Overview

Pruritic urticarial papules and plaques of pregnancy (PUPPP), also referred to as polymorphic eruption of pregnancy (PEP), is the most prevalent skin condition during pregnancy. It is a harmless, itchy, inflammatory skin condition with a varied appearance and normal lab results with a negative direct immunofluorescence. PUPPP commonly impacts first-time pregnant women in the last three months of their pregnancy. It occurs less often right after giving birth and does not tend to happen again in future pregnancies.¹

Risk factors

PUPPP typically appears towards the end of pregnancy, usually in the third trimester around week 35. Though not as frequently seen, puppp rashes may occur soon after giving birth. Polymorphic eruption of pregnancy affects approximately 1 out of every 160 pregnancies. Risk factors include:

• First pregnancy (less common in later pregnancies)Lighter skin tone
• Excessive weight gain or multiple births (such as twins or triplets)
• Male foetus increases risk compared to a female foetus 

Causes

The specific reasons for PUPPP are still unknown, but different hypotheses have been suggested. The prevailing theories suggest that rashes tend to appear in stretched areas of the skin, like the abdomen, which expands significantly during pregnancy. The increased blood vessel formation and compromised collagen in the skin may lead to an immune inflammatory reaction, causing the development of the PUPPP rash.

It is important to mention that approximately 90% of the time, the rash appears close to regions containing impaired connective tissue, such as stretch marks. The hormonal shifts that happen while pregnant might also play a role in causing the PUPPP rash to develop. Many people with PUPPP rash have been found to have elevated progesterone levels.

Finally, foetal DNA may be a causative factor in the onset of PUPPP. Some theories suggest that the presence of foetal DNA, particularly from male foetuses, on the mother's skin, particularly in the third trimester, may be linked to PUPPP.

It is also unknown how lesions spread to other parts of the body. The skin irritation is uncommon in later pregnancies, perhaps because of a more robust reaction from the body's defense system.¹

Symptoms

PUPPP rashes appear very similar to hives. Here are a few indicators that you might be experiencing PUPPP:

• Raised patches of skin or a rash on or around stretch marks on your belly causing scattered, itchy bumps to appear
• The rash extends to your thighs, buttocks, chest, and arms
• The rash is absent in the perimeter around your navel
• On skin with lower levels of melanin, the bumps or patches might appear pink or red
• On skin with increased melanin, the bumps or patches might have a similar hue to your skin or a deeper tone than your skin tone

The itchiness of your rash hinders your ability to concentrate on daily tasks and disrupts your sleep routine

Diagnosis 

PUPPP is frequently identified by excluding other possibilities, so doctors may conduct lab tests to eliminate other skin conditions. Possible lab tests include:

• Complete blood count
• Liver function test
• Metabolic panel
• Serum cortisol test
• Serum hCG test

Other specific tests that might be necessary are checking the serum for indirect immunofluorescence or biopsying the lesions for direct immunofluorescence to diagnose pemphigoid gestationis (a skin-blistering autoimmune disease which develops during pregnancy). Skin biopsy results, if done, show non-specific alterations with inflammation surrounding blood vessels, spongiosis (swelling of skin cells and fluid accumulation), and the existence of eosinophils (specialised white blood cells). In PUPPP, direct immunofluorescence testing with special stains to detect antibodies against specific skin structures typically yields negative results.

Differential diagnosis

Identifying and ruling out urticarial pemphigoid gestationis is crucial. Special staining tests done on the skin tissue are required to differentiate between these two disorders due to the potential overlap in clinical features. In pemphigoid gestationis, lesions typically appear earlier in pregnancy and commonly affect the umbilicus (navel), in addition to showing positive immunofluorescence of the skin surrounding the lesions. 

Eczema is usually seen in patients with a personal or family history of atopy (predisposition to allergies and asthma), and it presents with itchy red lesions on the body's flexural areas (areas that bend with motion). Possible skin reactions like drug eruptions, hives, or viral rashes are also considered in the clinical differential diagnosis.¹

Treatment

The typical duration of PUPPP is four to six weeks. Typically, it will naturally resolve within a few days to a few weeks after the birth of your baby. While you are waiting for your rash to go away, you can use medication and home remedies to relieve your symptoms.

Home remedies

• Soaking in baths with oatmeal
• Having cool baths or showers
• Using moisturiser without fragrance
• Dressing in comfortable, breathable garments made of cotton fabric
• Applying cold packs to your bumps or rash

Medications

• Anti-itch creams
• Antihistamine pills
• Corticosteroids

Antihistamines and corticosteroids typically provide relief from itching within one or two days.

