Postpartum Pruritic Urticarial Papules And Plaques of Pregnancy (PUPPP)

Introduction 

Postpartum Pruritic Urticarial Papules and Plaques of Pregnancy, a mouthful I know but known as PUPPP rash for short, is a common but very distressing condition that affects women's skin during or after pregnancy.¹ It is manifested as an itchy rash that usually develops around a woman's 3rd trimester or shortly after giving birth. The rash can be up to 1 cm in diameter, and small papules can fuse into larger plaques on the skin. Understanding PUPPP rash is very important for individuals that have been affected, healthcare professionals, and support networks to ensure that the correct support is given to alleviate its symptoms. In this article, we will be covering the causes, symptoms, common misconceptions, treatment options and prevention strategies for PUPPP rash. 

Causes of PUPP rash 

The exact cause of PUPPP is not fully understood, but several factors have been identified to contribute to its development. These include:

• Hormonal changes: a fluctuation in hormone levels during pregnancy, especially increased estrogen levels, progesterone and human chorionic gonadotropin (hCG) have been suggested to play a role in triggering PUPPP rash.² This level change can cause a disruption in your normal skin physiology and function. This imbalance may lead to changes in your skin barrier function, increasing the sebum production and altering your immune response. 
• Immune response: PUPPP rash is believed to be an immune-mediated condition, where the body’s immune system reacts in an abnormal way by reacting to certain triggers. Increased estrogen and progesterone can lead to inflammation and hypersensitive skin reaction³
• Fetal DNA exposure: some research has suggested that the exposure to fetal DNA, especially in women caring male fetuses can cause PUPPP rash. The detection of fetal DNA in a mothers circulation can trigger a response which leads to inflammation and skin reaction⁴
• Skin elasticity stretching: when there is an increased level of estrogen and progesterone during pregnancy it promotes stretching and elasticity of the skin to accommodate the growing fetus. However , this stretching can sometimes also lead to mechanical stress on the skin causing irritation and inflammation. The combination of skin stretching and hormonal changes can create an environment conducive to develop PUPPP rash.²

Symptoms of PUPPP rash 

PUPPP rash typically presents as a red, itchy rash that develops on the abdomen but can also spread to other areas of the body. Common symptoms of PUPPP rash include:⁵

• Intense itching: this is the most common characteristic of PUPPP rash is severe itching. It can be relentless and significantly impact the affected individuals’ quality of life 
• Raised, red bumps: PUPPP rash often appears as clusters of small, red, raised bumps or papules on the abdomen, resembling hives or insect bites  
• Spreading to other areas: the rash usually starts developing around the abdomen and has the potential to spread to other areas of the body, such as the thighs, buttocks, arms and breasts  
• Burning or stinging feeling: sometimes individuals experience a burning or stinging sensation in addition to the itching, especially when the rash has been aggravated by scratching or rubbing 
• Discomfort and irritation: PUPPP rash can cause lots of discomfort and irritation, making it difficult for affected individuals to sleep, concentrate or perform daily activities 

Common misconceptions of PUPPP rash

Despite its prevalence, there are several misconceptions surrounding PUPPP rash that can often confuse people and cause misunderstandings. Some of these misconceptions include:

• Poor hygiene or allergic reactions: while it's important to maintain good skin hygiene, PUPPP rash is primarily triggered by hormonal changes, immune responses, and other internal factors rather than external factors like hygiene or allergies 
• Contagious or poses a risk to the baby: PUPPP rash is not contagious and does not pose any threat to the foetus 

It is important to dispel these misconceptions and educate individuals about the true causes and nature of PUPPP rash to ensure accurate understanding and effective management of the condition. 

Treatment of PUPPP rash

While there is currently no cure for PUPPP rash, there are several treatment options available to help alleviate symptoms to give relief. These treatment options include:^6,7

Topical corticosteroids

Topical corticosteroids are commonly prescribed to reduce inflammation and itching associated with PUPPP rash. With these types of medication, it is applied directly to the area that is affected on the skin and provides significant relief from symptoms  

Oral antihistamines

Diphenhydramine and loratadine are oral antihistamines that can be recommended to help alleviate itching and reduce the severity of PUPPP rash. This medication works by blocking the effects of histamine, which is a chemical released by the body in response to allergens or irritants 

Cool compression

Applying cool compressions or taking cool, not cold showers/baths have been shown to soothe the skin and provide temporary relief from the feeling of itchiness and discomfort associated with PUPPP rash. Avoiding hot water is important because it can exacerbate your symptoms  

Oatmeal baths

Adding colloidal oatmeal to your bathwater can help in soothing inflamed skin and help relieve some of the itching sensation associated with PUPPP rash. Oatmeal contains compounds that have anti-inflammatory and moisturizing properties which make it an effective and natural at-home remedy that can be used to alleviate PUPPP rash 

Moisturizing

It is important to use fragrance-free, gentle moisturizers to ensure you keep your skin hydrated and prevent dryness, as this can cause excessive itching and irritation. Creams with menthol can provide relief from itching. Avoid any products that have harsh chemicals and additives as this can also irritate your skin further 

Avoiding triggers 

Identifying and avoiding triggers that worsen PUPPP symptoms, like tight-fitted clothes, hot showers, harsh soaps, etc can help in preventing flare-ups and managing the symptoms experienced 

Prevention of PUPPP rash 

Whilst preventing PUPPP rash may not be possible entirely, some strategies that can be employed to reduce the risk of developing the condition to minimize its severity. These prevention strategies include:⁷

• Good overall skin and body hygiene: practising good skin hygiene, like taking showers regularly, using fragrance-free soaps and gently patting the skin dry with a soft towel can help prevent major irritation and inflammation that can cause the development of PUPPP
• Regularly moisturizing skin: make sure your skin is constantly moisturized, especially the areas that are prone to PUPPP during pregnancy. This can help keep the skin hydrated and reduce the risk of developing PUPPP 
• Wearing loose-fitted clothes: wearing clothing that is loose and not fitted will allow the skin to feel more free and breathable. Wearing clothes made from cotton also helps prevent friction and irritation that may exacerbate PUPPP rash symptoms 
• Managing stress levels: high levels of stress may exacerbate PUPPP symptoms, so practising stress reduction techniques such as meditation, yoga and breathing exercises can all help promote relaxation and alleviate symptoms 
• Seeking medical help: when you notice any unusual changes or symptoms on your skin during pregnancy or after giving birth it is very important that you seek medical attention from your doctor. Early diagnosis and treatment of PUPPP rash can help prevent complications and relieve symptoms more effectively.

Summary 

PUPPP rash is a common but overly distressing skin condition that can affect women during and after pregnancy. While the exact cause of PUPPP rash remains unclear, hormonal changes, fetal DNA exposure, skin stretching and immune response are believed to play a role in its development. Common symptoms of PUPPP rash include intense itching, red raised bumps and a burning sensation. Prevention is better than cure although for PUPPP there is no way to prevent it. It's important to maintain good skin health, moisturize skin often, wear breathable loose-fitted clothes and manage stress levels.