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 is most commonly experienced in the case of first pregnancies or multiple births (2). After the rash subsides, the itch might persist and appear intermittently. Therefore, it is important 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 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
- Eczema 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. 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).
What Are The Causes Of PUPPP?
The exact cause 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
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.
Your doctor will suggest some tests such as:
- Complete blood count (CBC)
- Liver function test
- Serum hCG (human chorionic gonadotropin)
- Serum 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).
Can You Treat PUPPP?
PUPPP rash and itching might disappear within 15 days after your delivery, without any medical intervention. However, there are treatments to help relieve the symptoms (4).
Medical treatments for PUPPP rash include (4):
- Moisturizers: They primarily relieve itching and remove the discomfort. You can use moisturizers containing vitamin E, cocoa butter, Shea butter, collagen, glycerin, and elastin. Avoid moisturizers that contain retinol, salicylic acid, vitamin A, tropic acid, and retinyl palmitate.
- Topical steroids: Topical steroid creams with one percent hydrocortisone is considered as the first-line treatment to reduce the itching. Oral corticosteroids are also prescribed when local corticosteroids fail to relieve pain and itching (7). In severe cases, corticosteroid injections may be prescribed to relieve symptoms.
- Oral antihistamines: They also relieve the itching and are safe to use during pregnancy. Some of the more reliable antihistamines 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, could help relieve 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 likelihood 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.
Frequently Asked Questions
1. Is PUPPP rash contagious?
PUPPP rash is not contagious as it develops as a response to the changes in your body. Other people cannot develop a rash through physical contact.
2. Can you develop a PUPPP rash when not pregnant?
PUPPP develops only during pregnancy, due to the stretching of the skin, functioning or migrating fetal cells.
3. Does having a PUPPP rash mean you are carrying a boy?
A study has found almost six male fetal DNA in skin biopsies of ten pregnant women with PUPPP but found none in any of the controls of pregnant women without PUPPPs (12). But this does not mean that having PUPPP is a sure sign of a baby boy.
4. Will PUPPP reappear in a second pregnancy?
The PUPPP rash could recur during the second pregnancy (13), but it is not a given.
PUPPP rash in pregnancy is a common complication that can continue for several weeks after birth. It might occur as rashes, tiny blisters, and other unpleasant skin conditions, especially in the belly around stretch marks. Taking your prescribed medications, including topical ointments, creams, other oral medications, and some natural remedies, such as an oatmeal bath, cold compressions, and essential oils, could help reduce the itching and pain. The rash will eventually resolve with time; however, consult your doctor if you see a rash that hasn’t gone away after a while.
2.Mario Sánchez-Borges, et al.; Diagnosis and Treatment of Urticaria and Angioedema: A Worldwide Perspective; WAO Journal
3.En Hyung Kim; Pruritic Urticarial Papules and Plaques of Pregnancy Occurring Postpartum Treated with Intramuscular Injection of Autologous Whole Blood; Karger- Case Reports In Dermatology
4.Pruritic Urticarial Papules And Plaques Of Pregnancy; American Osteopathic College of Dermatology
5.Anju S. Nair, George Kurien, V. G. Binesh; ; A study of pregnancy specific dermatoses and their effect on the outcome of pregnancy; International Journal of Research in Dermatology
6.Sophia Giatrakou, et al.; Dermatological disorders unique to pregnancy; Research Gate
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8.Plaques of Pregnancy or Puppp – A Rare Pregnancy Rash; RRMCH (2019)
9.Ankit Goyal, et al.; Flax and flaxseed oil: an ancient medicine & modern functional food; Journal of Food Science and Technology
10.Health Library; Winchester Hospital
11.Disha Arora, Anita Rani, and Anupam Sharma; A review on phytochemistry and ethnopharmacological aspects of genus Calendula; Pharmacognosy Review
12.Matthew Bremmer, et al.; 6 skin disorders of pregnancy: A management guide; OBG management; OBG management
13.Ellen Cathrine Pritzier and Carsten Sauer Mikkelsen; Polymorphic eruption of pregnancy developing postpartum: 2 case reports; Dermatology Reports