Pregnancy Rash: What is PUPPP?

Pruritic uticarial papules and plaques of pregnancy (PUPPP) is a skin condition that can make expectant moms miserable. But is it dangerous? Find out the symptoms, risk factors, and treatments for this common pregnancy rash.
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Pregnancy brings with it many things, some joyous and some...not. For about 1 in 160 expectant moms (less than 1 percent), one of the unfortunate side effects can be a rash with a mean itch known as PUPPP, or pruritic urticarial papules and plaques of pregnancy. PUPPP poses no harm to Baby, and no long-term or dangerous consequences to you, but it’s still important to understand the condition.

What is PUPPP?

A PUPPP rash is extremely itchy, with raised, hive-like bumps and streaks on the abdomen and other areas, says Jessica J. Krant, M.D., a board-certified dermatologist and assistant clinical professor of dermatology at SUNY Downstate Medical Center and a physician at the Laser & Skin Surgery Center of New York. It usually first appears on the abdomen—specifically, on a woman's developing stretch marks—during the third trimester of a first pregnancy, but it can also affect the thighs, legs, hands, arms, breasts, back, or buttocks. It generally doesn't affect the face, and there shouldn't be any blisters, water bubbles, scaling, or flakiness, Dr. Krant adds.

Unlike many other unpleasant pregnancy side effects that can be blamed on surging hormones, this condition can't. "Some studies suggest a relationship between skin distention (stretching/expanding of the skin) and the development of this condition; this is because the rash usually starts in stretch marks and there is a higher incidence of PUPPPs in multiple gestation pregnancies, as well as pregnancies with increased maternal weight," says Ray Kamali, M.D., FACOG, New Mommy Media Contributor and Department Chair at Sharp Chula Vista Medical Center in Chula Vista, Calif. "Other studies suggest a possible immunologic response to the circulating fetal antigens."

Don't just assume that any itchy rash you get during pregnancy is PUPPP, however. There are pregnancy skin conditions that can be harmful to the mother or baby, such as pustular psoriasis and pemphigoid gestationis. And a condition called cholestasis of pregnancy, a liver disease that typically develops in the third trimester of pregnancy, also causes intense itching. But cholestasis of pregnancy may increase the risk of preterm birth, stillborn birth, or fetal distress. "That's why it's important to immediately seek help from your obstetrician or dermatologist with any rash during pregnancy," Dr. Krant says.

PUPPP Pregnancy Risk Factors

PUPPP only manifests during pregnancy, and usually occurs in women who are pregnant for the first time and with multiples. While experts haven't determined an absolute cause of PUPPP, the most common theory "is that excessive stretching of the skin's connective tissue leads to inflammation in the skin, which causes the rash," says Lauren Ploch, M.D., a board-certified dermatologist in Aiken, South Carolina. "This is why PUPPP most commonly occurs during first pregnancies or multiple gestation pregnancies. Familial associations have also been reported, so you may be at risk if other women in your family have developed PUPPP in the past." (Indeed, another theory is that the condition is genetic, and can be traced through the father's side.) Your baby's sex may play a role, too. Approximately 70 percent of women who have PUPPP are expecting boys, which leads some experts to believe that PUPPP is attributable to hormones from the male fetus.

PUPPP Treatment

Your Ob-Gyn or dermatologist can likely diagnose the condition with a clinical exam, "but some patients may require a small skin biopsy for definitive diagnosis," says Dr. Ploch. There's no way to predict who will get PUPPP, and there's nothing you can do to prevent it. All you can do is try to manage it as best you can; the itch may range from mild to very severe, but it does clear up within a couple of weeks after delivery.

A quick internet search will turn up dozens of home remedies by moms who swore by them when they were experiencing PUPPP during pregnancy. Note that these are not scientifically tested, but many moms have had good results in reducing or relieving the itch with them. (Remember to share your condition with your healthcare provider to get a proper diagnosis; there are other causes for dermatitis and rashes during pregnancy, so a proper evaluation is important. Get the OK before you start experimenting with remedies.)

  • Drink V8 juice (be careful not to overindulge, or choose the lower-sodium option; the original version has quite a bit of sodium per glass).
  • Wash with a product called Grandpa's Wonder Pine Tar Soap, a soothing soap containing allantoin (anti-inflammatory), aloe vera gel, baking soda and coconut oil (emollient). Available online and at health food stores such as Whole Foods.
  • Take oatmeal baths.
  • Apply aloe vera gel or Cetaphil to your skin.

Dr. Kamali also has a few suggestions for PUPPPs treatment:

  • Non-sedating anti-histamines, such as Benadryl.
  • Topical corticosteroids (AKA over-the-counter hydrocortisone creams) such as Aveeno Active Naturals 1% Hydrocortisone Anti-Itch Cream.
  • For severe cases, systemic corticosteroids such as prednisone may be used.
  • Steroids may be prescribed by your healthcare provider.

Delivering your baby is the only "cure" for this condition, although Dr. Kamali notes that it may actually get worse right after birth before clearing up within approximately two weeks. Although some women have begged for early delivery to relieve the extreme discomfort, Dr. Kamali notes this is rarely, if ever, necessary, due to the risks associated with early birth.

The good news: There are no long-term effects aside from scar tissue caused by scratching. "Most studies report small risks for recurrence in subsequent pregnancies," he says. Soon after you welcome your baby, you will be free from the itch to enjoy the new little life you and your partner created.

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