Pregnancy is a unique stage in a woman’s life, accompanied by numerous physical and hormonal changes that may contribute to the development of various skin conditions. One of the most common pregnancy-related skin disorders is Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP), a condition characterized by an itchy skin rash that can become particularly bothersome during the later stages of pregnancy.Although PUPPP is generally a benign condition and does not pose a direct risk to the fetus, the intense itching and skin rash can cause significant discomfort and may interfere with the mother’s sleep, daily activities, and emotional well-being. Furthermore, because its symptoms may resemble those of other dermatological or pregnancy-related liver conditions, accurate recognition and diagnosis are important.In this Dalili Medical article, we will explore PUPPP during pregnancy, including its causes and risk factors, the most common symptoms and stages of development, and how the condition is diagnosed. We will also discuss its potential effects on the mother and fetus, the most effective treatment options, and practical tips for relieving itching and managing symptoms, along with the warning signs that require prompt medical attention.

What Is Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP)?

Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP), also known as Polymorphic Eruption of Pregnancy (PEP), is a skin condition that may develop during pregnancy, particularly in the later stages. It is characterized by an itchy skin rash that can cause significant discomfort and may interfere with sleep and daily activities.

Despite the intensity of the itching, PUPPP is generally considered a benign skin condition and does not usually pose a direct risk to the mother or fetus. In most cases, the condition gradually improves and resolves after delivery.

Is PUPPP Dangerous?

In most cases, no. PUPPP is a benign skin condition and is not usually associated with serious complications for either the mother or fetus.

Does PUPPP Affect the Baby?

Usually, no. PUPPP generally does not affect the fetus and is not typically associated with birth defects or serious pregnancy complications.

Is PUPPP Contagious?

No. PUPPP is not contagious and cannot be transmitted from one woman to another because it is not caused by a viral, bacterial, or fungal infection.

Can PUPPP Appear Early in Pregnancy?

PUPPP most commonly develops during the third trimester, particularly during the final weeks of pregnancy. Its occurrence during early pregnancy is less common.

Does PUPPP Only Occur During the First Pregnancy?

No. PUPPP can occur during any pregnancy, although it is more commonly observed in women experiencing their first pregnancy. It may also develop during subsequent pregnancies.

Does a Twin Pregnancy Increase the Risk of PUPPP?

Yes. PUPPP has been associated with greater stretching of the abdominal skin. Therefore, it is observed more frequently in women carrying twins or multiples, in whom the degree of skin stretching is often greater.

Is PUPPP Related to Stretch Marks?

Rapid and significant stretching of the abdominal skin, particularly when stretch marks develop, is believed to play a role in the development of PUPPP. However, the exact cause and underlying mechanism of the condition are not yet fully understood.

Can PUPPP Be Prevented?

There is currently no proven way to completely prevent PUPPP. However, keeping the skin moisturized and avoiding excessive heat, friction, and skin irritation may help reduce skin discomfort and itching. These measures, however, cannot guarantee prevention.

Does PUPPP Require Blood Tests?

In typical cases, PUPPP usually does not require specific laboratory tests for diagnosis. Doctors generally rely on the clinical examination, the appearance and distribution of the rash, and the timing of its onset.

Additional tests may be ordered when symptoms are unusual or when the doctor needs to rule out other causes of itching or skin rashes during pregnancy.

Is a Skin Biopsy Necessary?

Usually, a skin biopsy is not necessary to diagnose PUPPP. However, a doctor may recommend a biopsy when the diagnosis is uncertain or when other similar skin conditions, such as pemphigoid gestationis, need to be excluded.

Can Corticosteroids Be Used During Pregnancy?

Certain appropriate topical corticosteroids may be used during pregnancy when necessary to reduce inflammation and itching. The specific medication, strength, and duration of treatment should be determined by a doctor according to the severity of the condition.

In very severe cases, additional treatment may sometimes be required under specialist medical supervision.

Can Antihistamines Be Used?

Yes. Some antihistamines can be used during pregnancy and may help relieve itching, particularly when the symptoms interfere with sleep. However, the appropriate medication and dosage should be determined by a doctor based on the stage of pregnancy and the woman’s overall health.

Does PUPPP Go Away After Delivery?

Yes. In most cases, PUPPP gradually improves and resolves after delivery. Some women may experience itching or residual skin changes for a short period after giving birth before the condition completely disappears.

Does PUPPP Leave Permanent Scars?

