Introduction

PUPPP is the most common itchy skin disorder associated with gestational dermatosis. It is also known as “polymorphic eruption of pregnancy”. This inflammatory skin disorder is common in first-time pregnancies (primigravidas) and is reported in 14-20% of pregnancies.⁵ It typically develops during the third trimester of pregnancy, and its prevalence tends to decrease as the pregnancy progresses, becoming rare in subsequent pregnancies. 

Discovery

The condition was first described by Lawrence D. Holmes in 1979, who called it “toxic erythema of pregnancy.” The more familiar and catchy acronym PUPPP came later and has remained in use ever since ¹. The signs and symptoms reported by Lawrence D. Holmes included itchy red papules and plaques in pregnant women during the final weeks of pregnancy.

This condition does not typically cause any harm, so you and your baby are absolutely safe. Regardless of the lack of harm, hive-like itchy bumps and stretch marks can be very uncomfortable to experience. 

What causes PUPPP rash?

The cause of PUPPP is still unknown. There are quite a few theories revolving around PUPPP, but not all are accurate. Some suggest hormonal imbalances, such as high levels of estrogen and progesterone. Others believe it can be due to stretch marks. When your belly becomes too big, the connective tissues get damaged and can start an inflammatory process, leading to papule formation. Due to this, PUPPP rash is more common in pregnancies with twins or triplets, as rapid weight gain and abdominal expansion occur.

The rash does not occur in your second pregnancy because you have already built immunity against it in your first. Some of the causes of PUPPP Rash are:

1. Stretch Marks 
2. Twin or Triplet Pregnancy
3. High levels of sex hormones

Primary symptoms

The primary signs and symptoms that first-time mothers face during Pruritic urticarial papules and plaques of pregnancy are:³

• Intense Itching with small pink papules on the abdomen 
• Rash that spreads to the thighs, buttocks, arms, and legs
• Burning or stinging sensation 
• Irritability and Sleep Disturbance
• Eczematous Patches 

The small papules can merge and form larger vesicles encircled with pale halos. 

Common locations

It usually affects:

1. Abdomen 
2. Thighs
3. Arms 
4. Legs 

Diagnosis and evaluation

PUPPP is easily diagnosed as the disorder is symptomatic and is easily evaluated during the routine check-ups of the mother. However, the diagnostic procedure may follow:²

History and physical examination

The physician will ask for details about the onset of itching and take notes during the physical examination. He will rule out any underlying secondary disease.

Medical examination

The doctor might also run some tests to confirm the diagnosis, which might include:

1. Full blood count (FBC)
2. Liver Function Test
3. Serum hCG test

These tests will help rule out any other underlying skin disorders and confirm that you are specifically experiencing PUPPP.

Skin biopsy

If the diagnosis remains unclear, the next step may involve a skin biopsy, though this is considered a more drastic measure and is not typically necessary.

Differential diagnosis

Differential Diagnosis is done to rule out other conditions that might be causing PUPPP. The most crucial condition to exclude is “urticarial pemphigoid gestationis” which is an autoimmune disorder that occurs during pregnancy and has symptoms like hives and lesions similar to PUPPP.¹ One way to differentiate between the two conditions is that urticarial pemphigoid gestationis (UPG) typically has an earlier onset during pregnancy.

To rule out the chances of PG, your doctor will take a sample of your skin and perform a test called immunofluorescence. Both conditions can occur in your last trimester. But, PG accompanies Blister formation as well, while PUPPP is a normal rash with red papules and itching. 

Other than this, other conditions with somewhat similar symptoms may be:

• Eczema 
• Urticaria 
• Drug-induced reaction
• Contact Dermatitis
• Scabies

Therapy

Most of the time, the rash disappears on itself after a few days of delivery. In such cases, there is no need for medicinal therapy. However, symptomatic treatment can be prescribed to you for the itchiness, redness, and bumps. Medications considered first-line treatments, upon a doctor’s recommendation, include:

• Topical Corticosteroids, i.e., hydrocortisone, betamethasone, etc
• Oral antihistamines i.e. loratidine, cetirizine, fexofenadine, etc
• Emollients or creams to soothe the affected areas

In addition, there are a few home remedies you can perform:

• Cold Compress: Apply an ice pack to the affected area for 10-15 minutes, and it will provide a soothing effect
• Aloe Vera Gel: Soothes itchy and inflamed patches
• Avoid Hot Showers
• Always wear loose and baggy pieces of clothing
• Keep the affected area moisturised with any emollient

Prognosis: What’s the outlook?

The rash disappears after a few weeks or days of postpartum. Pruritic urticarial papules and plaques of pregnancy are oftentimes not harmful to your baby or you; however, one study has reported an increase in body weight of the newborn baby and the mother.⁴

In conclusion, the prognosis of this disorder is excellent. 

If you take into consideration and abide by a few rules, it can definitely get better. For example, taking a bath with cold water, using body wash that is odour-free and does not contain any irritants. 

The food that you eat can also have an impact on the stinging sensation as well as itching. Incorporate leafy green vegetables, fish, watermelon, cucumber, apples, and pears, as well as rice and oats. Some skin-friendly fats you can have are avocado oil, olive oil, and nuts. You should be encouraged to eat hydrating foods with anti-inflammatory properties.

What is PUPPP rash not?

PUPPP Rash can lead to papule formation, plaques, and itchiness, which can lead to emotional and physical discomfort, but it is not harmful in many ways: 

• Not contagious
• No long-lasting harm to you or your baby
• No blister formation
• Not harmful to the baby 
• Not Pemphigoid Gestationis: an autoimmune disorder involving blister formation
• Not a sign of poor hygiene

Summary

There are still many questions related to PUPPP that are still unanswered, but if you are suffering from this disorder, especially at the time when you are waiting for your baby the most, it can be frustrating. Nevertheless, there is no point in worrying because with the right diet, medication, and care, PUPPP Rash is very much reversible. 

PUPPP Rash is a very common skin disorder that often affects first-time mothers, particularly those experiencing a twin or triplet pregnancy. It occurs during the third trimester. The primary signs and symptoms include itching, stinging or burning sensations, papules, which later coalesce to form plaques around the abdomen, thighs, arms, or buttocks. 

The ideal management therapy is through symptomatic treatment via oral antihistamines, corticosteroids, and topical ointments or emollients. Home remedies should be performed to alleviate the discomfort. All sorts of irritants that may further aggravate the condition should be avoided. The prognosis of the condition is excellent. 

The condition usually resolves on its own after delivery and remains harmless for the baby and the mother. Another similar condition to this is pemphigoid gestationis, which can be differentiated from PUPPP by blister formation.