What Is a PUPPP Rash?

Introduction

A PUPPP rash, also known as pruritic urticarial papules and plaques of pregnancy, is a skin condition wherein pregnant women get a hives-like rash on their skin. These rashes or bumps are itchy and usually appear on the stomach or stretch marks during pregnancy, especially in the third trimester. The specific cause of PUPPP rash is not clearly understood. However, it has been observed that skin stretching can potentially trigger rashes or bumps to occur on the belly. 

PUPPP occurs in every one of 150 pregnancies. This condition is also called by the following names:

• Bourne’s toxemic rash of pregnancy
• Polymorphic eruption of pregnancy (PEP)
• Nurse’s late-onset prurigo
• Toxic erythema of pregnancy

PUPPP is very likely to occur during the first pregnancy, but it can occur in the subsequent pregnancies as well. Even though PUPPP is quite itchy and can make pregnant women very uncomfortable, it is not usually a cause for concern. PUPPS is not harmful to the mother or baby. 

Symptoms

The PUPPP rash usually appears during the last trimester of pregnancy, when the baby is growing at a faster rate. The rash most likely occurs during a woman's first pregnancy or in a multiples pregnancy, since the skin tends to stretch even more. A pregnant woman's skin sometimes stretches faster than the skin cells can keep up with. For this reason, stretch marks and PUPPP appear during pregnancy. 

PUPPP initially appears on the abdomen, and then later spreads to the extremities after a few days. PUPPP rashes resemble pinkish pimple-like spots or hive-like bumps in the stretch marks. Later on, the rashes start to form large plaque-like red bumps that can spread from the abdomen to the buttocks, thighs, legs, or arms. In some cases, blisters may form around the rash. However, it is unusual for the rash to spread beyond the breasts. 

PUPPP can become quite itchy, particularly at nighttime, which is why some pregnant women with the rash may have a difficulty getting a good night's sleep. 

Causes

The exact cause of PUPPPs is still unknown. However, there are theories about the occurrence of this rash:

1. An overtaxed organ system

The main detox organ of the body is the liver, and when this organ is overwhelmed with toxins, symptoms such as skin discoloration and rashes appear. Another organ that is in charge of filtering blood is the kidneys, which may also be potentially involved in PUPPP. There are some herbalists that use certain herbs to purify the blood and get rid of the rashes. 

2. Skin inflammation caused by abdominal stretching 

Having large babies, gaining extra weight, or carrying multiples can put extra stress on the skin, which may lead to connective tissue damage. Although these factors initially cause stretch marks, skin damage may lead to inflammation and may develop into PUPPP. 

3. Fetal cell migration into maternal skin

Fetal cells are known to migrate into different areas of the mother's body, which include the skin and heart during pregnancy. According to research, although this process provides protective benefits against illnesses, maternal skin may consider fetal cells as foreign invaders, which can trigger an immune response and cause a PUPPP rash. 

This fetal cell migration is often observed in mothers who are having a baby boy. Male DNA was detected in the PUPPP rash of around 60-70 percent of mothers who were carrying boys. 

Diagnosis

The doctor would be able to diagnose PUPPP by carrying out a skin examination. Most of the time, further testing is not required. However, your healthcare provider may need to rule out other skin conditions, such as scabies or fungal infection.  

To rule out other infections, the following blood tests may be carried out:

• Liver function test
• Serum cortisol
• Complete blood count (CBC)
• Serum human choriogonadotropin or HCG

Risk Factors

There are some women who are more prone to developing a PUPPP rash than others. The risk factors may include:

• Pregnant for the first time
• Having a baby boy
• Being Caucasian
• Gestational hypertension
• Multiple pregnancies
• Excessive weight gain during pregnancy

Regardless of the above risk factors, there are still some women who develop this rash. 

Treatment

Childbirth is the ultimate cure for PUPPP. A PUPPP rash usually goes away around 1-2 weeks after giving birth. However, some women report that PUPPP persists even after a few weeks after delivery. While waiting for labor and childbirth, the symptoms can be managed using the following remedies:

• Use moisturizers: You can use moisturizers to relieve skin itching and discomfort. However, it is important to avoid moisturizers that have harsh ingredients or products that do not have baby-friendly ingredients, such as retinol, salicylic acid, vitamin A, tropic acid, and retinyl palmitate.

• Topical steroids: Although there are creams that are safe to use during pregnancy, such as 1 percent hydrocortisone cream to relieve skin itching, it is recommended to consult your doctor before applying any steroid-containing creams. Your healthcare provider might prescribe stronger topical steroids depending on your skin condition. 

• Take itch-relieving baths: Taking a bath using baking soda or oatmeal can help ease the itching due to PUPPP. A cool wet compress may also help relieve the itching. As much as possible, do not scratch the rash to avoid worsening the symptoms. Your healthcare provider might also prescribe oral steroids to help ease the pain and itching. However, oral steroids are only prescribed to pregnant women with severe PUPPP symptoms, such as extreme itching and discomfort. 

• Taking antihistamines: Antihistamines are drugs that can help relieve symptoms of allergies including itching. However, always consult your doctor before taking any antihistamines. The antihistamines that are considered safe during pregnancy are cetirizine (Zyrtec) and diphenhydramine (Benadryl).

Prevention

Since the exact cause of PUPPP still remains unknown, there is also no guaranteed way to prevent its development. However, pregnant women can make better and healthier choices to help reduce or prevent their chances of developing the condition. 

Conclusion

Mothers who have PUPPP may give birth to babies with a milder form of the rash. However, the rash does not in any way cause any complications for both the mother and baby. After having a PUPPP rash, there are chances of not having the rash in future pregnancies. However, a milder rash could still develop if women with a previous PUPPP rash become pregnant again.