Introduction

Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP) is a painful and itchy rash, which often appears later in pregnancy. It is sometimes referred to as polymorphic eruption of pregnancy in other parts of the world, such as Europe, and about 1 in 200 pregnancies are affected worldwide.¹

The good news is that PUPPP usually resolves on its own after the baby is delivered, even though its exact cause is unknown.¹ According to research, PUPPP is probably caused by a combination of factors, including high blood pressure, excessive stomach stretching, pregnancies where the mother gives birth to multiple babies at once, such as twins or triplets, and weight gain whilst the mum is pregnant.² 

We know that PUPPP frequently happens in the third trimester; this could be because the woman gains weight at this time due to the baby's rapid growth. The rash normally starts as a raised, red, itchy, hive-like patch on the stomach, but it can also spread to the upper thighs and buttocks. After the baby is born, the rash usually fades away.²

It's critical to know about PUPPP since it can be extremely uncomfortable, disrupt sleep, and raise anxiety in pregnant moms who may be concerned about the health of the unborn child. Recognising the risk factors of PUPPP and knowing how to manage them can help reduce stress and improve quality of life during pregnancy. In this article, we will explore what PUPPP is, its possible causes and treatment options to help expectant mothers better understand and manage this condition.

Risk factor 1: First pregnancies 

According to research, 70% of pregnant women with PUPPP were in the later stages of their pregnancies, and 88% of them were expecting their first child.

 PUPPP does not endanger the child, despite the fact that it may cause discomfort for the mother. However, women who are pregnant for the first time are more prone to having this condition.⁴ The cause of this is not entirely clear. 

Some scientists suggest that the immune system is responsible for PUPPP, while others think that hormonal changes during pregnancy may be the culprit. Since this is the first time the abdomen has become this enlarged, it could produce an immunological reaction if it keeps swelling and distending.² The distension theory states that when a pregnant woman's abdominal wall distends for the first time, it causes tissue damage and therefore an inflammatory response.^2,3

Risk factor 2: Carrying multiple babies

The risk of having PUPPP is much higher in women carrying multiples (such as twins, triplets, etc). This is because of the uterus's larger size as it is carrying more than one baby, resulting in the mum's skin stretching more and at a faster pace. Because the body tries to adjust to having more than one baby during these pregnancies, the abdomen frequently expands more rapidly and faster than it would during a pregnancy with only one child.⁵

The inflammatory response that may underlie PUPPP could be triggered by the increased risk of skin and tissue irritation brought on by this additional straining. Additionally, some medical professionals think that the elevated hormone levels in several pregnancies may be a factor. Twin or triplet pregnancies frequently have higher levels of pregnancy hormones, which can exacerbate the skin's reaction.⁶

Risk factor 3: Rapid abdominal growth

Rapid growth of the abdomen, which often occurs in the third trimester, is the third significant risk factor for PUPPP. The skin and connective tissue of the abdomen may get overextended as the uterus swells and the baby grows rapidly. The itchy, hive-like rash may result from the microscopic rips and inflammation caused by this straining beneath the skin. A large baby or high weight gain during pregnancy are common factors for women who develop PUPPP. The skin stretches more quickly than usual in each of these circumstances. Fast growth is a major factor, as evidenced by the fact that more than 70% of women who receive PUPPP develop it in the third trimester.⁷

Implications for treatment

Pregnancy becomes more uncomfortable due to the severe itching of PUPPP, even though it poses no threat to the child. Early identification of the risk factors can help your healthcare team identify the rash early and provide symptom-relieving medications. Topical steroids, antihistamines, and calming lotions are common forms of treatment. Oral steroids could be recommended in extreme circumstances. Treatment usually focuses on comfort rather than curing the illness because the rash normally fades away after birth.⁸

FAQs

What is PUPPP rash?

The acronym PUPPP represents Pruritic Urticarial Plaques and Papules of Pregnancy. This itchy rash typically shows up during the third trimester of pregnancy. Usually beginning on the abdomen, it might extend to the lower legs, thighs, and bottom. Despite being uncomfortable, it normally fades away after giving birth and poses no risk to either you or your unborn child.¹

Who is most at risk for PUPPP?

PUPPP is prevalent in:

• Initial pregnancies
• Women having triplets or twins
• Pregnancies in which the abdomen grows quickly or significantly

Each of these elements causes additional skin stretching, which could irritate the tissue and cause a rash.¹

Why does PUPPP happen in first pregnancies?

During a first pregnancy, your body is adjusting to abdominal stretching for the very first time. This can cause small tears or irritation in the skin and connective tissue, possibly triggering an inflammatory reaction that leads to the rash.⁷

How does carrying multiples increase the risk?

When you're pregnant with twins, triplets, or more, your uterus expands more than usual. This stretches your skin more quickly and more dramatically—a key factor believed to contribute to PUPPP. Higher hormone levels with multiples might also play a role.⁵

What does rapid belly growth have to do with PUPPP?

The faster your belly grows — whether from weight gain, a large baby, or multiples — the more your skin is stretched. This sudden stretching can stress your skin and lead to inflammation, which may cause or worsen the PUPPP rash.⁷

How do I determine whether I have PUPPP?

In the third trimester, if you observe:

• Red, itchy pimples or hives next to stretch marks
• Rash that spreads to your arms, buttocks, or thighs
• High levels of itching without any other signs of sickness

If you exhibit these symptoms, you might have PUPPP. To confirm and rule out other skin disorders, it is advisable to have your doctor check it.²

Will my infant be harmed by the rash?

No, although PUPPP causes discomfort for you, it poses no threat to your unborn child.⁸

Does PUPPP disappear by itself?

Yes. After delivery, PUPPP usually goes away in a few days to weeks. If you continue to develop a rash a few weeks after giving birth, please contact your doctor or midwife.⁸

What can I do to get relief?

Treatments focus on managing the itching:

• Cool baths and moisturisers
• Topical steroid creams (with a doctor’s advice)
• Antihistamines for itch relief
• Loose clothing to reduce skin irritation

Always check with your doctor before using any medication, especially during your pregnancy.⁸

Can PUPPP happen in other pregnancies, too?

It’s less common in second or third pregnancies, but it can happen, especially if you're carrying multiples or experience a lot of belly growth again.¹

Summary 

Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP) is a painful and itchy rash that develops later in pregnancy. There are three main risk factors for PUPPP, and all the risk factors mentioned can also overlap. For example, a woman who is pregnant for the first time and carrying twins is at a significantly higher risk of developing PUPPP, and the growing stomach is common in both first pregnancies and multiple gestations. When a woman has several of these risk factors together, the likelihood of developing PUPPP increases. This overlapping of risk factors makes it difficult to find the single cause, but it also helps explain why the condition appears more frequently in certain groups of women. Treatment is often symptomatic rather than treating the underlying condition, as the rash often goes away on its own after birth.