What Is PUPPP Rash?

Pruritic urticarial papules and plaques of pregnancy (PUPPP) is the most common pregnancy-related itchy rash and is one of the most common diseases associated with pregnancy. Often looking like hives, the rash normally starts on the abdomen and then spreads to the surrounding area.

It most often occurs during the third trimester of someone’s first pregnancy and if carrying multiples (two or more babies). The rash is self-limited, which means that it will resolve on its own, usually between four and six weeks.

It is not harmful to the baby and causes no long-term harm to the pregnant person. Its cause is unknown but is thought to be linked to trauma related to skin stretching.

Pruritic means the skin will have an unpleasant sensation, giving you a strong urge to scratch the rash. Pruritus affects up to 20% of pregnant people and is most commonly caused by dry skin, but can also indicate an underlying condition unique to pregnancy, such as PUPPP.

It is also known as polymorphic eruption of pregnancy (PEP), toxaemic rash of pregnancy, toxic erythema of pregnancy, and late-onset prurigo of pregnancy.

Treatment normally involves oral antihistamines and topical steroids. In some cases, oral steroids are needed.

Signs and Symptoms

PUPPP rash typically starts in stretch marks on the abdomen during the third trimester. It begins with urticarial papules, which are small, red, itchy bumps. At this point, the rash may look like hives. Eventually, these small bumps can come together to form broad raised areas, called plaques, that are also very itchy.

While the rash starts on the abdomen, it tends to avoid the belly button. It may also spread to the buttock and thighs. However, it is rare for PUPPP to spread above the breasts, hands, or feet or appear on the face. Depending on how itchy the rash is, it may cause sufficient discomfort such that your ability to sleep is affected.

You are more likely to develop a PUPPP rash during your first pregnancy or if you are carrying multiples. It normally lasts between four and six weeks, independent of when you give birth. It will normally stop a few days after delivery. The most severe itching normally lasts for no more than one week.

Diagnosis of PUPPP

Diagnosis of PUPPP will be made by a healthcare professional and will be clinical, meaning it will be based on the appearance of the rash. Unless there are questions about the diagnosis, a skin biopsy will not be performed, but your healthcare provider may order blood tests to rule out other causes.

PUPPP can sometimes be confused with a more serious condition called pemphigoid gestationis (PG). PG is a rare autoimmune rash that occurs during the second and third trimesters. It affects one in 50,000 pregnancies.

Unlike in PUPPP, PG lesions usually start earlier in pregnancy and tend to cluster around the belly button. PUPPP may also be confused with other conditions such as atopic dermatitis and contact or irritant dermatitis.

Itching in pregnancy may also be due to cholestasis of pregnancy, in which the flow of bile from the gallbladder is slowed or stopped. This can lead to complications, including stillbirth or preterm birth.

Causes

The causes of PUPPP rash are unknown. However, due to the increased risk of it in pregnancy with multiples, it has been suggested that its development may be linked to the stretching of the skin on the abdomen.

Some studies have suggested a link with increased maternal weight gain during pregnancy, increased birth weight, and sex hormones, but these have not been proven. It is not associated with preeclampsia, autoimmune disorders, hormonal abnormalities, or fetal abnormalities.

Treatment

Treatment of PUPPP rash will focus on relieving the rash and reducing itching. The most common treatments are:

• Topical corticosteroids: These ointments are used to relieve itching and prevent the spread of the rash. They work to reduce inflammation and also suppress the body’s immune response. Once the rash is under control, your healthcare professional will likely recommend the switch to lower-strength corticosteroids.
• Oral antihistamines: These are generally less effective in treating symptoms than topical corticosteroids but may be useful for helping with side effects, such as if you are having trouble sleeping. Remember, not all antihistamines are approved during pregnancy.
• Oral steroids: These are generally avoided during pregnancy, however they may be necessary to treat severe cases.

If you have a serious case of PUPPP that is not responding to common treatments, your healthcare provider may explore alternative ways to treat the condition. In one case of postpartum PUPPP, where the rash occurred after birth, an intramuscular injection of autologous whole blood was used as an alternative treatment option.

Risk Factors

PUPPP rash occurs more commonly in a multiple pregnancy and during a first pregnancy. It does not usually return in subsequent pregnancies, except for those who are carrying multiples (in this case, it tends to be less severe than the first episode).

Other factors that might increase the risk of developing PUPPP include certain assistive reproductive technologies, however this has not been established.

A 2021 study, reviewing 517 in vitro fertilization pregnancies and 1,253 spontaneous pregnancies, found a higher rate of PUPPP among in vitro fertilization pregnancies, which were all single, than spontaneous pregnancies. Researchers also found that the duration of progesterone treatment was associated with the rash’s development.

Coping

PUPPP can be uncomfortable and is sufficiently severe enough to affect sleep and quality of life in some cases. This can be very difficult to cope with and may lead to or worsen depression. As well as getting treatment for PUPPP, you can also use coping strategies to help relieve symptoms.

Suggestions for coping with PUPPP include:

• Cool, soothing baths or showers: A cool compress may also help with symptoms.
• Avoiding scratching: Although it can be difficult, avoid scratching the rash when possible. Doing this will likely only make the rash symptoms worse.
• Frequent application of emollients: These work by adding moisture to the skin and preventing moisture from evaporating.
• Wearing light cotton clothing: This can help make sure the area of the rash is not irritated more than it is already.

A Word From Verywell

Experiencing an itchy rash during pregnancy, such as PUPPP, can not only be uncomfortable, but can also cause quite a lot of anxiety, especially if it is affecting your sleep.

It is important to speak to your healthcare provider if you have itching in pregnancy, because it can be associated with more serious conditions such as urticarial pemphigoid gestationis or cholestasis of pregnancy.

Remember that PUPPP will normally clear up within a month or so, and it is not dangerous for you or your baby. Speak to your healthcare provider if you have any concerns or need help with coping with your symptoms. They will be able to tell you the best way to manage the condition.