Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP), also known as Polymorphic Eruption of Pregnancy (PEP), is the most common skin condition to arise during gestation, typically occurring in the late third trimester. This non-dangerous inflammatory disorder is characterized by a rash that causes intense itching. Although PUPPP poses no long-term risk to the developing fetus, the severe discomfort can significantly impact the mother’s quality of life and sleep.
The Visual Description of the Rash
The PUPPP rash initially appears as small, raised, red papules that often look similar to hives. These papules are usually firm to the touch and can be surrounded by a pale ring, known as a blanched or urticarial halo, especially on lighter skin tones. On darker complexions, the bumps may be skin-colored or slightly darker than the surrounding skin.
As the condition progresses, these individual papules often merge, forming larger, elevated patches called plaques. The rash is considered “polymorphic” because its appearance changes over time, evolving from simple bumps into widespread areas of redness and swelling. The lesions can sometimes develop small, fluid-filled tops (vesicles), but large, tense blisters are rare and may suggest a different diagnosis.
Where the Rash Typically Appears
The onset of the PUPPP rash almost always begins within the stretch marks (striae) on the abdomen. The rash typically develops where the skin has undergone the most stretching, often occurring in the last five weeks of pregnancy. A distinguishing characteristic is its tendency to spare the skin immediately surrounding the belly button, known as periumbilical sparing.
After its initial appearance on the abdomen, the eruption spreads outward over a matter of days. It commonly moves to the thighs, buttocks, and upper arms, following the limbs and trunk. Areas that are rarely affected, which helps distinguish it from other rashes, include the face, palms, and soles of the feet.
Itching Intensity and Duration
The most prominent symptom of PUPPP is intense itching, which often precedes the appearance of the full rash. The sensation is frequently described as debilitating and severe enough to interfere with daily activities and disrupt sleep, often worsening significantly at night. This intense itching is the main reason individuals seek medical attention.
PUPPP most commonly appears late in the third trimester of pregnancy, though in a small percentage of cases, it can begin immediately postpartum. The condition is temporary, and the rash typically resolves completely within one to two weeks after delivery. Recurrence in subsequent pregnancies is possible but uncommon.
Finding Relief and Treatment Options
Treatment for PUPPP focuses on managing symptoms and providing relief until the condition resolves after delivery. For mild to moderate cases, over-the-counter and home remedies are the first line of defense against the persistent itch. These remedies can help calm the skin:
- Applying cool compresses.
- Taking lukewarm baths with colloidal oatmeal.
- Using soothing, itch-relieving moisturizers like calamine lotion.
- Using aloe vera gel.
Medical management often includes topical corticosteroids, applied directly to the rash to reduce inflammation and itching. Mild-potency topical steroids are used for localized areas, while mid- or high-potency creams may be prescribed for more extensive plaques. Oral antihistamines are frequently prescribed, primarily to help with sleep disruption caused by nocturnal itching. In the most severe cases, a healthcare provider may prescribe a short course of oral corticosteroids, such as prednisone, for rapid relief. Consulting a healthcare provider is important to confirm the diagnosis and rule out other, potentially more serious, gestational dermatoses.