I wish I could say that PUPPP was a cute new term for a tiny dog, but, alas, it is not. Instead, it is an acronym for the worst rash ever. I briefly touched on this rash in my last post, but I feel that it now warrants its very own dedicated post because it ended up progressing in the postpartum period to a point that felt truly unbearable.
Background:
A little background on PUPPP/PUPPS/PEP (aka Pruritic Urticarial Papules and Plaques of Pregnancy): I am no expert on this, but from my rudimentary internet searching, it seems there are several schools of thought on what causes this awful rash:
- Allergic reaction to circulating fetal cells in the mother’s blood stream.
- Liver dysfunction due to some type of “over toxification” that occurs during pregnancy.
- Inflammatory response to skin that has been over-stretched.
The rash typically affects first time pregnancies (aka primigravidas), and women who are pregnant with boys/multiples/extra large babies (in other words, women whose bellies undergo a hefty amount of stretching). On average, it seems that PUPPP affects around 0.5% of all pregnant women, and [thankfully] has a very low incidence of recurrence with subsequent pregnancies.
PUPPP almost always begins on the belly as insanely itchy eruptions along newly formed stretch marks (usually during the third trimester, but some women get it earlier than this). From there, it may spread to the back, buttocks, arms, legs, hands, and feet. It typically spares the belly button, face, neck, palms and soles.
The rash is historically “cured” by giving birth, but in a small subset of women, the rash worsens in the postpartum period. Unfortunately, this was my experience.
Prior to giving birth, my case of PUPPP was confined to my belly and a small area of my back/buttocks. Within 24 hours of giving birth, the rash had spread to involve all of my abdomen, back, arms, hands, buttocks, legs, and feet. It was unbearable. And the itch always seemed worse at night, as if it was taunting my already sleepless state of health.
So, without further ado, here are 8 things I wish I knew about PUPPP when I first got this horrific rash. However, before reading through this list, please understand that none of these things are intended as medical advice and that you should consult your OB/GYN and/or Pediatrician/Lactation consultant before trying any of them.
8 Things I Wish I Knew About PUPPP:
- Itching makes the rash worse. Therefore, try your absolute hardest NOT to itch even though this is easier said than done. The ugly truth is that while the rash is raging on, anywhere (and I mean ANYWHERE) that you aggravate your skin, you WILL get a new eruption. At the end of the day, it’s not worth the misery of a brand new patch of horrendously itchy, red, blistery skin just to have the satisfaction of a few minutes of itching.
- Increased body heat makes the rash worse. Unfortunately, this means that you will need to avoid hot showers and keep your body temperature cool. So how do you do this? Take lukewarm (or cold if you can!) showers and sleep in the nude (or with minimal undergarments). Do not use more than a sheet for a cover to allow for maximum cooling and direct a large fan at your bed while you sleep. Don’t wear any heavy layers and try your best to keep from sweating. Wear loose-fitting cotton clothing as it will help cut back on incidental skin aggravation and allow for maximum air circulation to keep your body cool. And, under no circumstances should you apply a heating pack as it will undoubtedly cause a new eruption of awful rash at the application site. For me, the hardest part about keeping my body temperature cool was avoiding skin-to-skin contact with my husband; his skin is perceptibly warmer than mine and, as a result, his touch literally caused the rash to spread. It was terrible not being able to snuggle up to him at night or feel his hand on my leg…I felt incredibly lonely and isolated, even though my husband would be sitting right next to me.
- Anti-itch creams CAN and DO help with the itch. Proper moisturization is key to recovery, and lotions with anti-itch ingredients are like little guardian angels. Keep a bottle of anti-itch cream with you at all times and apply it whenever your fingers are tempted to scratch. My favorites are Gold Bond Extra Strength Body Lotion and Sarna Anti-Itch Lotion. But, beware that both of these lotions contain menthol which causes a sudden cooling sensation about 1-3 minutes after application. This is wonderful for chasing the roving itch in the middle of the night, but awful if you’re just getting out of the shower and think it’s a good idea to slather every square inch of your body with this stuff. In truth, if you apply these lotions right after a shower, you will feel tremendous relief of your itch…followed by an earth-shattering sensation of hypothermia. So…consider yourself warned. Another important point to consider when using mentholated products is that they are very aromatic and may be harmful to your baby if he/she breathes them in when they have been freshly applied.
- Ice packs are your best friends. The shock your skin receives from the icy cold will stop the itch in its tracks (sadly this relief is only temporary). Keep a supply of ice packs handy and use them on the worst parts of your rash (i.e., where you think you will not be able to keep your fingernails from scratching off your skin). I love gel ice packs because they are flexible and can be molded around the affected body part to provide maximum relief. They also seem to keep their cool for a long time, so you can easily get 1-2 hours of relief. I had 4 gel packs and at night, I would bring 2 of them to bed with me while keeping the other 2 in a cooler next to my bed. When the 2 gel packs in bed no longer felt cold, I would swap them out with the 2 in the cooler so that I had a constant source of icy cold relief while never having to get out of bed.
- Don’t be afraid of topical steroids. If your case is unbearable and the rash just seems to keep spreading, don’t delay talking to your doctor about starting steroids. At 3 days postpartum, the rash had taken over >75% of my body and I couldn’t endure it anymore, especially with a newborn who was depending on me. In complete desperation, I called my OB/GYN and begged for something to relieve the itch, and was ultimately prescribed a topical steroid called clobetasol propionate ointment 0.05%. The tube was comically small and only gave me 2 applications (15g doesn’t go very far when you’re 6’1″ tall and have the rash on >75% of your body). But, I was still grateful for it as it provided more long-term itch relief (approx. 4-6 hours) than Gold Bond or Sarna. However, it did not begin acting immediately, so there was about 20-30 minutes where I felt the insane desire to itch while the medication took effect. It was a terrible time.
