What is Pruritic Urticarial Papules and Plaques of Pregnancy?
Pruritic urticarial papules and plaques of pregnancy (PUPPP), also often called polymorphic eruption of pregnancy (PEP), is the most common skin condition that can occur during pregnancy. It’s a harmless, but very itchy skin problem that consists of different symptom presentations. It’s identified by normal lab tests and does not show any signs of an immune system reaction when the skin is tested. Usually, PUPPP affects women who are pregnant for the first time during their third trimester, but it can also occur less frequently just after childbirth. It typically does not happen again in future pregnancies.
The first time PUPPP was described by experts was in 1979 by Lawley and his colleagues. They noted it caused hives and raised skin areas that developed within stretch marks. There are also other skin changes that can happen with this condition, which is why the term “polymorphic eruption of pregnancy” has been suggested and is now also widely used.
What Causes Pruritic Urticarial Papules and Plaques of Pregnancy?
The exact cause of pruritic urticarial papules and plaques of pregnancy (PUPPP), a skin condition that causes itchy bumps and patches during pregnancy, is unclear. However, several theories have been suggested, including the stretching of the abdomen, changes in hormones, the influence of the placenta, and the mixing of the baby’s DNA within the skin of the pregnant person with PUPPP.
In a research study conducted by Holms and colleagues, about 90% of the participants were observed to have developed the rash due to damage to the tissue that connects different structures within the body, especially in the stretch marks. Therefore, rapid and significant stretching of the skin on the abdomen, particularly common in multiple pregnancies, could lead to damage in this connecting tissue. This damage could tip off an allergic-type reaction, causing the rash to appear, especially in the stretch marks.
Another theory suggests that a phenomenon known as peripheral chimerism, which refers to the dispersal of the baby’s DNA, primarily during the last three months of pregnancy, could trigger an immune response. This could be particularly true for areas of skin with high blood flow and damaged connective tissue, making them a possible target for this immune response.
However, how this skin condition spreads across the body remains unknown. One possibility is that an inflammatory response (the body’s reaction to injuries or infections) might be triggered due to a reaction between the immune system and collagen, a protein in the skin, in skin which appears otherwise healthy. There’s also a theory that an immune tolerance mechanism (the body’s way to coexist with something foreign, like a baby) during future pregnancies could prevent recurrence.
Moreover, high levels of progesterone – a hormone that rises during pregnancy and is particularly high in multiple pregnancies – have been noticed in patients with PUPPP. One more hypothesis involves the growth of skin cells called fibroblasts, which could be stimulated by a hormone-like substance from the placenta.
Risk Factors and Frequency for Pruritic Urticarial Papules and Plaques of Pregnancy
Pruritic urticarial papules and plaques of pregnancy (PUPPP) occurs in around 0.5% of single pregnancies, 2.9 to 16% of twin pregnancies, and 14 to 17% of triplet pregnancies according to reports. It is typically seen in women who are pregnant for the first time and doesn’t usually return in future pregnancies. Some research has linked PUPPP to more significant weight gain during pregnancy and higher birth weights in newborns.
- In a study by Ghazeeri and colleagues, patients affected were predominantly Rh-positive and 89% of them had conceived through in vitro fertilization.
- Regarding the gender of the baby, twice as many cases have been reported in pregnancies with male fetuses compared to female fetuses.
- Mostly, there is no family history of PUPPP and studies have not found a connection to autoimmune diseases or a specific HLA type.
Signs and Symptoms of Pruritic Urticarial Papules and Plaques of Pregnancy
Pruritic urticarial papules and plaques of pregnancy (PUPPP) is a rash that can occur in the last part of pregnancy. In rare cases, it might also appear after giving birth. The rash is itchy and includes small red, swollen bumps and patches, and usually appears first in the stretch marks around the belly, but often avoids the belly button area. These bumps can merge and form larger, rash-like areas on the belly, usually surrounded by lighter-colored outlines. The rash can spread within days to the chest and limbs, but it rarely affects the face, hands, or feet.
