Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP), currently known as Polymorphic Eruption of Pregnancy (PEP), is a condition characterised by a rash that pregnant women may experience, especially during the last trimester of pregnancy.

Currently, limited evidence links diet to PUPPP rash. However, there is an increasing interest in using dietary approaches to aid in reducing symptoms and improving the quality of life of women affected by PUPPP. Well-planned dietary changes or adjustments that have been discussed with a doctor and/or nutritionist may provide an additional tool to manage PUPPP, while introducing no risk to the mother or the baby.

Below, you can read more to learn about PUPPP, its possible causes, its potential connection to diet, and some easy-to-implement dietary changes that may ease the time dealing with PUPPP.

What is PUPPP and what does it cause? 

PUPPP is the most common skin condition during pregnancy and consists of an itchy rash that usually starts on the belly within stretch marks. Typically, the region around the navel is spared.^1,2

PUPPP tends to progress into red and itchy plaques that could also spread to the lower belly, tights, and trunk. The face, palms, soles of the feet, genitals, and mucosas are usually not affected by PUPPP.^1,2

According to the British Association of Dermatologists, women who develop PUPPP usually are 

• first-time mothers²
• expecting a baby boy
• going through the last trimester of pregnancy
• experiencing a multiple pregnancy

PUPPP is very unusual during early pregnancy or after. However, some women may still experience it in those instances. 

Women who experienced PUPPP during their first pregnancy have a lower risk of it during their following pregnancies (less than 7% of cases), unless they have twins or a multiple pregnancy.^2,3

PUPPP causes bothersome symptoms, such as:²

• Small raised lumps (papules) 
• Large red inflamed areas of skin (plaques)

Depending on the severity of these symptoms, PUPPP may lead to difficulty focusing on daily activities, disturbed sleep, and depressed mood. Psychological distress is what usually takes new mothers to the doctor’s office.¹

Despite the big burden that PUPPP may be on pregnant women affected by it, it is harmless for them and the baby. On top of that, it usually resolves days or weeks after giving birth.¹

Is food linked to the development of PUPPP? can diet help? 

The cause of PUPPP is still unknown. However, experts think that the rapid belly growth and the inability of the skin to keep up may lead to internal skin breakage, which typically results in the well-known stretch marks. In some women, such skin damage may trigger an inflammatory response that manifests as PUPPP rash. 

Some of the following factors could contribute to it:^1,3

• Rapid weight gain to both the mother and/or the baby
• Rapid hormonal changes
• Multiple pregnancy

Experts think that the small wounds in the internal side of the belly skin may be more exposed than usual to molecules coming from the baby's placenta. As a result, the mother’s immune system may build a defensive response that worsens the skin inflammation.

In line with this, specific foods or diets may not have a direct role in the onset of PUPPP. It is also unlikely that any food is linked to the cause of PUPPP. This is why doctors rarely suggest dietary changes to tackle PUPPP and focus their efforts on prescribing anti-inflammatory creams, ointments, and antihistamines to alleviate the itchiness and skin inflammation.

However, the impact of diet on the way our immune system works and the level of inflammation it may cause is already well-known. In fact, an overwhelming number of studies show that diet may impact other inflammatory skin conditions, such as:^4,5

• Psoriasis
• Eczema
• Acne

In that sense, some of that knowledge may be easy to apply usefully for women affected by PUPPP.

Potential dietary triggers of PUPPP (What to avoid)

Diet is one of the main sources of external unknown molecules or antigens that turn our immunity on. That’s how our bodies remain clear of infections and abnormal cells.

Some specific types of foods also influence the level of inflammation our bodies have at baseline and in the face of a real and apparent threat (e.g. virus, bacteria, parasite, allergen). 

For example, people who follow a Western diet tend to have higher levels of chronic inflammation and may be more prone to chronic inflammatory diseases.⁶ In line with this, improving our diet may reduce our bodies’ inflammatory response and lessen the severity of inflammatory conditions, such as PUPPP.

A dietary improvement women with PUPPP may safely attempt is avoiding the following foods, which are known for worsening symptoms in inflammatory skin conditions:^4,5

• Refined sugars
• Processed foods
• Dairy
• Gluten

Multiple studies have documented the impact of these foods on the development and severity of inflammatory conditions in the skin and beyond it. However, it’s worth noting that:

1. Many nutrient-rich foods may contain gluten or dairy
2. Their harm and, thereby, the benefits of quitting their consumption depends on each person’s sensitivity and tolerance.

Considering that no dietary change should prevent the mother or baby from getting all the necessary nutrients for a healthy pregnancy and growth, it’s important to discuss any dietary change or restriction with a doctor before implementing it.

Anti-inflammatory foods for PUPPP

Just like some foods are associated with the development and severity of inflammatory skin diseases, some other foods may soothe their symptoms and support overall health, including:⁵

• Fibre-rich foods (e.g., leafy greens, brown rice)
• Healthy fats (e.g., olive oil, omega-3s, fish)
• Antioxidant-rich fruits (e.g., grapes, kiwi, oranges, guava)
• Fermented/probiotic foods
• Whole grains (e.g., chickpeas, green peas, lentils, kidney beans)

The exact mechanism for the benefits of these foods in inflammatory skin conditions is still a matter of research. However, some studies suggest they may improve immunity and tolerance towards external or unknown substances or molecules. As discussed before, this may reduce the skin’s inflammatory response against them and make it less prone to skin conditions like PUPPP.⁷

Practical tips for managing PUPPP through diet

• Eat plenty of fruits and vegetables every day, especially those that may reduce skin inflammation
• Avoid foods linked to other inflammatory skin conditions, such as refined sugar, dairy, processed foods, and gluten. However, any dietary change or restriction should first be discussed with a doctor
• Drink enough liquids during the day to keep the skin healthy and hydrated. Dry skin may feel itchy and be more likely to crack, swell, and become infected
• Work with a dietitian to get additional support when planning meals that provide all the necessary nutrients

When to see a doctor

• When planning any dietary adjustment, especially if it includes restricting one’s intake of a full food group (e.g. dairy)
• Unbearable discomfort, itchiness, and skin redness
• Disrupted sleep for several days
• When prescribed creams and antihistaminic drugs don’t provide sufficient relief

FAQs

Can PUPPP be cured with diet alone? 

While dietary adjustments may help improve and manage symptoms, they may not be enough to resolve PUPPP. Hence, it is important to discuss with a doctor what actions to take in addition.

How long until I notice improvements? 

Current evidence does not provide information on the impact of dietary changes, specifically on PUPPP. In consequence, it’s unknown how fast they may provide benefits.

Summary

• PUPPP rash is a bothersome but also harmless condition that some pregnant women may experience during the last stage of their pregnancy
• Research is still needed to determine the cause of PUPPP
• No evidence links diet with PUPPP being triggered or worsening. However, eating a balanced, anti-inflammatory diet that prioritises healthy foods may potentially help improve symptoms
• Any dietary change should be discussed with a doctor to guarantee sufficient intake of necessary nutrients for a healthy pregnancy