Usually, PUPPP does not leave permanent scars. The rash generally resolves gradually after delivery. However, temporary changes in skin color may remain, particularly in areas affected by inflammation or repeated scratching, and these changes usually improve over time.

Can PUPPP Recur in a Subsequent Pregnancy?

Yes, PUPPP can recur during a subsequent pregnancy. However, having PUPPP once does not necessarily mean that it will occur during every future pregnancy. The likelihood of recurrence varies from woman to woman.

How Can PUPPP Be Distinguished From Intrahepatic Cholestasis of Pregnancy?

PUPPP and intrahepatic cholestasis of pregnancy (ICP) differ in several important ways.

With PUPPP, there is a visible skin rash accompanied by intense itching. The rash usually begins on the abdomen, particularly within or around the stretch marks, and may later spread to other areas of the body.

In contrast, intrahepatic cholestasis of pregnancy typically causes intense itching without a primary visible skin rash. The itching is often more pronounced on the palms of the hands and soles of the feet and may require liver function tests and measurement of bile acid levels.

Therefore, not all itching during pregnancy should be assumed to be caused by PUPPP. Severe itching without an obvious rash, particularly when it is unusual or persistent, should be evaluated by a doctor to determine the underlying cause.

Are There Different Types of PUPPP?

PUPPP, also known medically as Polymorphic Eruption of Pregnancy (PEP), is considered a single skin condition rather than a group of officially distinct types. However, the rash can take several clinical forms as it develops, including:

• Papular form: Small, red or pink, intensely itchy raised bumps, often beginning within the stretch marks on the abdomen.

• Plaque form: The papules may gradually merge to form larger, raised, red plaques that can resemble hives.

• Urticarial form: Raised, swollen areas resembling hives, usually accompanied by redness and intense itching.

• Vesicular form: Small blisters or vesicles may occasionally develop over some of the plaques, although this presentation is less common.

• Widespread form: The rash may extend from the abdomen to the thighs, buttocks, and hips and may occasionally spread to the trunk or arms.

Conditions That Are Not Types of PUPPP

Several pregnancy-related or dermatological conditions may resemble PUPPP but are separate medical conditions. Important examples include:

• Pemphigoid gestationis: The rash may begin around the belly button and can progress in some cases to form obvious blisters.

• Intrahepatic cholestasis of pregnancy: This condition is usually characterized by intense itching without a primary skin rash, often affecting the palms and soles.

• Atopic eruption of pregnancy: This may cause dry, red, itchy skin and is more common in women with a history of eczema or an underlying tendency toward atopic skin disease.

Who Is More Likely to Develop PUPPP?

Some women are more likely to develop Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP) than others. Factors associated with an increased likelihood include:

• First pregnancy: PUPPP is more commonly observed in women experiencing their first pregnancy.

• Multiple pregnancy: Carrying twins or more is associated with greater stretching of the abdominal skin.

• Rapid or significant stretching of the abdominal skin: Particularly when numerous stretch marks develop.

• Larger fetal size: A higher fetal weight may be associated with greater abdominal stretching, which may contribute to the development of PUPPP.

• Third trimester: Most cases occur during the later stages of pregnancy, particularly during the final weeks.

• Individual susceptibility and genetic factors: Certain genetic factors may contribute to an individual's susceptibility, although no specific genetic pattern has been established that can reliably predict who will develop PUPPP.

It is important to note that having one or more of these risk factors does not necessarily mean that a woman will develop PUPPP. The condition can also occur in women who have no obvious risk factors.

What Causes PUPPP During Pregnancy?

Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP), also known as Polymorphic Eruption of Pregnancy (PEP), is a benign skin condition that most commonly develops during the later stages of pregnancy. It is characterized by an itchy skin rash that can range from mild to severe.

What Causes PUPPP?

The exact cause of PUPPP is not fully understood. However, researchers believe that several factors may contribute to its development, including:

Rapid stretching of the abdominal skin: As the uterus and fetus grow, the abdominal skin undergoes significant stretching. This may cause microscopic changes or tissue stress that can trigger inflammation and contribute to the development of the rash and itching.

Stretching of connective tissue and collagen fibers: Significant stretching of the skin may cause microscopic changes in connective tissues, potentially triggering an inflammatory response that results in the development of papules, plaques, and itching.

First pregnancy: PUPPP is more commonly observed during a woman's first pregnancy. This may be related to the degree of abdominal skin stretching and the changes that occur in the skin during pregnancy.

