Introduction

Pregnancy brings many changes to the body, from increased heart rate to altered sleep patterns. The skin is particularly affected, with more than 90% of pregnant women experiencing some type of skin change.¹ While many expect stretch marks or darkening of the skin, the sudden appearance of an itchy rash can be alarming.

One such condition is pruritic urticarial papules and plaques of pregnancy (PUPPP), also called polymorphic eruption of pregnancy (PEP). PUPPP is harmless to both mother and baby, but it can cause significant discomfort and distress.²

Definition and Epidemiology

PUPPP is a benign skin condition that usually develops in the third trimester of pregnancy, though in some cases it appears shortly after delivery.³

It affects about 1 in 160–300 pregnancies (0.3–0.6%).⁴ First-time mothers and women carrying twins or triplets are at higher risk. Other possible risk factors include:

• Significant abdominal stretching
• Multiple pregnancies
• Caesarean section delivery
• Carrying a male baby (suggested in some studies)⁵

Although the rash looks worrying and can be intensely itchy, it does not harm the pregnancy. Treatment focuses only on managing symptoms.

Clinical presentation

The main symptom of PUPPP is severe itching. The rash usually begins in stretch marks on the abdomen and appears as red, raised bumps or hive-like patches that can merge into larger areas.⁶

Typical features include:

• Rash starting in stretch marks on the abdomen
• Spread to thighs, buttocks, breasts, and sometimes arms and back
• Sparing of the area around the belly button (periumbilical region)
• No involvement of the face, palms, or soles⁷
• Itchiness that is often worse at night, leading to sleep problems
• No blisters or large fluid-filled spots

Importantly, PUPPP does not cause systemic symptoms such as fever, high blood pressure, or liver problems. Blood tests, if done, are usually normal.

Differential diagnosis

Because several pregnancy-related skin conditions can cause itching, PUPPP must be distinguished from others:

• Pemphigoid gestationis – begins with itchy red patches but later develops fluid-filled blisters, often around the belly button. Diagnosis requires a skin biopsy and immunofluorescence⁸
• Intrahepatic cholestasis of pregnancy (ICP) – causes intense itching, especially on the hands and feet, but usually without a rash. Blood tests show raised bile acids
• Atopic eruption of pregnancy – appears earlier (first or second trimester), often in women with eczema or a family history of atopy. Rash usually affects arms and legs
• Other causes – such as scabies, viral rashes, or rare conditions like pustular psoriasis of pregnancy

Diagnosis

Diagnosis of PUPPP is usually clinical, based on:

• Rash starting in stretch marks in late pregnancy
• Sparing of the area around the navel
• Absence of blisters or mucosal involvement
• No abnormal blood test results^2,7

Skin biopsy is rarely needed, but when performed, it shows nonspecific inflammation without the immune deposits seen in pemphigoid gestationis.

In practice, a careful examination and exclusion of other conditions are usually enough for diagnosis.

Management and treatment

PUPPP is benign and self-limiting, so treatment is aimed at relieving symptoms.

First-line measures:

• Regular use of moisturisers and emollients
• Oatmeal baths for a cooling effect
• Mild to moderate strength topical corticosteroids (e.g. triamcinolone 0.1% or desonide 0.05%) applied 2–3 times daily⁴

For itch relief:

• Non-drowsy antihistamines (loratadine, cetirizine) are safe for use during pregnancy
• Sedating antihistamines (diphenhydramine, chlorpheniramine) may be given at night to improve sleep²

In severe cases:

• Short courses of oral corticosteroids such as prednisolone (0.5–1 mg/kg for 1–2 weeks, then tapered) may be prescribed
• Narrowband UVB phototherapy may be considered in resistant cases and is regarded as safe in pregnancy⁸

All treatment decisions should be guided by a doctor or midwife.

Prognosis

The outlook for PUPPP is excellent. The rash usually resolves within 2–6 weeks after delivery, often sooner in mild cases.⁶

Key points about prognosis:

• No scarring or skin damage remains once the rash resolves
• Recurrence in later pregnancies is uncommon, though it may happen in about 15% of women⁷
• PUPPP has no effect on the baby – pregnancies progress normally, with healthy infants and no increased risk of complications²

FAQs

What causes PUPPP rash?

The exact cause is unknown. It is thought to be linked to stretching of the skin in late pregnancy, particularly in first-time mothers or women carrying twins or triplets. Hormonal changes and immune responses may also play a role.

Does PUPPP rash affect my baby?

No. PUPPP is uncomfortable for the mother but does not harm the baby. Pregnancies affected by PUPPP progress normally, and babies are healthy at birth.

How is PUPPP diagnosed?

Doctors usually make the diagnosis by examining the rash and taking a history. The typical signs include red, itchy bumps starting in stretch marks, sparing the belly button area, and appearing late in pregnancy. Blood tests are usually normal, and special tests are not often needed.

How can I relieve the itching at home?

Moisturising creams, cool baths (such as oatmeal baths), and wearing loose cotton clothing can help. Some women also find that keeping the skin cool reduces irritation. Always check with your midwife or doctor before using any creams or medicines.

Will I get PUPPP in future pregnancies?

Most women do not develop PUPPP again. Recurrence is uncommon, but if it does happen, it is usually milder than the first time.

Summary

PUPPP is a common, harmless skin condition of pregnancy, most often seen in first-time mothers during the third trimester. Its hallmark is an intensely itchy red rash that begins in stretch marks, spares the belly button, and does not affect the face, hands, or feet.

Diagnosis is clinical, based on careful examination and exclusion of other pregnancy rashes. Management focuses on comfort through moisturisers, topical steroids, and antihistamines, with stronger treatments reserved for severe cases.

The condition clears after delivery and has no impact on the health of mother or baby. With reassurance and symptom relief, women can expect full recovery and normal pregnancy outcomes.

Key points

• PUPPP is a benign pregnancy rash, most common in first-time mothers
• It appears in stretch marks on the abdomen and spreads but spares the belly button
• It causes severe itching but no harm to the pregnancy
• Diagnosis is clinical; no special tests are needed
• Symptoms can be managed with moisturisers, corticosteroids, and antihistamines
• The rash resolves within weeks after delivery