The Bottom Line

PUPPP (Pruritic Urticarial Papules and Plaques of Pregnancy) is the most common pregnancy-specific skin rash, affecting about 1 in 160 pregnancies. It typically starts in stretch marks on the abdomen during the third trimester, causing intensely itchy hive-like bumps. While extremely uncomfortable, PUPPP poses no risk to the baby and resolves on its own within days to weeks after delivery.

What Is PUPPP?

PUPPP (also known as PEP — Polymorphic Eruption of Pregnancy) is an intensely itchy inflammatory skin condition unique to pregnancy. Key characteristics:

  • Usually begins in the third trimester, most commonly around weeks 34-36
  • More common in first pregnancies (75% of cases) and rarely recurs in subsequent pregnancies
  • More frequent with multiple gestations (twins, triplets) — likely related to greater skin stretching
  • More common in women with excessive weight gain during pregnancy
  • Starts within stretch marks (striae) on the abdomen in 90% of cases

Recognizing PUPPP

Appearance: Red, raised, hive-like bumps (urticarial papules and plaques) that are intensely itchy. They may merge into larger patches. Some patients develop tiny blisters or target-like lesions. The rash notably spares the navel (umbilicus) — a helpful diagnostic feature.

Distribution:

  1. Starts in abdominal stretch marks
  2. Spreads to thighs, buttocks, and arms
  3. May spread to the entire body
  4. Typically spares the face, palms, and soles

Itch severity: The itching can be severe enough to interfere with sleep and daily activities. Many women describe it as the most uncomfortable aspect of their pregnancy.

Diagnosis

PUPPP is diagnosed clinically (by its appearance and pattern). No specific blood test exists. Your doctor will want to rule out other conditions, particularly:

  • Intrahepatic cholestasis of pregnancy (ICP): Causes severe itching (especially palms and soles) WITHOUT a rash. Requires bile acid and liver function blood tests. Unlike PUPPP, ICP can be harmful to the baby.
  • Pemphigoid gestationis: A rarer autoimmune condition causing blisters. Biopsy can distinguish it from PUPPP.
  • Atopic eruption of pregnancy: Eczema-like rash that can occur earlier in pregnancy

Safe Treatment Options

First-line treatments:

  • Topical corticosteroids: Medium-potency (triamcinolone 0.1%) or potent (betamethasone 0.05%) applied to affected areas 1-2 times daily. Considered safe in pregnancy when used appropriately. These are the most effective topical treatment.
  • Oral antihistamines: Cetirizine (Zyrtec), loratadine (Claritin), or diphenhydramine (Benadryl) to reduce itching. All are Category B (generally safe) in pregnancy.
  • Emollients: Calamine lotion, menthol-containing creams, and thick moisturizers provide soothing relief. Cool compresses help temporarily.
  • Oatmeal baths: Colloidal oatmeal soaked in lukewarm bath water soothes widespread itching

For severe cases:

  • Short course of oral prednisone (40mg, tapering over 1-2 weeks) for intractable itching
  • Early delivery may be considered if the condition is severe and the pregnancy is near term, though this is rarely necessary

Frequently Asked Questions

Is PUPPP harmful to my baby?

No. PUPPP does not affect the baby's health, growth, or delivery outcome. It is purely a maternal discomfort issue. This distinguishes it from ICP (cholestasis), which can cause complications for the baby.

When will the rash go away?

PUPPP typically resolves within 1-2 weeks after delivery, though some women see improvement in the final days before delivery. In rare cases, it may persist for up to 6 weeks postpartum. Treatment can continue safely during breastfeeding.

Will PUPPP come back in my next pregnancy?

Recurrence is uncommon — only about 5% of women experience PUPPP again in subsequent pregnancies. When it does recur, it's often milder.

  1. Ambros-Rudolph CM, et al. "The specific dermatoses of pregnancy revisited and reclassified." JAAD. 2006;54(3):395-404.
  2. Kroumpouzos G, Cohen LM. "Specific dermatoses of pregnancy: an evidence-based systematic review." American Journal of Obstetrics and Gynecology. 2003;188(4):1083-1092.
  3. Vaughan Jones SA, et al. "A prospective study of 200 women with dermatoses of pregnancy." British Journal of Dermatology. 1999;141(1):71-81.