Multiple pregnancy: The condition is more frequently observed in women carrying twins or more, possibly because of greater abdominal enlargement and increased skin stretching.

Larger fetus or rapid abdominal growth: Increased fetal size or rapid abdominal expansion may increase tension on the abdominal skin and may be associated with a higher likelihood of developing PUPPP.

Hormonal and immune changes: Pregnancy involves extensive hormonal and immune-system changes. These changes may play a role in triggering the inflammatory skin response associated with PUPPP, although no specific hormone has been established as the direct cause.

Genetic factors and individual susceptibility: Some women may have a greater predisposition to developing PUPPP. Genetic factors may contribute to this susceptibility, although the exact mechanisms and role of heredity have not been conclusively established.

When Does PUPPP Usually Develop?

PUPPP most commonly develops during the third trimester, particularly during the final weeks of pregnancy. In less common cases, it may begin toward the end of the second trimester.

The rash usually starts on the abdomen, particularly within or around stretch marks, and may then spread to the thighs, buttocks, hips, and sometimes the trunk or arms.

One clinical feature that may help doctors distinguish PUPPP from certain other pregnancy-related skin conditions is that the umbilical area is usually spared.

Is PUPPP Related to Food or Allergies?

In general, PUPPP is not considered a food allergy and is not caused by a specific food. It is also not caused by poor hygiene or a skin infection.

Therefore, a special diet is usually not necessary solely because of PUPPP unless another medical condition requires dietary changes.

Does PUPPP Pose a Risk to the Baby?

In most cases, PUPPP is a benign condition and does not pose a direct risk to the fetus. It is generally not associated with fetal abnormalities or serious pregnancy complications, and symptoms usually improve gradually after delivery.

However, obtaining an accurate diagnosis is important because itching and skin rashes during pregnancy can also be caused by other conditions that differ in their significance and management, such as intrahepatic cholestasis of pregnancy (ICP) or pemphigoid gestationis. These conditions may require additional medical evaluation, laboratory testing, and different treatment.

Therefore, pregnant women should consult a doctor if they develop a new rash or unexplained itching, particularly when symptoms are severe, persistent, or unusual.

Symptoms of PUPPP During Pregnancy

PUPPP is characterized by an itchy skin rash that may range from mild to severe. The severity and distribution of symptoms vary from one woman to another, but several common features can help identify the condition.

Main Symptoms

Severe itching: Itching is the most prominent symptom. It can sometimes be intense enough to interfere with sleep and daily activities and may become worse at night in some women.

Red papules: Small, raised skin bumps may develop. They are usually red or pink and are often accompanied by significant itching.

Formation of skin plaques: The papules may gradually merge to form larger, raised areas of skin that can resemble hives.

Skin redness and irritation: Redness is usually noticeable in affected areas and may become more pronounced as a result of repeated scratching.

Burning or warmth of the skin: Some women may experience a burning sensation or feel that the affected skin is warm, although this symptom does not occur in every case.

Where Does the Rash Begin?

In most cases, the rash begins on the abdomen, particularly within or around stretch marks, during the later stages of pregnancy.

It may then spread to other areas, including:

• The thighs

• The buttocks

• The hips

• The trunk

• The arms in some cases

One feature that may help doctors distinguish PUPPP from certain other pregnancy-related skin disorders is that the umbilicus itself is usually spared, even when the surrounding skin is affected.

How Does the Rash Progress?

The rash typically begins with small, intensely itchy papules developing within the abdominal stretch marks. These papules may then merge together to form larger and more noticeable plaques.

As the condition progresses, the rash may gradually spread to the thighs, buttocks, and hips and, in some cases, to the trunk and arms.

Small vesicles may occasionally develop over the affected areas. However, large blisters or prominent fluid-filled bullae are not typical features of PUPPP and may warrant reassessment of the diagnosis and evaluation for other pregnancy-related skin conditions.

When Do the Symptoms of PUPPP Usually Appear?

The symptoms of PUPPP (Pruritic Urticarial Papules and Plaques of Pregnancy) usually develop during the third trimester of pregnancy, particularly during the final weeks before delivery. In less common cases, symptoms may appear toward the end of the second trimester or shortly after delivery.

The condition usually improves gradually after childbirth. The rash and itching may disappear completely within a relatively short period, although some redness or temporary changes in skin color may persist for a longer time in some women.

