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Postpartum PUPPP: When a pregnancy rash develops postpartum

A tub of skin cream1

February 4, 2020

Skin conditions are extremely common during and after pregnancy. One of the chief complaints is itchiness (also called pruritus). Often this itchiness is due to the dryness that is caused by hormonal changes, but in rare cases it is severe and accompanied by small, raised areas of skin. This condition is called PUPPP and, while uncomfortable to experience, is harmless and easily treated.

What is PUPPP?

Pruritic urticarial papules and plaques of pregnancy (PUPPP) is a common skin condition that arises during and after pregnancy. It’s also called polymorphic eruption of pregnancy (PEP) in Europe. It typically affects first-time pregnancies, developing during the third trimester and going away within weeks of giving birth. However, on rare occasions (15% of PUPPP cases) it develops postpartum. Its cause is unknown.

What are the symptoms of PUPPP?

PUPPP is characterized by small (1-2 mm), raised areas of skin called papules. They may look a lot like hives, but can last weeks. They typically appear within stretch marks, almost always on the abdomen or thighs.

What if there’s no rash, just itchy skin?

If there’s no raised skin, it’s unlikely to be PUPPP. That means the typical treatments for PUPPP might not be effective. However, it could be a symptom of other medical conditions, including liver conditions and thyroid disorders. It’s always a good idea to talk to your healthcare provider to find out what it is.

If it’s not severe, there’s a good chance that your skin is just itchy because it’s dry. Even if you apply a lot of lotion, it may not make up for the decrease in your skin’s natural oils that results from hormone changes. It should resolve as your hormone levels return to normal, but in the meantime, dry to keep your skin as hydrated as possible.

Related: Why is your skin so itchy?

When will it go away?

When PUPPP occurs during pregnancy, it typically resolves within days following delivery. However, in 15-20% of women, it lasts 2-4 weeks postpartum. It usually leaves no scarring.

What can you do about it?

If you think you might have PUPPP, talk to your doctor. An OB/GYN or midwife should be familiar with PUPPP, but may refer you to a dermatologist.

The treatment typically includes oral antihistamines (like Benedryl), skin emollients, and topical corticosteroids to relieve the itching. These generally are considered safe for pregnancy and for breastfeeding, but it’s always a good idea to remind your doctor and pharmacist.

In rare cases of severe itchiness, systemic corticosteroids are prescribed, which may have risks during pregnancy and breastfeeding.

Sources:
Cunningham, F. G., & Williams, J. W. (2014). Williams Obstetrics, 24th edition. Stamford, Conn: Appleton & Lange.

Pritzier, E. C., & Mikkelsen, C. S. (2012). Polymorphic eruption of pregnancy developing postpartum: 2 case reports. Dermatology reports, 4(1), e7. doi:10.4081/dr.2012.e7. Retrieved on February 3, 2020 from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4212670/

Kim E, H: Pruritic Urticarial Papules and Plaques of Pregnancy Occurring Postpartum Treated with Intramuscular Injection of Autologous Whole Blood. Case Rep Dermatol 2017;9:151-156. doi: 10.1159/000473874. Retrieved on February 3, 2020 from https://www.karger.com/Article/Fulltext/473874

Dehdashti, A. D., & Wikas, S. N. (2015) Pruritic Urticarial Papules and Plaques of Pregnancy Occurring Postpartum. Cutis. 2015 June;95(6):344-347. Retrived on February 2, 2020 from https://www.mdedge.com/dermatology/article/100462/contact-dermatitis/pruritic-urticarial-papules-and-plaques-pregnancy

Drugs and Lactation Database (LactMed) [Internet]. Bethesda (MD): National Library of Medicine (US); 2006-. Diphenhydramine. [Updated 2018 Oct 31]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK501878/

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