Overview

Pruritic Urticarial Papules and Plaques of Pregnancy, PUPPP for short, has been renamed recently to Polymorphic Eruption of Pregnancy, or PEP for short. It is a benign skin disorder that occurs during pregnancy. However, it is one of the most uncomfortable yet common skin conditions that affects expectant mothers, affecting 1 in every 130 mothers. Its onset typically happens during the third trimester and it manifests as plaques and hive-like itchy red bumps on the abdomen especially on stretch marks with a potential of spreading to other areas like the thighs, buttocks and occasionally the arms.¹ While being extremely uncomfortable and distressing, PUPPP rash poses no serious harm or complications to either the baby or the mother and it spontaneously clears up after delivery. 

Pharmacological treatment of PUPPP rash targets symptoms such as itchiness and redness as there is no specific cure, and this is because scientists have not figured out the exact cause. However, many people are turning to natural remedies in search of relief and to avoid any unintended complications that can accompany the use of pharmacological treatments. 

Whether you are currently battling a PUPPP rash or you’re pregnant and searching to understand it, in this quick read we will explore PUPPP rash more, how to diagnose it, and provide you with a guide to natural remedies that were proven to help in alleviating the distressing symptoms associated with it and how to use them.

Causes and triggers of PUPPP rash

The specific cause for the sudden onset of PUPPP rash during the third trimester is not fully known yet but it might be related to the development of stretch marks. However, nothing is proven yet, there are also a number of other speculations about what could be triggering it. There is an increased risk in people with first-time pregnancies, multiple gestations (pregnant with multiple foetuses), carrying a male foetus and a familial history of developing a PUPPP rash. Genetic, hormonal, and physical factors can play a part in developing it and here’s how:

Physical factors 

One of the first proposed reasons for PUPPP rash is the extensive skin stretching during pregnancy. The abdomen expands significantly as the baby grows which can damage the connective tissue, causing stretch marks to appear. Scientists assume that this damage can lead to allergic reactions to the areas of the skin affected.

Genetic factors 

Studies show that there might be a genetic predisposition to developing a PUPPP rash making certain individuals more susceptible. If there is a history of the condition in your family, the more likely it is for you to experience it. Additionally, scientists suggested that Foetal Chimerism (the disposition of foetal DNA to the mother which happens strictly during the third trimester) can trigger an immune response leading to inflammation and hives.

Hormonal factors 

The rapid fluctuation in the levels of certain hormones during pregnancy can be considered a trigger for the rash. People with PUPPP rash displayed higher-than-normal levels of progesterone and also increased sensitivity to it (especially people with multiple gestations).²

Other environmental factors 

Other triggers can exacerbate the condition like tight clothes, dry skin, some skin care products, and certain foods that may cause an allergic reaction. It’s important to consult with your healthcare provider to try and eliminate any of the environmental triggers.

Diagnosing PUPPP rash 

If you notice any rashes or itching on your abdomen while pregnant, the first step is to seek professional help. While PUPPP rash is relatively safe it should be differentiated from other pregnancy dermatoses that might pose a risk to you and your baby’s health. A PUPPP rash diagnosis is done through a clinical exam by your doctor, as biopsies and histopathology always offer non-specific findings.³

Your healthcare provider might still order a biopsy to eliminate any possible differential diagnoses which include: 

• Pregnancy eczema
• Drug reactions
• Pruritic Folliculitis
• Pemphigoid gestationis (a pregnancy-related herpes infection, which is the most dangerous as it resembles PUPPP rash in its early stages and poses a serious risk to the foetus)⁴

Management and natural remedies

There is currently no specific pharmacological cure for PUPPP rash and physicians mostly prescribe topical corticosteroids and antihistamines to help alleviate the painful symptoms. In some severe cases where the itching is intense and the patient is not responding to topical treatment, doctors might prescribe a short course of systemic glucocorticoids.

