it disappears it does not reappear on another area. It spreads out or shrinks as a whole. The rash rarely appears on the hands, feet, or face. In almost all cases of PUPPPs, the rash abates or is completely gone within two weeks of delivery. In a small number of cases, the rash can appear for the first time in the days directly following delivery, and last into the first few weeks postpartum. The hives, rash, and lesions are not likely to leave scarring, but may take several weeks to fade after the initial itching subsides.
While the condition does not pose a threat to the mother or unborn baby, the severe itching can be extremely disruptive, even painful, for those women suffering from it. PUPPPs can look very similar to another pregnancy related dermatological condition called pemphigoid gestationis. Pemphigoid gestationis is an autoimmune condition that can have harmful consequences for the unborn baby. It is therefore crucial for any rash seemingly similar to a PUPPPs presentation to be examined, and perhaps biopsied in order to rule out the potentially more harmful condition pemphigoid gestationis.

Causes

The exact cause of PUPPPs is unknown. Studies have eliminated the possible connection to carrying a male baby or fetal weight gain. PUPPPs is not associated with pregnancy hormones. PUPPPs occurs in 0.05% of pregnancies, about 1 in 200 total pregnancies. Women most likely to be diagnosed with PUPPPs are pregnant for the first time, or carrying multiples. One study suggests that excessive maternal weight gain is associated with the onset of the condition. Recurrence of PUPPPs is rare, meaning if it’s diagnosed during a first time pregnancy, it is not likely to happen in any future pregnancies.

Treatment

The most success in treating the rash is the application of topical ointments or creams containing a mild steroid. One study conducted by the Department of Dermatology at Columbia University found success treating PUPPPs with a 0.05% fluticasone lotion. Fluticasone is a mild corticosteroid. There were 57 patients in the study, all were pregnant women late in their third trimesters and suffering from PUPPPs. They applied the lotion to affected areas two times a day. The fluticasone lotion helped immensely to reduce the rash and relieve itching. Any steroids, topical or oral, should be discussed with a physician before starting.
Eliminating dairy from the diet can reduce the symptoms of the rash, although that has not been scientifically proven. Since the extreme itching and urge to scratch can disrupt sleeping patterns, oral antihistamines can aid in sleeping, but are considered not very helpful with relieving the actual itching sensations. General remedies for itching can help keep that particular symptom at bay for a short time. These include oatmeal bath soaks, applying coconut oil, and unscented moisturizers. These can reduce the appearance of the lesions and relieve itching. The hives do not scar on their own, although it may take several weeks for their appearance to fade. In order to prevent scarring, it is crucial to refrain from scratching the rash. Furthermore, scratching can create micro tears in the skin, allowing bacteria to invade and cause infection.

Management

There is no direct cure for the condition. This means that only the symptoms can be managed through mild or topical treatments. Since PUPPPs is a pregnancy related condition, the rash subsides or disappears completely shortly after the delivery of the baby. Other things that can be done to give temporary relief for general itching include bathing in soft water, avoiding bathing in hot water, washing with unscented bath products, pat or air drying the skin, drinking plenty of water, cold compresses on rash areas, and avoiding excessive sweating.

Although PUPPPs can be extremely uncomfortable, it is important to remember that the condition is benign. It is not dangerous to have, and does not pose a threat to mom or unborn baby. If it is experienced during the first pregnancy, it’s very unlikely to happen again in future pregnancies. There are several home remedies that relieve the intense itching, and a few options available through a doctor to help reduce the rash. General prognosis for PUPPPs is very good, it recedes completely within weeks of delivery and doesn’t leave scarring.