What is the topical steroid of choice for Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP)?

Topical Steroid of Choice for PUPPP

Medium to high potency topical corticosteroids are the first-line treatment for Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP), with fluticasone propionate 0.05% lotion being particularly effective and safe during pregnancy.

Treatment Algorithm for PUPPP

First-Line Treatment:

• Medium to high potency topical corticosteroids:
  • Fluticasone propionate 0.05% lotion applied twice daily 1
  • Clobetasone butyrate (moderate potency) 2
  • Triamcinolone acetonide 0.1% for moderate cases

For Severe or Refractory Cases:

1. Oral antihistamines for additional symptom relief:

   • Non-sedating options: fexofenadine 180mg or loratadine 10mg daily 2, 3
   • For nighttime relief: cetirizine 10mg or hydroxyzine (short-term use only) 2

2. Short course of oral corticosteroids for severe, widespread cases:

   • Prednisone (starting at 0.5-0.75 mg/kg/day) with rapid taper 3

Clinical Evidence and Rationale

Research demonstrates that fluticasone propionate 0.05% lotion (a class 5 low-medium potency corticosteroid) can completely resolve PUPPP symptoms within one week of twice-daily application 1. This option has a favorable safety profile during pregnancy, making it an excellent first choice.

The British Association of Dermatologists guidelines support using topical corticosteroids for pruritic conditions, with medium potency options like clobetasone butyrate being available over-the-counter and recommended for generalized pruritus 2.

Important Clinical Considerations

• Treatment duration: Typically 1-2 weeks is sufficient; PUPPP usually resolves spontaneously after delivery 4
• Application technique: Apply a thin layer to affected areas twice daily
• Treatment area: Focus on abdomen, thighs, and buttocks where PUPPP commonly presents, but include palms and soles if affected (unusual but possible) 5
• Monitoring: Assess response after one week; if inadequate, consider increasing potency or adding oral antihistamines

Pitfalls and Caveats

1. Avoid overtreatment: PUPPP is self-limiting and typically resolves within one week of delivery 6
2. Differential diagnosis: Important to distinguish PUPPP from pemphigoid gestationis, which requires different management and has potential fetal consequences 5
3. Steroid side effects: Limit use of high-potency steroids to 2-3 weeks to avoid skin atrophy and striae formation
4. Postpartum presentation: While PUPPP typically occurs in the third trimester, it can occasionally present postpartum, requiring the same treatment approach 3

The choice of topical steroid should consider the extent and severity of the eruption, with fluticasone propionate 0.05% lotion offering an excellent balance of efficacy and safety during pregnancy based on the most recent evidence.