Introduction

Pruritic urticarial papules and plaques of pregnancy (PUPPP) is one of the most common skin conditions in pregnancy. Due to its broad clinical spectrum, it is now commonly known as polymorphic eruption of pregnancy (PEP),¹ with an incidence of 1 in 160 pregnancies.² It is usually evident in the first pregnancy during the third trimester and resolves after delivery. However, some women experience PUPPP in their late second trimester and the postpartum period. It is considered a benign and self-limited condition, unlikely to recur in a subsequent pregnancy, with symptoms typically beginning from the abdomen, specifically in an area with stretch marks.¹ PUPPP recurrence in subsequent pregnancies is infrequent. In a study of 57 patients, only 3 cases of recurrence have been observed.³

Causes and risk factors

The definite cause of PUPPP is unclear, although some suggest the involvement of abdominal skin overdistention and hormonal changes during pregnancy.¹ Some conditions are associated with PUPPP/PEP, such as first pregnancy, twin pregnancy, maternal excessive weight gain and maternal hypertension. Those conditions are mostly related to the distention of the skin tissue, which generates an immune reaction causing skin manifestations, particularly during the third trimester.⁴ Pregnant women carrying male fetuses might be at increased risk of developing PUPPP due to fetal cell migration to the maternal skin, which is likely to cause skin disorders in pregnancy.⁵ However, its significance still needs to be clarified.⁶

Common symptoms and characteristics

PUPPP most commonly originates in the striae area where the abdominal skin stretches. It begins with typically abrupt itching, followed by a rash or small lumps (papules) with the reddish, inflamed area (plaques) in the skin, sparing the belly button.⁷ Despite that, it can also happen in women without abdominal striae. The other areas of the lesions that develop outside the abdomen are the extremities.⁸ In the following days, it may spread to the buttocks and inner thigh, even generalise to other body parts, including the trunk, under the breasts and extremities. Areas of the face, head, genital area, palms and soles are rarely involved. In a few cases, patients can present with red patches, eczema or target-like lesions with dark centres and paler surrounding areas, with or without vesicles^9,10. There may be small blisters, which, if scratched, will omit fluid.¹

Treatment options

PUPPP is a mild and self-limiting condition that has no considerable consequences for mothers and fetuses. Patients with PUPPP are commonly treated symptomatically, mainly to reduce the itch.⁶ Injection of autologous whole blood is a proposed alternative treatment method for PUPPP occurring postpartum.¹¹

General measures

In treating PUPPP, the focus is on soothing the skin and reducing the symptoms of itch. Several simple methods can be considered before or in conjunction with taking medications, as follows:

• Avoid scratching
• Taking cool baths
• Wearing light cotton clothing
• Applying antipruritic menthol lotion, emollients, calamine lotion, and 
• Cold compress, if needed

Those are the suggested initial measures to relieve pruritus.¹² Trying not to scratch itchy skin is challenging, but scratching can further irritate the skin and promote the entry of an infecting agent into the skin's surface. Instead, pat it lightly while applying moisturisers at regular intervals. A cool bath can help reduce inflamed skin and provide a soothing effect, while emollients and lotion assist in keeping the skin moisturised and improving the skin barrier in an overstretched state. Light cotton clothing is suggested to minimise friction to the skin while absorbing sweat and maintaining adequate air circulation.

Prescribed medications

Some treatment choices, such as oral antihistamines and topical or oral corticosteroids, are proven to relieve itch symptoms. Antihistamines and corticosteroids are generally safe to use in pregnancy as long as they are used according to the prescribed dosage by physicians. Always consult your medical provider before taking the medications.

Antihistamines

Administering first-generation antihistamines with soothing properties, like pheniramine, seems to be a safe option during pregnancy. Given their classification as category A drugs, they can serve as supplementary therapy for PUPPP, offering relief from intense pruritus that may occasionally disrupt sleep and contribute to maternal exhaustion.¹¹

Corticosteroids

Most symptoms can be effectively managed with a topical corticosteroid cream. Oral corticosteroid is considered when topical corticosteroids prove ineffective or when lesions are extensive. This oral corticosteroid treatment leads to a prompt resolution of symptoms and the eruption. Although using oral corticosteroids in this manner during the later stages of the third trimester of pregnancy seems to have minimal adverse effects on the pregnancy, it is seldom necessary. It should only be considered if symptoms of unrelenting itch persist despite intensive topical therapy.⁶

