How do I manage a pregnant patient with PUPPPS?

Management of PUPPP (Pruritic Urticarial Papules and Plaques of Pregnancy)

Start with a medium-potency topical corticosteroid (fluticasone propionate 0.05% lotion or equivalent) applied twice daily, combined with oral antihistamines for symptomatic relief. 1, 2

Initial Assessment

When a pregnant patient presents with suspected PUPPP, confirm the diagnosis by identifying:

• Timing: Onset typically in the third trimester (though can occur earlier in 2 of 15 cases) 2
• Distribution: Symmetric eruption starting on the abdomen (particularly within striae), spreading to proximal extremities 2
• Morphology: Urticarial papules and plaques, may include erythema multiforme-like target lesions 2
• Pruritus: Moderate to intense itching present in nearly all cases 2

Higher risk populations: Multiple gestations have significantly increased incidence—2.9% in twin pregnancies and 14% in triplet pregnancies compared to 0.5% in singleton pregnancies 3

First-Line Treatment

Topical corticosteroids are the mainstay of therapy:

• Apply fluticasone propionate 0.05% lotion (class 5, low-medium potency) twice daily to affected areas 1
• This has a benign side effect profile appropriate for pregnancy and can achieve complete resolution within one week 1
• Higher potency topical corticosteroids can be used if medium-potency agents fail 1, 2

Adjunctive symptomatic management:

• Oral diphenhydramine for pruritus control 2
• Antihistamines provide relief in most cases when combined with topical therapy 2

Second-Line Options

If topical corticosteroids and antihistamines provide inadequate relief:

• Oral corticosteroids can be considered for severe, refractory cases 1
• Intramuscular autologous whole blood injection has shown efficacy in small case series with no adverse fetal effects, though this remains investigational 4

Expected Clinical Course

Reassure the patient about prognosis:

• PUPPP is completely benign with no fetal complications or wastage 2
• Resolution occurs in one of three patterns: before delivery (33% of cases), within 1 week postpartum (60% of cases), or by 6 weeks postpartum (7% of cases) 2
• The condition can resolve entirely during pregnancy even without delivery 1
• Subsequent pregnancies are typically uneventful without recurrence 2

Critical Pitfalls to Avoid

• Do not delay treatment waiting for spontaneous resolution—the intense pruritus significantly impacts quality of life and responds well to therapy 1, 2
• Do not avoid topical corticosteroids due to pregnancy concerns—medium-potency agents like fluticasone propionate 0.05% have excellent safety profiles 1
• Do not confuse PUPPP with other pregnancy dermatoses that may require different management or signal fetal risk 2
• Do not assume all pruritic pregnancy rashes are PUPPP—ensure proper diagnosis as other conditions may have fetal implications 2

Monitoring

• Follow-up within 1 week to assess treatment response 1
• If symptoms persist beyond 1 week of appropriate therapy, consider escalating to higher potency topical corticosteroids or adding oral corticosteroids 1, 2
• No special fetal monitoring is required as PUPPP has no adverse fetal outcomes 2