PUPPP Rash: Causes, Symptoms And Treatment

Pruritic urticarial papules and plaques of pregnancy or PUPPP rash in pregnancy is one of the most common skin conditions to occur during pregnancy. This condition causes an intense rash in the belly area surrounding the stretch marks.

The rashes can be extremely itchy, and the itchiness might last for about a week or two. The rashes are characterized by slightly raised red-colored patches on the skin, sometimes surrounded by a light-colored halo. This condition is also known by various names including, Bourne’s toxemic rash of pregnancy, toxic erythema of pregnancy, and nurse’s late-onset prurigo (1).

PUPPP usually develops towards the third trimester of pregnancy or right after the baby’s delivery. Studies have shown that PUPPP affects about one in 300 pregnancies, and its prevalence is high in the case of first pregnancies and multiple births (2). After the rash subsides, the itch might persist and appear intermittently. Therefore, it is vital to seek immediate medical care to avoid complications.

Read on to know more about PUPPP, its causes, diagnosis, treatment, and prevention techniques.

What Are The Symptoms Of PUPPP Rash?

Itching is perhaps the worst part of PUPPP. Along with the distinctive red marks or eruptions that cause itchiness in the abdominal region, these are the other signs and symptoms you should look for:

• Stretch marks, which are the initial signs
• Severely itchy rash
• Small blisters
• Redness
• Eczemaⁱ  Extremely dry rash in response to an allergenic food or specific medications. like lesions

PUPPP begins as tiny, itchy bumps and turns into red, more significant patches that welt over time. They initially look like stretch marks on the abdomen, and as time passes, they grow larger, spreading towards the extremities, including stomach, chest, hands, armpits, back, and thighs.

A blogger and mother of two reveals her encounter with PUPPP during her pregnancy, “I was at 35 weeks when I suffered these rare pregnancy rashes called PUPPP, short for Pruritic Urticarial Papules and Plaques of Pregnancy. It commenced when the stretch marks of my abdomen got inflamed with raised spots and increasing itchiness. Then, my legs, thighs, arms, and lower back eventually had tiny red rashes, too, except for the face. Every night, I can’t sleep peacefully, and in the daytime, I can’t function well because I kept on scratching those extremely itchy rashes (i).”

About 22% of affected women experience PUPPP rashes on the abdomen and limbs, followed by 18% on the abdomen only. Rashes on limbs (4%), limbs and trunk (1%), and abdomen, limbs, and back (1%) account for a minuscule percentage. Additionally, about 25% of PUPPP rashes have a generalized distribution.However, PUPPP rash does not spread to the face, palms, and soles of the feet. You will also never see a rash in the navel region (3). PUPPP rash may look like allergy rashes, but it does not occur due to an allergic reaction.

Distribution of PUPPP rashes in pregnant women

Quick fact

Generally, PUPP rash lesions on or above the breasts are also rare (14).

What Are The Causes Of PUPPP?

The exact etiology of PUPPP is not known (4). However, studies suggest that a pregnant woman may get a PUPPP rash due to the following reasons:

1. Abdominal stretching

Carrying multiples, heavy or large babies might put more stress on the skin, damaging the connective tissue. This begins with stretch marks and could later cause skin inflammation, and eventually, the PUPPP rash (4).

2. Migrating fetal cells

Fetal cells migrate to different body parts of the mother, including the skin. Sometimes, your skin will treat these fetal cells as foreign substances, triggering a reaction that might cause a skin rash. The migration of skin cells is more likely to occur in male fetuses, but the cause for this is still under research (5).

Apart from the above-presumed causes, there are certain factors that increase the likeliness of PUPPP.

What Are The Risk Factors Of PUPPP?

You are likely to develop PUPPP if you:

• Are pregnant for the first time
• Are carrying multiples (6)
• The baby is overweight
• Are pregnant with a boy
• Are overweight
• Change in hormones

Some women might experience this skin rash in spite of the above risk factors. And treating it in time is possible only when you are certain of the condition. Keep reading to know about its diagnosis.

How Is PUPPP Rash Diagnosed?

PUPPP is determined by ruling out skin infections after conducting biopsy or other tests to examine the histology of the affected area.

A dermatology expert will suggest some tests such as:

• Complete blood count (CBC)
• Liver function test
• Serum hCG (human chorionic gonadotropin)ⁱ  Test to measure hCG, a hormone produced during pregnancy in the blood that can help diagnose pregnancy abnormalities.
• Serum cortisolⁱ  Test to measure the blood level of a stress hormone called cortisol.

If all other skin conditions, such as rabies and fungal infections are eliminated, and the belly button is unaffected, it could be a PUPPP rash (4).

Quick fact

PUPP rash can be very itchy and hence may disrupt one’s sleep at night (14).

Can You Treat PUPPP?

The PUPPP rash and itching may naturally disappear within 15 days after delivery during the postpartum period without medical intervention. Nonetheless, there are treatments available to alleviate the symptoms (4).

Medical treatment

Medical treatments for PUPPP rash include (4):

1. Moisturizers: They primarily relieve itching and remove the discomfort. You can use moisturizers containing vitamin E, cocoa butter, Shea butter, collagenⁱ  Protein that provides structural support to connective tissues with its fiber-like structure. , glycerin, and elastinⁱ  A connective tissue protein responsible for the elasticity of the skin. . Avoid moisturizers that contain retinol, salicylic acid, vitamin A, tropic acid, and retinyl palmitateⁱ  A combination of retinol and palmitic acid found in meat, eggs, fish oil, and dairy. .