Prevention strategies

Preventing itchy skin

To help prevent itching, the American Academy of Dermatology Association¹³ recommends the following tips:

1. Avoid hot water and limit shower time to no more than 10 minutes, as hotter water and longer bath duration will dry the skin
2. Use "fragrance-free" toiletries to minimise the risk of skin irritation caused by the added fragrant chemicals.
3. Apply medications advised by the medical provider before moisturising, followed by applying the moisturiser to all areas of the skin
4. Wear loose and cotton clothes to reduce skin friction and prevent irritation
5. Prevent drastic temperature fluctuations and keep your home environment cool with neutral humidity. If you experience dry skin and eczema, consider using a humidifier, especially during winter
6. Minimise stress, as it is associated with an increased level of inflammatory chemicals in the body, which can cause more intense itch and irritation

Lifestyle adjustment

As one of the possible risk factors for PUPPP is maternal excessive weight gain during pregnancy, keeping a recommended weight gain can be considered. Normal weight gain is said to be within 10 to 12.5 kilograms (22-28 lbs) during pregnancy. Inadequate weight gain can lead to a malnourished state of the mothers and babies. In contrast, excessive weight gain, in addition to the risk of developing PUPPP, can result in more morbid conditions such as gestational diabetes and preeclampsia.

Choosing healthy food and regular physical activity, particularly exercising appropriately for one's pregnancy condition, can help maintain proper weight gain.

Home remedies

Some of the natural remedies can be considered for their moisturising, cooling and soothing effects, such as:

• Aloe vera

Aloe vera can be used as a gel. It is well known for its active components, which prevent inflammation and infection, promote skin protection, and heal wounds.¹⁴

• Coconut oil

It can be applied to all body parts or focused on the lesions for comfort. Coconut oil has been reported to be safely and effectively used as a moisturiser to treat xerosis, a dry skin condition.¹⁵

• Olive oil

Olive oil is famous for its phytochemical content, which helps heal wounds and manage some skin diseases.¹⁶

• Oatmeal

With its various properties, including anti-inflammatory, antipruritic, and barrier repair, oatmeal in colloidal form in a cream has been proven to enhance skin microbiome composition and improve the skin barrier in dry, itchy, and inflamed skin.¹⁷

Psychological support

While PUPPP is a common and mild skin disorder in pregnancy, managing the rash is more than treating the skin. It also involves supporting mental well-being. The increased level of stress will impact the disease progression. Some approaches include deep breathing or meditation to ease anxiety, connecting with others to share experiences and gain practical advice, keeping positive thoughts and self-compassion, and always remembering that this is temporary. If it gets tougher, look for advice from a professional. 

Importance of seeking medical advice

If blisters or more intense symptoms are evident, seeking advice from the dermatologist or obstetrician is highly advised as PUPPP can resemble an initial stage of another serious skin condition in pregnancy which may require different treatment approach for mothers and babies. There have been cases of PUPPP suggested as a toxaemic rash of pregnancy in a report, which may be related to an increased risk of fetal adverse effects.¹⁸ Still, another newer study¹² has found that fetal prognosis is normal in PUPPP. In severe cases, collaborative management between the dermatologist, obstetrician and neonatologist is needed.⁶

FAQs

What does PUPP look like?

It appears initially as intense, itchy bumps and plaques in the abdomen but can spread to other body parts.

What causes PUPPP?

Stretching of the skin, hormonal changes, and immune response are suggested to be involved in the disease's progression. However, the exact cause remains unclear.

Does PUPPP have consequences for the baby?

PUPPP is typically a mild, self-limiting disease with no profound significance to the mothers and the babies.

How long does PUPPP last?

Some cases will resolve shortly after delivery but can last up to 4-6 weeks, independent of delivery.

How do you manage PUPPP?

Managing PUPPP can be done by taking cool baths or cold compresses, wearing light cotton clothing, applying lotion and emollients, and taking prescribed medications such as antihistamines and corticosteroids (topical or oral regimen).

Summary

PUPPP, an itchy rash usually arising from distended abdominal skin, is well-recognised and specifically associated with pregnancy. It is crucial to emphasise that the condition is typically mild and self-limited, rarely recurs in subsequent pregnancies, and does not pose any increased risk to the fetus or the mother. Adjunctive to prescribed medications such as antihistamine and corticosteroids, treatments also include:

• cool baths
• wearing cotton clothing
• applying lotion and emollient, and
• taking prescribed medications such as antihistamines and corticosteroids (topical or oral regimen)