Introduction

What is a PUPPP rash?

Pruritic urticarial papules and plaques of pregnancy, also known as PUPPP rash, is a non-cancerous raised reddish coloured itchy rash that usually starts on the abdomen around the stretch marks as very itchy plaques and then can progressively involve the thighs, chest, arms and feet as well.¹

Pruritic urticarial papules and plaques of pregnancy (PUPPP), also called polymorphic eruption of pregnancy (PEP), is the most common skin condition that occurs during pregnancy.¹ PUPPP rash is a non-cancerous, self-limited skin condition that typically begins as intensely itchy, red, and raised patches on the abdomen near stretch marks. This may gradually spread to the thighs, chest, arms, and feet.⁷

It is the most common skin condition that occurs only during pregnancy, affecting about 1 in every 200 pregnancies.⁵

Who is most likely to develop PUPPP rash?

Who is more likely to develop PUPPP rash?

PUPPP rash mostly affects:

• First-time moms in the third trimester of pregnancy
• If it's a male foetus
• In twin or triplet pregnancies
• First-time mothers, especially during the third trimester
• Pregnancies involving a male baby
• Twin or triplet (multiple)  pregnancies¹

What causes PUPPP rash?

Causes of PUPPP

The exact cause is still not fully understood, and no specific immune or hormonal abnormalities have been identified.⁷ Several theories have  been proposed:

1. Abdominal enlargement - As pregnancy advances, your belly gets bigger and your cells can’t keep up, resulting in stretching of the skin. The underlying connective tissue damage leads to inflammation, leading to the initial appearance of stretch marks and a raised, itchy rash on the skin. This condition is highly frequent in twin or triplet pregnancies. As the belly expands during pregnancy, especially in twin or triplet pregnancies, skin can stretch faster than the body can adapt. This can damage the underlying connective tissue, triggering inflammation that appears as stretch marks followed by an itchy, raised rash 
2. Hormonal changes- When there is a rise in progesterone levels, it can lead to immune reactions, causing PUPPP rash. Increased levels of pregnancy hormones, particularly progesterone, can play a role by triggering an immune response that leads to the rash¹ 
3. When male foetal DNA is present in the mother’s immune system, it can induce PUPPP rash in the third trimester²  

During late pregnancy, small amounts of fetal material may enter the mother’s body and trigger an immune response, particularly in areas where the skin is already stretched or damaged. This may explain why PUPPP is more common in the third trimester and in pregnancies with male babies.⁹

How long does a PUPPP rash last?

Duration of PUPPP rash

PUPPP rash usually shows up in your last trimester of pregnancy and usually resolves within 4 to 6 weeks post-delivery.

It occurs mainly in the third trimester or shortly postpartum.⁷ Symptoms generally resolve within 7 to 10 days following delivery.⁵

Complications of PUPPP rash

Puppp rash can lead to short and long-term complications if left untreated:

• Short span effects
  1. Infections:- Secondary infections are caused by intense itching
  2. Sleep disturbance:- Extreme itching can interfere with sleep, leading to stress and tiredness
• Long span effects
  1. Changes in skin:- Continuous scratching can result in scarring and skin changes
  2. Psychological impact:- Itching can be annoying and cause discomfort, leading to stress, anxiety and depression in some women³

How does scratching break the skin barrier?

PUPPP rash alone does neither cause infection nor is contagious, but intense scratching can break the skin barrier, leading to bacterial invasion, causing secondary infections.

Warning signs

Watch out for:

• Rash that spreads rapidly
• Yellow discharge or crusting
• Inflammation and swelling
• Breathing difficulty
• Fever 

Seek medical advice if you notice the above symptoms.

How to manage PUPPP rash?

Your healthcare provider may suggest the following options:-

• Maintain the hygiene of the skin
• Topical corticosteroids
• Oral antihistamine pills
• Cool soothing baths⁶
• Apply non-allergenic fragrance-free moisturisers
• Wear light cotton clothes
• Cold compress for blisters and rashes⁴

In case of secondary infections, your healthcare provider would advise:

1. Wound care
2. Monitoring the wound
3. Oral or topical antibiotics

FAQ’s

Is PUPPP rash contagious?

PUPPP rash itself is not contagious. It does not cause any serious harm to the mother and fetus.

How is PUPPP rash diagnosed?

The doctor will do physical examinations and may also order some tests to rule out the skin condition. Tests include:

• Complete blood count
• Liver function test
• Serum hCG test
• Serum cortisol test
• Metabolic panel⁶

In addition, a skin test called direct immunofluorescence may be done to help rule out a similar condition called pemphigoid gestationis.⁶  

Summary

PUPPP (Pruritic Urticarial Papules and Plaques of Pregnancy) is an itchy, raised, reddish rash. It starts on the abdomen around the stretch marks and can then progressively involve the thighs, chest,arms and feet. It often appears in the third trimester, particularly in first-time mothers, and is more common in pregnancies involving male babies or twins. The exact cause is unknown, but the rash is thought to be linked to abdominal stretching, hormonal changes, and immune response.

While PUPPP is not harmful to the baby or mother, it can be very uncomfortable

PUPPP rash usually shows up in your last trimester of pregnancy and usually resolves within 4 to 6 weeks post delivery, but it can cause discomfort, sleep disturbances, and in some cases, skin infections if scratched excessively and the skin barrier is broken., 

Treatment includes cool baths, skin hygiene, topical steroids and oral antihistamines. Seek medical attention if there are signs of infection.