When you think about pregnancy skin, one of the first things that often comes to mind is the pregnancy glow. But a healthy glow is not the only thing pregnancy can do to your skin.
It can also bring acne, stretch marks, and, for some women, a painful and itchy rash known as PUPPP.
Let’s talk about what causes PUPPP rashes, what you can do about them, and when you can expect relief.
What Is PUPPP?
PUPPP, short for pruritic urticarial papules and plaques of pregnancy, is an itchy but benign rash that occurs during pregnancy, usually in the third trimester. It’s fairly common, occurring in about 1 in every 160 pregnancies, and is more common in first-time moms and moms carrying multiples (1). Also, you might be more likely to experience PUPPP if women in your family had it.
The PUPPP rash begins typically in the stretch marks on your belly and looks like small pimple-esque hives at the beginning (2). The rash is often red and patchy, closely resembling eczema. It is also extremely itchy.
Within a few days, it will then move onto other parts of your body like your back, legs, thighs, buttocks, and arms. The good news? It never goes to your face for some reason. No one seems to know why, but we are grateful either way.
It’s Also Known As
PUPPP is a rash of many names.
Your doctor might use any one of the names below to describe the same condition:
- Bourne’s toxemic rash of pregnancy.
- Toxic erythema of pregnancy.
- Nurse’s late-onset prurigo.
- Polymorphic eruption of pregnancy (PEP).
While some of these sound scarier than others, they are all the same condition.
Who Gets It?
PUPPP develops at a higher rate in Caucasian women, experiencing their first pregnancy, or are pregnant with multiples. Those expecting triplets have a higher chance of developing PUPPP than those with twins. It also seems to occur twice as often in women pregnant with a boy. It’s more common in those who are experiencing high blood pressure during their pregnancy.
While these scenarios might make you more likely to experience PUPPP, remember that women can still have PUPPP without these risk factors. PUPPP does not discriminate and can affect women of all nationalities and skin types. And most importantly – despite the apparent discomfort, it is benign.
In up to 15% of women who get PUPPP, it actually happens after the delivery.
What Causes It?
No one knows exactly what causes PUPPP, but some studies show the following reasons may cause a woman to experience PUPPP while her friends do not.
1. Skin Stretching
When stress is put on the skin, causing it to stretch quickly, it can damage the connective tissue. This is what causes stretch marks, but in some pregnancies, it can also cause a PUPPP rash.
This is why it’s more common for PUPPP to occur in women who are pregnant for the first time or are carrying multiples. The faster your skin stretches, and the more it stretches, the more damage occurs and the higher the risk for PUPPP.
The same thing can happen in women with increased maternal weight gain during their pregnancy because, consequently, they have more skin stretching.
2. Fetal Cells
Fetal cells can migrate to different parts of the mom’s body, and that includes your skin. While sometimes this benefits the mom because it protects against certain diseases, your body can also look at these fetal cells as a foreign body it needs to fight against.
Some studies show that PUPPP rash is a reaction to the fetal cells that migrate to your skin. Fetal cells seem to migrate to the skin more often in women who are pregnant with boys, which would explain why 60 to 70 percent of PUPPP cases occur in moms who are carrying a boy.
3. An Overworked Organ System
The liver is our body’s main detoxification organ, while the kidneys are in charge of filtering out our blood. If your liver is overworked and unable to detoxify your body’s toxins properly, this can sometimes reveal itself in a skin rash or discoloration. The same can happen if the kidneys are having a hard time keeping up.
How Is It Diagnosed?
It’s important to see your doctor for an official diagnosis instead of assuming your rash is PUPPP. That’s because while PUPPP is generally harmless, other similar conditions can develop during a pregnancy which is a lot more serious.
Conditions such as pemphigoid gestationis, which can be passed on to your baby, need to be ruled out (3). Intrahepatic cholestasis, which can also cause a rash, is a liver disease that can occur in pregnancy and carries risks such as preterm birth, fetal distress, and even stillbirth (4). Your doctor will also exclude allergic reactions, some infections and other, less frequent, possible causes of a rash.
Will It Require a Test
Can I Prevent It?
Unfortunately, no, there is no way you can fully prevent PUPPP from happening. That’s because we aren’t completely sure what causes it, and some things, like migrating fetal cells, can’t be prevented.
What you can do is make sure to eat a healthy diet, gain weight slowly and steadily, and try not to scratch as your skin stretches to prevent irritation. These things can help lower your risk for PUPPP.
Having PUPPP in one pregnancy does not mean you will or won’t have it again in your next pregnancy. If it does happen again, which is very rare, it will usually be milder than the first time.
