What is a PUPPP rash?

Pruritic urticarial papules and plaques of pregnancy (PUPPP) are the most common pregnancy-related pruritic rash and one of the most common conditions associated with pregnancy. Usually looking like hives, the rash usually starts on the abdomen and spreads to the surrounding area.

It most commonly occurs during someone’s third trimester of their first pregnancy and if carrying multiple babies (two or more babies). The rash is self-limiting, which means it goes away on its own, usually between four and six weeks.

It is harmless to the baby and causes no long-term harm to pregnant women. The cause is unknown, but it is thought to be related to trauma associated with skin stretching.

Itching means an unpleasant feeling on the skin that gives you a strong urge to scratch the rash. Itching affects up to 20% of pregnant women and is most commonly caused by dry skin, but may also indicate an underlying disorder specific to pregnancy, such as PUPPP.

It is also known as polymorphic rash of pregnancy (PEP), toxemic rash of pregnancy, toxic erythema of pregnancy, and prurigo of delayed pregnancy.

Treatment usually includes oral antihistamines and topical steroids. In some cases, oral steroids are required.

It is estimated that approximately 1 in 160 pregnant women will develop PUPPP.

signs and symptoms

A PUPPP rash usually begins with stretch marks on the abdomen in the third trimester. It starts with hives papules, which are small, red, itchy bumps. At this point, the rash may look like hives. Eventually, these small bumps can come together to form broad raised areas called plaques that are also very itchy.

Although the rash starts on the abdomen, it tends to avoid the belly button. It may also spread to the buttocks and thighs. However, PUPPP rarely spreads over the breasts, over the hands or feet, or on the face. Depending on how itchy the rash is, it may cause enough discomfort to interfere with your ability to sleep.

READ ALSO:  What is a missed miscarriage?

You’re more likely to have a PUPPP rash when you’re pregnant for the first time or when you’re carrying multiples. It usually lasts four to six weeks, regardless of when you give birth. It usually stops a few days after delivery. The worst itching usually lasts no more than a week.

Diagnosis of PUPPP

The diagnosis of PUPPP will be made by a healthcare professional and will be clinical, meaning it will be based on the appearance of the rash. A skin biopsy is not done unless the diagnosis is in doubt, but your healthcare provider may order blood tests to rule out other causes.

PUPPP is sometimes confused with a more serious condition called pemphigoid gestationis (PG). PG is a rare autoimmune rash that occurs in the second and third trimesters. It affects 1 in 50,000 pregnancies.

Unlike PUPPP, PG lesions usually begin early in pregnancy and tend to cluster around the navel. PUPPP can also be confused with other conditions, such as atopic dermatitis and contact or irritant dermatitis.

Itching in pregnancy can also be due to cholestasis of pregnancy, where the flow of bile from the gallbladder slows or stops. This can lead to complications, including stillbirth or premature birth.


The cause of PUPPP rash is not known. However, due to the increased risk of multiple pregnancies, it has been suggested that its development may be related to stretching of the abdominal skin.

Some studies have linked maternal weight gain, birth weight gain, and increased sex hormones during pregnancy, but these have not been proven. It was not associated with preeclampsia, autoimmune disease, hormonal abnormalities, or fetal abnormalities.


The focus of treatment of PUPPP rash is to relieve the rash and reduce itching. The most common treatments are:

  • Topical corticosteroids: These creams are used to relieve itching and prevent the rash from spreading. They reduce inflammation and suppress the body’s immune response. Once the rash is under control, your healthcare professional may recommend switching to a lower-strength corticosteroid.
  • Oral antihistamines: These are usually less effective than topical corticosteroids in treating symptoms, but may help with side effects, such as trouble sleeping. Keep in mind that not all antihistamines are approved during pregnancy.
  • Oral steroids: Usually avoided during pregnancy, but serious conditions may require treatment.
READ ALSO:  What is a zygote?

If you have a severe case of PUPPP that is not responding to common treatments, your healthcare provider may explore alternative ways to treat the condition. In one case of postpartum PUPPP, where the rash appeared after birth, intramuscular injection of autologous whole blood was used as an alternative treatment option.

risk factor

PUPPP rash is more common in multiple pregnancies and during the first pregnancy. It usually doesn’t recur in subsequent pregnancies, except for those carrying multiples (in which case it tends to be less severe than the first episode).

Other factors that may increase the risk of PUPPP include certain assisted reproductive technologies, but have not been identified.

A 2021 study reviewed 517 IVF pregnancies and 1,253 natural pregnancies and found that IVF pregnancies (all singletons) had higher rates of PUPPP than natural pregnancies. The researchers also found that the duration of progesterone treatment was associated with the development of the rash.


In some cases, PUPPP can be uncomfortable and severe enough to affect sleep and quality of life. This can be very difficult to deal with and can cause or worsen depression. In addition to being treated with PUPPP, you can use coping strategies to help relieve your symptoms.

Recommendations for dealing with PUPPP include:

  • A cool, soothing bath or shower: A cool compress may also help relieve symptoms.
  • Avoid scratching: While it can be difficult, try to avoid scratching the rash if possible. Doing so may only make the rash symptoms worse.
  • Regular use of emollients: These emollients work by adding moisture to the skin and preventing moisture from evaporating.
  • Wear light cotton clothing: This will help ensure that the rash area isn’t more irritated than it is.
READ ALSO:  What to know about heart disease and pregnancy

VigorTip words

Having an itchy rash, such as PUPPP, during pregnancy is not only uncomfortable, it can also cause quite a bit of anxiety, especially if it interferes with your sleep.

Be sure to talk to your healthcare provider if you have itching during pregnancy, as it may be associated with a more serious condition, such as gestational urticaria or cholestasis of pregnancy.

Keep in mind that PUPPP usually clears up within a month or so, and there is no danger to you or your baby. Consult your healthcare provider if you have any concerns or need help dealing with your symptoms. They will be able to tell you the best way to manage your condition.

Frequently Asked Questions

  • Where does the PUPPP rash appear?

    Pruritic urticaria and plaques of pregnancy (PUPPP) rash appear on the abdomen and avoid the navel. The rash can spread to the buttocks and thighs. Rarely, it can also reach the hands, feet or face.

  • What is polymorphic rash of pregnancy?

    Polymorphic pregnancy eruption (PEP) is another name for PUPPP rash. Toxemic rash of pregnancy, prurigo delayed onset, and toxic erythema of pregnancy may also occur.

  • How long does it take for a PUPPP rash to go away after pregnancy?

    A PUPPP rash usually goes away on its own within 15 days of pregnancy. It can cause itching until the rash goes away. Many people relieve this itching with topical corticosteroids, but oatmeal baths and the use of moist and cold compresses can also relieve itching.