While antihistamines and corticosteroids are relatively safe during pregnancy, many expectant mothers are turning toward natural remedies to avoid any complications of pharmacological treatments and also because they only offer symptomatic relief which can be achieved through several natural remedies and proper management. The following are some general measures to follow: 

• Keeping your skin moisturised to increase its elasticity and avoid the development of stretch marks is an intervention you can make early on during your pregnancy
• Avoiding hot showers as they tend to worsen the itchiness and might increase redness, and cold compressions on the rash proved to provide patients with relief from the symptoms
• Wearing loose cotton clothes is a helpful way to not aggravate the itchiness and avoiding irritating fragrances in soaps and perfumes can also be helpful

Natural therapies and their effectiveness

Topical treatments

• Aloe vera gel: In a study conducted to compare the efficacy of aloe vera gel to Betamethasone (a corticosteroid medication), aloe vera was almost as effective as Betamethasone. A lot of people with PUPPP rash also reported that applying aloe vera gel provided a soothing relief to their symptoms⁵
• Coconut oil: It can be used as a moisturising agent to keep your skin nourished and elastic, and many people with PUPPP rash reported that it provided them with relief from itchiness and dryness. Others went further by saying that it cured their rash
• Oatmeal baths: Oatmeal is known to have anti-inflammatory properties and is considered to relieve the painful symptoms of many skin conditions. Taking baths with oatmeal can reduce inflammation and gently moisturise your skin

Dietary changes

During pregnancy, people make mindful decisions about their diets to maintain overall health for mothers and babies and to avoid any consequences. Here are some options that could aid in PUPPP relief and others that could worsen your condition:

• Foods to include: Hydration is very important for skin health. Drinking plenty of water and including hydrating foods, like watermelons and fruits is a great way to avoid stretch marks or to reduce the dryness accompanied by the rash. Nuts and cooked fish are great sources of Omega-3 which reduces inflammation and provides you with antioxidants that help your skin heal
• Foods to avoid: Processed food is known to cause inflammation in normal individuals and it can aggravate the inflammation, itchiness and irritation of PUPPP rash. Dairy and red meat can also be inflammatory foods for some people, so it’s better to listen to your body and avoid any food choices that can worsen your condition

Herbal remedies

Nourishing herbal teas were found to have a soothing effect, such as chamomile, dandelion root, peppermint, and nettle leaf teas. They all produce an anti-inflammatory, relaxing effect.

FAQs

How can I stop the PUPPP rash from spreading?

Unfortunately, you can not. Symptomatic management and keeping your skin properly hydrated and moisturised is the only way until it clears up on its own.

Is PUPPP rash considered an autoimmune disease?

No, there is no immune response involved in developing it.

How long does PUPP rash take to go away?

PUPPP rash usually resolves on its own within a week after delivery.

How does PUPPP rash start?

It starts with a few itchy bumps on your belly, especially in your stretch marks, and then it spreads and the sores become larger and more painful.

Summary

PUPPP rash, (Pruritic Urticarial Papules and Plaques of Pregnancy), recently renamed PEP (Polymorphic Eruption of Pregnancy), is a self-limiting and potentially harmless skin condition that affects people in the third trimester and it spontaneously clears up after delivery. It causes hive-like pumps and plaques in stretch marks on the abdomen accompanied by dryness, inflammation and itching. It also can spread to other areas of the body. The exact cause of its occurrence is still unknown, although it’s widely speculated that it has a connection to the appearance of stretch marks, among other genetic, hormonal, and physical factors. 

If you experience any rashes during pregnancy, seeking professional help is essential to ensure the right course of treatment and to exclude any differential diagnoses that might pose a bigger health risk. Doctors often prescribe antihistamines and corticosteroids to alleviate the uncomfortable symptoms. However, natural remedies can offer a similar soothing relief, as can lifestyle changes and being selective about your diet. It’s important to seek medical advice before trying any remedies at home. Whilst painful and uncomfortable, the right approach and management of PUPPP can offer you the symptomatic relief you’re searching for.