Introduction

As you are approaching your final weeks of pregnancy, getting ready to welcome your bundle of joy into this world, or you might have even given birth, when all of a sudden your skin chooses to rebel into intensively itchy, hive-like bumps. These red hive-like bumps often start around your stretch marks on your belly. Soon after they spread to your thighs, breasts or arms while sparing your face, hands, and feet. Caught by surprise, you may wonder what triggered this allergy, but if truth be told, this rash is not an allergy at all. It is known as PUPPP, (Pruritic Urticarial Papules and Plaques of Pregnancy) also referred to as PEP, which stands for Polymorphic Eruption of Pregnancy.² Despite being one of the most encountered skin conditions during pregnancy, it often goes unnoticed until it flares up. 

What is PUPPP?

PUPPP is one of the most common skin conditions in pregnancy. It is a benign, inflammatory, itchy skin disorder characterised by reddish, hive-like bumps and patches.² 

These red papules and plaques firstly start on the abdomen within stretch marks making their way over the thighs and buttocks.³ Sometimes, it may spread to the arms and breasts. It is highly unlikely that they appear on the face, palms, and soles.⁵

Who is affected by PUPPP?

It mainly affects women in the third trimester of their first pregnancy, in multiple pregnancies and less commonly in the period following childbirth.⁴ The pruritic lesions start in the 34 +/- 5 weeks of pregnancy or immediately after giving birth and often go away within 6 weeks after delivery.⁵ According to a study the reported occurrence is 0.5% in single pregnancies.⁴ Women carrying two fetuses have a higher risk of developing these lesions with 2.9% and the percentage rises to 14% in women carrying triplets.⁴

Risk factors

The exact cause of PUPPP is not yet fully understood, although there are a number of studies suggesting a few potential risk factors. First of all, there is a higher risk that pruritic urticarial papules and plaques of pregnancy appear in first pregnancies and in the ones where women carry multiples. This may lead to abdominal skin stretching as a result of rapid weight gain that is more significant in these situations. Also, rapid weight gain is another factor. 

Furthermore, one study shows that pruritic urticarial papules and plaques of pregnancy are a trauma response caused by damaged connective tissue within stretch marks. Stretching of the abdominal skin in the last weeks of pregnancy, occurring more frequently in multiple pregnancies may lead to damaged connective tissue.²

A hormone known as progesterone contributes to abdominal skin stretching.² Progesterone causes fluid retention and makes connective tissue looser. Additionally, levels of progesterone rise dramatically in the last weeks of pregnancy along with two other hormones - oestrogen and cortisol. Progesterone is known for its anti- inflammatory properties under normal conditions, but potentially its imbalance contributes to the rash worsening PUPPP.

Additionally, fetus DNA deposited in the third trimester, especially in the areas with high vascularity and damaged collagen on the mother’s skin, is considered a triggering factor for an immune response that later leads to rash. 

Prognosis after delivery

Pruritic urticarial papules and plaques of pregnancy (PUPPP) - even though it is an itchy rash, it is highly unlikely that it may cause harm to the mother and baby. It resolves spontaneously or after delivery usually over an average of 4 weeks. In the post-inflammatory stage, there is no change in the skin’s pigment or scarring of it.² One study shows that similar eruptions consisting of pruritic urticarial papules and plaques were found on a 19-year-old female and her newborn son.⁷

Recurrence in future pregnancies

Recurrence of polymorphic eruption of pregnancy in future pregnancies is uncommon, except in multiple pregnancies. Even in this case PUPPP tends to be milder than the first time it erupts.² Studies show that these lesions may recur in up to 5% of following pregnancies.⁶ 

Testing and results

This condition shows normal lab tests and negative DIF results.² Direct Immunofluorescence, also known as DIF, is a test that doctors use to rule out autoimmune diseases. This means that PUPPP is not an autoimmune condition. Also, PUPPP is not a medical condition for inducing labor early.²

Treatment and management

Most patients with PUPPP are treated only with medication to relieve symptoms. A combination of topical corticosteroids and oral antihistamines is usually prescribed and the majority of the individuals experience a satisfactory response. First generation antihistamines known for their sedating effect are considered safe during pregnancy and they can be used to provide relief from pruritic urticaria.²

In severe conditions of PUPPP with intense flare-ups where the patient is exhausted and has trouble sleeping, oral corticosteroids for a short period of time may be necessary. In addition, it is recommended to use other methods like cool, soothing baths and applying emollient creams frequently for more relief. Wearing light cotton clothes also helps.²

An alternative treatment for the symptoms of PUPPP is referred to as intramuscular injection of autologous whole blood.² This treatment involves drawing of venous blood from the person with PUPPP and then injecting it into a gluteal muscle that is located in the buttocks. It helps by calming intense itching from PUPPP. It is a very important treatment especially when the mother does not accept to take medication while being pregnant or breastfeeding. This treatment does not have any adverse effects on the mother, or the baby.³

FAQs

What is PUPPP?

Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP) is also referred to as Polymorphic Eruption of Pregnancy (PEP). This is one of the most common skin conditions in pregnancy that appears with an itchy rash, red hive-like bumps that appear in the third trimester of the pregnancy. It often starts in the stretch marks found on the abdomen and then it can spread to the thighs and buttocks. Sometimes it can spread on the arms and breasts.

Will PUPPP spread on my face?

It has been rarely seen on the face, palms and soles of feet, so most likely it won’t spread on your face.

What causes PUPPP?

It is still not known what causes PUPPP. However, it is believed that it is related to abdominal skin stretching due to rapid weight gain and hormonal fluctuations during pregnancy. It happens mostly in the first pregnancies, in women who carry multiple fetuses, and immediately after delivery. 

What are the treatment options for PUPPP?

The treatment is based on providing relief for the itchy rash. Topical corticosteroids and oral antihistamines are the most prescribed medications. Topical corticosteroids help with the inflamed skin because of the anti-inflammatory properties they have. Oral antihistamines alleviate the itchy rash. Cool baths are highly recommended for the symptomatic relief as well as emollient creams to provide soothing skin.

Can PUPPP affect my baby?

It is highly unlikely that PUPPP will affect your baby’s health. This is a condition that affects the mother’s skin posing no risks for the baby.

Will I get PUPPP if I get pregnant again?

The probability that PUPPP recurs in the following pregnancies is very low. Most women who get PUPPP in their first pregnancies won’t experience it in subsequent ones.

Summary

Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP) is also known as PEP - short for Polymorphic Eruption of Pregnancy. It is characterised by intensively itchy reddish papules and plaques that erupt in the last weeks of pregnancy and start spreading from the stretch marks on the abdomen to the thighs, buttocks and occasionally on the arms and breasts. This is one of the most common skin disorders that appears more in the first pregnancy, multiple gestation pregnancy or immediately after delivery. There are a few risk factors such as rapid weight gain, hormonal fluctuations, fetal DNA. PUPPP usually resolves within 6 weeks postpartum. Treatment is symptomatic. Doctors frequently prescribe topical corticosteroids and first generation sedative antihistamines. In case of severe PUPPP, an oral corticosteroids prescription may be necessary.