When Should Pregnancy-Related Itching Require Medical Evaluation?

It is important not to assume that all itching during pregnancy is caused by PUPPP. If the itching is severe without an obvious skin rash, is particularly concentrated on the palms of the hands or soles of the feet, or is accompanied by yellowing of the skin or eyes, dark urine, or unusually pale stools, medical evaluation should be sought promptly.

These symptoms may indicate intrahepatic cholestasis of pregnancy (ICP), which is different from PUPPP and requires appropriate medical evaluation and laboratory testing.

Diagnosis of PUPPP

The diagnosis of PUPPP is primarily based on a clinical examination. The doctor evaluates the appearance and distribution of the rash, when it started, the severity of itching, and any associated symptoms. There is no specific blood test that can definitively confirm PUPPP.

1. Medical History

The doctor may ask several questions to help establish the diagnosis, including:

• At what stage of pregnancy did the symptoms begin?

• Is this the first pregnancy?

• Is the pregnancy a multiple pregnancy, such as twins or triplets?

• When did the itching begin, and where did the rash first appear?

• Did the rash begin within or around the abdominal stretch marks?

• How severe is the itching, and does it become worse at night?

• Is there a history of skin conditions such as eczema or allergies?

• Are there other symptoms, such as yellowing of the skin or eyes, dark urine, or upper abdominal pain?

2. Skin Examination

The doctor carefully examines the skin for findings that support a diagnosis of PUPPP, including:

• Small, red, intensely itchy papules.

• Papules that merge to form raised, red plaques.

• A rash that usually begins within or around the stretch marks on the abdomen.

• Spread of the rash to the thighs, buttocks, hips, and sometimes the trunk or arms.

• Relative sparing of the umbilical area.

• Absence of large, obvious blisters, as prominent blistering may suggest another diagnosis.

3. Does PUPPP Require Laboratory Tests?

In typical cases, PUPPP does not usually require specific laboratory testing because the diagnosis can generally be made from the medical history and physical examination.

However, the doctor may order tests when symptoms are unusual or when other conditions need to be ruled out. These may include:

• Liver function tests and bile acid measurements: particularly when severe itching occurs without an obvious rash or is concentrated on the palms and soles, to rule out intrahepatic cholestasis of pregnancy.

• Skin biopsy: may be performed when the diagnosis is unclear, particularly if pemphigoid gestationis is suspected.

• Additional tests: depending on the appearance of the rash, associated symptoms, and other possible diagnoses.

4. Differential Diagnosis

Because several pregnancy-related skin disorders can resemble PUPPP, distinguishing between them is important.

Condition	Key Features
PUPPP	An intensely itchy rash that usually begins within the abdominal stretch marks, with relative sparing of the umbilical area.
Pemphigoid gestationis	May begin around the umbilicus and can progress to clear, tense blisters.
Intrahepatic cholestasis of pregnancy	Severe itching, usually without a primary skin rash, often particularly prominent on the palms and soles.
Atopic eruption of pregnancy	Dryness, redness, and itching, often in women with a history of eczema or allergic disease.
Contact dermatitis	A rash that usually appears in areas exposed to an irritating or allergenic substance.

 

Why Is an Accurate Diagnosis Important?

Although PUPPP is generally a benign skin condition, any new rash or itching during pregnancy deserves appropriate medical assessment, particularly when the symptoms are severe or atypical.

The purpose of diagnosis is to confirm PUPPP and rule out other conditions that may require different treatment or monitoring.

When Should a Pregnant Woman See a Doctor Promptly?

A pregnant woman should seek medical advice if she develops new or severe itching, particularly when the itching is accompanied by unusual symptoms or occurs without an obvious rash.

Medical evaluation is particularly important when there is:

• Severe itching without a visible rash.

• Prominent itching of the palms or soles.

• Yellowing of the skin or whites of the eyes.

• Dark urine.

• Large skin blisters.

• Rapid spread of the rash or significant worsening of symptoms.

• Severe pain or other unusual systemic symptoms.

Prompt evaluation is important because some of these symptoms may indicate conditions such as intrahepatic cholestasis of pregnancy or pemphigoid gestationis, which are different from PUPPP and require specific evaluation and treatment.

Treatment of PUPPP During Pregnancy

The main goals of PUPPP treatment are to relieve itching, reduce skin inflammation, and improve the mother's comfort, since the condition is generally benign and tends to improve gradually after delivery.