2. Topical steroids: Topical steroid creams with one percent hydrocortisoneⁱ  A steroid medication used to soothe pain or inflammation. is considered as the first-line treatment to reduce the itching. Oral corticosteroidsⁱ  A group of steroid hormones produced in the adrenal cortex, used for treatments in synthetic form to reduce inflammation. are also prescribed when local corticosteroids fail to relieve pain and itching (7). In severe cases, corticosteroid injections may be prescribed to relieve symptoms.

3. Oral antihistamines: They also relieve the itching and are safe to use during pregnancy. Some of the more reliable antihistaminesⁱ  Medicines used for the treatment of allergies. include cetirizine (Zyrtec) and diphenhydramine (Benadryl) (7).

Problems with conventional treatments

Conventional medicine mainly focuses on managing the signs and symptoms, but not the actual problem. Most of the above treatments only relieve the itching and pain. So, always go for medical treatments only if your doctor prescribes them. There are studies showing that side effects of steroids are similar in pregnant women when compared to non-pregnant patients. Steroids are safe to use during pregnancy when medically indicated.

However, there are a few home remedies that might help relieve the itching due to PUPPP. Discuss it with your doctor before going in for any of these remedies. Also, note that there is less scientific evidence to prove the effectiveness of natural home remedies.

Natural Remedies For PUPPP

Herbal remedies, along with home care, may aid in the management and relief of the PUPPP itching and rash.

1. Do not scratch

One of the annoying symptoms of PUPPP is the itch, but you need to refrain from scratching, rubbing, and touching the rash as this might expose it to additional microbes that might be present in the fingernails. It can pose an additional risk of infection too.

2. Oatmeal bath

Soaking in an oatmeal bath might relieve the itching, moisturize, and soothe the skin (4). Take one cup of rolled oats and one cup of organic chamomile loose tea and place them in a cheesecloth or old cloth and tie it. Drop it in a tub full of lukewarm water and soak in the bath for 20 minutes. Before stepping in, you can also squeeze the cloth to release milky liquid oat extract into the bathwater.

3. Apply a cold compress

Applying an ice pack for 15-20 minutes on the rashes could also help in relieving the symptoms of PUPP (8).

4. Peppermint oil

The menthol in the peppermint oil might help in reducing the itching and cool the inflamed area. You can dilute the oil or apply it directly to the rashes (8).

5. Clove oil

You can also consider applying clove oil for two weeks to reduce the itch and soothe the inflamed skin area (8)

6. Flaxseed oil

Flaxseed oil is said to have anti-inflammatory properties and might be helpful in relieving the itching due to PUPPP. Mix two teaspoons of oil to a cup of milk and drink (9).

7. Dandelion root or nettle leaf tea

Dandelion tea is said to have detoxification and liver supporting properties, which might help in reducing the symptoms of PUPPP. However, the safety of dandelion tea during pregnancy is not established, so always consult your doctor before trying this remedy (10).

8. Anti-inflammatory herbs

Calendula and chamomile are believed to have anti-inflammatory properties that might help in reducing the inflammation and itching of the PUPPP rashes (11).

They can be combined with aloe vera, witch hazel or any other mild lotion, and applied to the rash, three times a day.

9. Olive oil

After taking a shower, do not dry your skin. Instead, apply olive oil on your wet skin and then pat dry using a clean towel. It might relieve the itching and keep the skin moisturized.

10. Other topical remedies

Anecdotal evidence suggests that applying the cornstarch-water paste on the skin might provide relief. You may also consider applying coconut oil or aloe vera gel, which are said to have soothing effects.

You can prepare baking soda-water paste and cornstarch-water paste and apply it to the skin rash for relief. Also, applying coconut oil and rubbing a banana peel on the rash helps.

11. Wear comfortable clothing

Wear loose and soft cotton clothes if you are suffering from PUPPP rash, as they might not aggravate the rash further.

12. Stay away from harsh chemicals

Stay away from shower gels with heavy perfume and harsh chemical formulations. Do not spray chemical-based deodorants and shower sprays on your body when you have PUPPP.

13. Practice good hygiene

Take a bath every day and stay on a healthy balanced diet. Regulate room temperature to prevent sweating, as moisture could trigger itching.

14. Vegetable juices

In addition to including fresh fruits and vegetables in your diet, you may also try to have a glass of vegetable juice that could help in detoxing the body and soothing the inflammation.

Can You Prevent PUPPP?

It may not be possible to prevent PUPPP as the exact cause of the condition is not known. Make healthy choices to decrease the incidence of a rash and remember that it is a temporary condition.

Women who are affected by PUPPP during their first or second pregnancy may not necessarily experience it in the subsequent pregnancies. However, there are chances of having a milder rash.

But is the rash contagious? Can other people get it from you? For answers to these and other common queries, read the FAQ section next.

Are you pregnant and experiencing an itchy rash? You may have PUPPP, a common skin condition in pregnancy. Learn more about PUPPP and how to manage it in this video.

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Dr. Burcu Saygan KaramürselMD

 

Burcu Saygan Karamürsel is a board certified obstetrics - gynecology and maternal-fetal medicine specialist with 22 years of experience. She is currently working in Ankara,Turkey. A graduate from Hacettepe University Medical School, she has also attended a fellowship programme at Bonn University Hospital, Perinatology Department.

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