Editor's Note:Dr. Irena Ilic, MD
Will It Hurt My Baby?
Getting sick while pregnant can be a scary situation. You don’t only have yourself to worry about, you have your healthy baby too. Thankfully, PUPPP is not a condition you have to stress over. What matters is that you don’t assume a rash occurring in pregnancy to be PUPPP without checking with your doctor.
The discomfort that PUPPP brings can make you feel tetchy and anxious, and in turn, affect your sleep. This is a good time to explore all the ways of ensuring sleep quality during pregnancy.
PUPPP will cause itching, and, in worse cases, can lead to permanent scarring on the areas in which it occurs, particularly if you scratch. But other than that, it is a relatively harmless and transient condition that does not have any long-term effects on either you or your baby.
9 Tips for Managing PUPPP
The bad news is there is no definitive cure for PUPPP — all that is known is it will usually go away within several weeks after your baby is born (5). But the lack of a cure does not mean you have to sit idly by while your body feels like it’s slowly being taken over by a colony of ants.
Below is a list of tried-and-true methods that can help gain some relief from the itching, and help you maintain your sanity while dealing with PUPPP.
- Do Not Scratch: When you have an itchy area of skin it’s normal for you to want to give it a good scratch. Don’t! Scratching only leads to further damaging already stretched-out skin and will eventually just make your rash worse.
- Antihistamines: Oral antihistamines can do a great deal to relieve the itching that comes with a rash like PUPPP. But while they are usually safe to take while pregnant, you should always talk to your doctor before deciding to take them and discuss the choice of the one that is right for you. Still, don’t expect wonders from these drugs as they are often only mildly effective (6).
- Oatmeal Baths: Oatmeal baths can help to relieve itching and also soothe and moisturize your skin. Its anti-inflammatory properties will help calm irritated skin. Take one cup of oats and process it with a blender or food processor until it reaches the consistency of fine powder. Then place it into a bathtub filled with warm but not hot water. If you do not want to deal with the mess the ground oatmeal can leave, you can also place the ground oats into a cheesecloth or muslin bag and allow the water to run over it into the bath.
- Moisturize: Aloe vera, Vitamin E, cocoa butter, coconut oil, and shea butter are all topical moisturizers that can help to soothe your skin and stop the discomfort that comes with PUPPP rash. You should avoid moisturizers that contain fragrances since they can be drying to the skin. You should also avoid moisturizers that contain retinol, calamine, Vitamin A, and salicylic acid since they have been known to cause birth defects (7).
- Steroids: Steroids can be an effective way to treat PUPPP rash, but it’s imperative you use them only with your doctor’s guidance. When you go to your doctor, they might first suggest a topical steroid cream with hydrocortisone to help with the areas of itching. If your rash continues to get worse, they might even prescribe a round of oral steroids to treat the condition more aggressively.
- Grandpa’s Pine Tar Soap: Why this soap works isn’t clear, but some moms swear by it. The best part is it doesn’t only seem to help with the itching, but for some women, it helps with making the rash go away. For this treatment, wash the affected area, as well as the skin around it, three times a day. After bringing up a good lather with the soap, rinse it off with cool or lukewarm water. Moms who have used this method say they have seen the rash start to disappear in as little as three days.
- Cold Compresses: Cold temperatures can slow down the transmission of nerve signals to your rash, temporarily helping with the itching the rash can bring on (8). Simply soak a cloth in cool water and then lay it on the affected area. You can also soak it in cold milk for a compress that will help nourish the skin while it cools it.
- Soft Clothing: Nothing is more annoying than an itchy sweater against the already aggravated skin. While dealing with PUPPP, choose soft and loose clothing. These will be more comfortable and won’t irritate your skin more than it already is. Try to wear cotton clothes as much as possible.
- Natural Anti-Inflammatories: Peppermint and chamomile are natural anti-inflammatories (9), and when applied topically can give some relief to itchy and irritated areas. Combine the herbs with either aloe vera or unscented lotion and apply to your rash three times a day.
The Bottom Line
PUPPP can be painful, itchy, and irritating. If it’s happening to you, we understand how annoying it can be. We’ve been there, done that, and with a lot of patience and self-control, we reached the light at the end of the PUPPP tunnel.
If your PUPPP rash requires taking medication, it’s likely you will be on your treatment for a week or two, and possibly even after the delivery. Make sure you discuss your treatment and how it may affect breastfeeding with your doctor.
Editor's Note:Dr. Irena Ilic, MD
If you’re currently experiencing the discomfort that PUPPP can bring, remember that this is not forever. The rash will go away within weeks of your baby being born, and soon it will all be just a distant, albeit annoying, memory.