1. Topical Corticosteroids

Topical corticosteroids are among the main treatment options when significant inflammation and itching are present.

• A low- to moderate-potency corticosteroid may be prescribed depending on the severity and location of the rash.

• It is generally used for the shortest appropriate period and at the lowest effective amount.

• In more severe cases, a stronger topical corticosteroid may be prescribed for a short period under medical supervision.

• Strong topical corticosteroids should not be used for prolonged periods without medical advice during pregnancy.

2. Antihistamines

Certain antihistamines may help relieve itching, particularly when itching interferes with sleep.

Depending on the stage of pregnancy and the woman's overall health, a doctor may consider medications such as:

• Cetirizine

• Loratadine

• Chlorpheniramine

Some antihistamines that cause drowsiness may occasionally be used at night when itching significantly interferes with sleep. The appropriate medication and dosage should be determined by a healthcare professional.

3. Oral Corticosteroids

Oral corticosteroids are generally not required for mild PUPPP.

However, in severe or widespread cases that do not respond adequately to topical treatment, a doctor may prescribe a short course of an oral corticosteroid.

Prednisolone may be considered in selected severe cases, but the dose and duration must be determined by the treating physician according to the stage of pregnancy and the woman's medical condition.

4. Supportive Measures to Relieve Symptoms

Several measures may help soothe the skin and reduce itching, including:

• Applying fragrance-free moisturizers regularly.

• Using cool compresses on particularly itchy areas.

• Taking lukewarm rather than very hot showers or baths.

• Wearing loose-fitting cotton clothing to reduce friction and heat.

• Avoiding soaps, perfumes, and skincare products that may irritate the skin.

• Avoiding vigorous scratching to reduce the risk of skin injury and secondary infection.

Important Note

No medication should be used during pregnancy, including over-the-counter medications, without first confirming that it is appropriate for pregnancy and determining the correct dose.

If itching persists despite treatment or the rash changes in appearance, the diagnosis should be reassessed to rule out another skin or liver condition.

Tips for Managing PUPPP During Pregnancy

Because PUPPP is generally a temporary and benign skin condition, management focuses mainly on controlling itching, soothing the skin, and improving comfort until the condition resolves, which usually occurs after delivery.

1. Relieving Itching and Soothing the Skin

The following measures may help reduce itching and skin irritation:

• Apply fragrance-free moisturizers regularly, especially after bathing.

• Use cool compresses on itchy areas for short periods.

• Take lukewarm showers instead of hot showers.

• Use gentle, fragrance-free cleansing products.

• Wear loose-fitting cotton clothing to reduce friction and improve ventilation.

• Avoid overheating and excessive sweating.

• Keep the bedroom at a comfortable temperature.

• Keep fingernails trimmed and avoid vigorous scratching to reduce the risk of cuts and secondary skin infections.

2. Medications

If itching is severe or interferes with sleep and daily activities, a doctor may recommend:

• Pregnancy-appropriate topical corticosteroids to reduce inflammation and itching.

• Pregnancy-appropriate antihistamines, particularly when itching interferes with sleep.

• A short course of an oral corticosteroid in very severe cases that do not respond adequately to topical treatment.

Medication should not be started during pregnancy, even if it is available without a prescription, without confirming its safety and appropriate dosage with a healthcare professional.

3. Things to Avoid

To prevent further skin irritation, it is advisable to avoid:

• Vigorous scratching or rubbing of affected areas.

• Very hot showers or baths.

• Perfumes and fragranced creams or skincare products on affected skin.

• Unproven home remedies or herbal preparations whose safety during pregnancy has not been established.

• Strong topical corticosteroids or prolonged corticosteroid use without medical supervision.

When Should You See a Doctor?

A pregnant woman should consult an obstetrician or dermatologist if:

• The itching is severe or significantly interferes with sleep.

• The rash spreads rapidly or changes noticeably.

• Large blisters or significant blistering develop.

• There are signs of skin infection, such as severe pain, increased warmth of the affected area, or pus-like discharge.

• Severe itching occurs without an obvious rash.

• Itching is particularly concentrated on the palms or soles.

• Yellowing of the skin or eyes develops.

• The urine becomes unusually dark.

These symptoms are particularly important because other causes of itching during pregnancy, such as intrahepatic cholestasis of pregnancy and pemphigoid gestationis, differ from PUPPP and require different diagnostic evaluation and treatment.