Over time, almost all patients experience a variety of symptoms as the condition develops. These symptoms may include widespread redness, rash-like lesions that look similar to targets, small blisters, and patches that look similar to eczema. However, it’s uncommon for the rash to affect the moist linings of body cavities like the mouth or nose. PUPPP typically clears up on its own after about four weeks or with childbirth, leaving no lasting color changes or scars on the skin. In most cases, the rash does not return in future pregnancies.
- Small red, swollen bumps and patches
- First appears in the stretch marks around the belly
- Bumps and patches merge to form larger rash-like areas
- Rash may spread to the chest and limbs
- May include widespread redness, target-like lesions, small blisters, and eczema-like patches
- Typically clears up on its own after about four weeks or with childbirth
- Most likely does not return in future pregnancies
Testing for Pruritic Urticarial Papules and Plaques of Pregnancy
If you have PUPPP (Pruritic Urticarial Papules and Plaques of Pregnancy), you will usually find that regular laboratory tests fall within the normal range. It’s important to assess how much discomfort you’re experiencing from itching, as treatment primarily focuses on relieving these symptoms. In addition, your doctor should track your weight and the growth of your baby throughout your pregnancy. Generally, having PUPPP is not a reason to have your baby delivered early.
Treatment Options for Pruritic Urticarial Papules and Plaques of Pregnancy
If you have PUPPP, a skin condition often associated with pregnancy, simple tactics can help manage your symptoms. Many women find relief with creams containing corticosteroids — substances that reduce inflammation — and antihistamines, which are drugs frequently used to relieve allergies. Antihistamines that can make you drowsy might be especially useful if itching from PUPPP interrupts your sleep.
In more severe cases, where the discomfort disrupts sleep and leads to tiredness, a brief treatment with corticosteroids in pill form could be beneficial. These medications help reduce inflammation and can Systemic corticosteroids are a type of anti-inflammatory drugs that are taken orally or by injection and can quickly help reduce the inflammation.
Some general practices might also bring comfort. For example, taking cool baths, using skin moisturizers frequently, or wearing light cotton clothing can lessen the itching. They are simple but effective ways to help your skin feel better.
Recently, there has been some success with using a new type of treatment. It involves an injection of the patient’s own blood, and was used to treat a case of PUPPP that occurred after childbirth. This approach showed a positive impact on the symptoms, with both the patient’s feelings and the outward signs of the condition improving.
What else can Pruritic Urticarial Papules and Plaques of Pregnancy be?
The condition that doctors should pay a lot of attention to when trying to make a diagnosis is known as urticarial pemphigoid gestationis. This can sometimes be confused with other conditions because they may have similar symptoms. Because of this, doctors often need to conduct skin tests and immune system analyses to tell them apart. Pemphigoid gestationis usually begins earlier during pregnancy and often affects the area around the belly button. Furthermore, tests during this condition usually show positive results for certain skin changes.
Potential red flags for eczema, on the other hand, include a person or their family’s history of allergies. Eczema rashes are known to be itchy and can turn the skin red. These rashes typically show up in areas where the body bends, like the inner elbow. Other conditions doctors will be considering could include drug reactions, hives, or viral skin rashes.
What to expect with Pruritic Urticarial Papules and Plaques of Pregnancy
Besides the discomfort linked to itchy hives caused by urticarial eruption, the overall health outcome for the mother often remains unaffected. A treatment often not used is facilitating an early delivery just to provide relief from unmanageable itching. It’s important to note that there are no apparent impacts on the baby’s health, and their skin typically remains unaffected.
The recurrence of this type of skin eruption in future pregnancies is not common, unless the mother is carrying more than one baby. In cases of multiple pregnancies, it is observed that the severity of the itching and hives, or PUPPP (Pruritic Urticarial Papules and Plaques of Pregnancy), is usually less severe than the first occurrence.