Other treatments include dietary changes

Foods to avoid 

The severity of the PUPPP rash is influenced significantly by one's diet. If you have this condition, it is essential to be mindful of your diet. Certain food options can significantly affect the degree of discomfort felt.

Sugar

Unhealthy foods are those that are high in sugar and have a high glycemic index. They can be particularly harmful to individuals with PUPPP rash. Consuming these foods can lead to increased inflammation within the body. This can cause the skin to become more itchy and irritated. The rash, already unpleasant, has the potential to worsen significantly.

Dairy

A lot of individuals incorporate dairy items into their everyday meals. Yet, these foods can lead to discomfort for those with PUPPP rash. Some individuals may experience sensitivity due to hormones or allergens found in dairy products. If someone is sensitive, consuming dairy products could worsen their skin issues. Identifying and steering clear of these triggers is crucial for controlling the symptoms.

Processed foods

PUPPP rash has been associated with the consumption of processed food. Additionally, processed foods, which are frequently convenient and easily accessible, present another danger. They often contain additives and preservatives that may worsen inflammation within the body. Inflammation may cause the skin to become more sensitive. This could lead to the PUPPP rash becoming more intense.

Red meat

Finally, red meat is well known for its significant levels of saturated fat. Despite being high in protein and nutrients, its connection with inflammation is widely acknowledged. Individuals suffering from PUPPP rash may opt to reduce their consumption of red meat. This could potentially decrease inflammation and alleviate the symptoms of the rash.

Understanding the impact of diet on their condition enables individuals to make decisions that may reduce the severity of their symptoms. This could result in increased comfort during a challenging time.

Positive modifications to one's diet are advantageous.

Changing your diet is a method for treating PUPPP rash during pregnancy.

Fish, flaxseed, and walnuts

Increase your consumption of fish, flaxseed, and walnuts. These foods have high levels of omega-3 fatty acids. They benefit your skin. They are also able to decrease inflammation within your body.

Fruits and vegetables

A selection of different fruits and vegetables is set out on a table.

Hydration

It is also important to ensure you maintain good hydration levels by consuming sufficient water. Maintaining proper hydration supports skin health, reduces itchiness, and prevents scratching. Additionally, consuming fruits and vegetables high in antioxidants can aid in healing your skin from the rash.

Prognosis

Other than the itchiness of a rash, the mother's outcome remains unaffected. Intractable pruritus (itchiness that cannot be relieved) is not often treated with early delivery. Foetal health is not at risk and newborn skin is typically unaffected. Reoccurrence of the eruption in future pregnancies is rare, except in cases of multiple pregnancies. In this situation, PUPPP is typically not as serious as the initial episode.¹

FAQs

Can scratching PUPPP cause it to spread?

While scratching doesn't cause PUPPP to spread, it can exacerbate the itching. Make an effort to avoid scratching. Discuss with your provider about safe methods to alleviate the itching, such as natural treatments, lotions, and corticosteroids.

Is it possible for PUPPP to trigger early labour?

PUPPP does not lead to early onset of labour. It does not indicate labour is occurring. The rash goes away once the baby is born.

Does PUPPP get worse during the night?

Indeed, the PUPPP rash can cause intense itching during the night and interfere with your ability to sleep. Inquire with your doctor about anti-itch creams.

Can a PUPPP rash cause permanent marks on the skin?

Typically, the PUPPP rash does not result in scarring. However, scratching this zone may result in the formation of scars.

Summary

PUPPP, or pruritic urticarial papules and plaques of pregnancy, is a prevalent and uncomfortable skin issue that pregnant women often experience in the third trimester. It is frequently seen in first pregnancies, Caucasian women, and women pregnant with multiples. The specific reason is uncertain, but it could be linked to skin expansion, hormonal shifts, or the existence of foetal DNA.

Signs of the condition consist of elevated areas of irritated skin on the stomach, legs, buttocks, chest, and arms. Diagnosis requires eliminating other skin conditions with the help of laboratory tests and skin biopsies.

Methods of treatment range from utilising natural remedies like oatmeal baths and cool showers to using medications like anti-itch creams and antihistamines. Usually, the issue resolves independently a couple of weeks after delivery, without affecting the mother's or baby's health. Recurrence is uncommon in subsequent pregnancies.