- If topical steroids fail, don’t be afraid of systemic (i.e., oral) steroids. These became necessary for me at the 4 day postpartum mark. In spite of using a prescription high-potency topical steroid, the rash continued to spread and prevented me from getting any sleep. Incidentally, I happened to be at the Emergency Department for a different reason that day (please see my birth story post for more details), and was able to get a prescription for prednisone from the ED doctor. He gave me a single dose of IV Solu-Medrol in the ER, then started me on prednisone 40mg by mouth daily for 5 days. At 7 days postpartum (3 days after starting prednisone), the rash was INFINITELY better and I had my first stretch of sleep since prior to labor beginning (no exaggeration here). Life began to feel a little bit hopeful at that point as I could tell that the rash was beginning to fade.
- Alternative therapies can be a big relief if you’re open to them. Do your due diligence to find out if they are safe for you (and your baby) to take…but once you decide to take them, BELIEVE IN THEM. Sometimes it’s the belief in something that makes it work, not the medical science behind it. I read on the internet that dandelion root extract and V8 juice provided good relief for lots of moms out there, so I decided to try them for myself. I ordered Nature’s Way dandelion root from Amazon and began taking 1 capsule 3 times daily (incidentally, I also started taking prednisone the same day that I started taking dandelion root and V8). Around 3 days into therapy, the rash became notably better…but, due to the fact that I was on concurrent therapy with Prednisone, I don’t have any good way of differentiating whether the improvement in the rash was owed to the alternative therapies or to prednisone…or, to a combination of the two. Although the next few remedies didn’t work for me, there are literally hundreds of stories on the internet from other moms for whom they did work, and for that reason I have decided to include them here:
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- Grandpa’s Pine Tar Soap (get it on Amazon) – to be fair, this did provide some relief, but the hassle of using it made it rank low on my list of PUPPP remedies. In order for this product to be effective, you need to lather the soap with minimal water and let it set for a good 5 minutes, then rinse off with a COLD shower. The mere act of standing naked in the shower waiting for this smelly product to take effect, followed by the uncomfortable sensation of a cold shower made me want to never use it again. And, in order to maximize its effectiveness, you need to lather/rinse at least 3-4 times per day. No thank you.
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- Aloe vera gel with lidocaine (get it on Amazon) – this works well for small patch jobs, but did not provide nearly the same level of itch relief as Gold Bond or Sarna. You can put the bottle in the fridge for some extra cooling sensation, but ultimately I found that it was lacking.
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- Over-the-counter topical steroids (try Hydrocortisone 10 ointment from Amazon) – this is good when you have a small area of rash to treat, but if your rash spreads beyond your belly, then you should not delay getting some of the other remedies mentioned above. And, when it comes down to a choice between an ointment or a cream, please know that a cream will likely leave your skin with a residue that promotes further itching whereas an ointment will soak in completely with time and leave no residue. For whatever reason, residues seem to only be an issue with steroid and antihistamine creams; I did not have any issues with residues left by moisturizing or anti-itch lotions.
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- Oral antihistamines (e.g.,Claritin/loratadine, Zyrtec/cetirizine, Allegra/fexofenadine) – for cases of PUPPP that care caused by an allergic reaction to circulating fetal blood cells, these medications should work in theory. However, I did not get any level of relief from them. I took generic Zyrtec (cetirizine) 10mg every day during pregnancy and have continued to take it in the postpartum setting because of severe environmental allergies. In an act of desperation, I added diphenhydramine (generic Benadryl) for a while to see if this would help with my PUPPP; unfortunately, I found no difference in my itchiness when taking Benadryl. Furthermore, I would caution anyone thinking of trying Benadryl to consider the following: it is very sedating and dries you out. What does this mean for a breastfeeding mom? You may be too drowsy to safely hold your baby while nursing, and your milk supply may dry up (to some degree). Even though Benadryl is considered safe during pregnancy/breastfeeding, please talk to your healthcare provider if you want to start using Benadryl to treat your PUPPP.
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- Topical antihistamines (e.g., Benadryl Cream) – as with oral antihistamines, topical antihistamines should also help in theory to reduce PUPPP by way of counteracting the allergic reaction to circulating fetal blood cells. However, once again, topical Benadryl cream did not seem to reduce my itchiness. In fact, I would actually say that it made my rash more itchy because my blisters were aggravated by the residue that the cream left on my skin.
- Above all else, keep reminding yourself that the rash WILL get better and it will NOT destroy your life. Your skin is dynamic and can change and heal in a matter of hours. Most cases of PUPPP should resolve without intervention within 1-2 weeks of delivery, but if your case is severe and prevents you from being able to carry on your activities of daily living, then please please PLEASE seek medical help.
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- Even if you have a resurgence of PUPPP after it clears up, don’t get discouraged! My case of PUPPP pretty much cleared up by 2 weeks postpartum, but came back again about 3-4 weeks later. The resurgence was much less itchy and only affected areas that hadn’t been hit hard the first time around (mainly my legs and back). I was able to manage the resurgence exclusively by Sarna lotion, dandelion root extract (1 capsule daily this time around instead of 3), and topical over-the-counter hydrocortisone ointment. By 7 weeks postpartum, PUPPP had left my system for good!
The Take-Away:
Here is a snapshot of all the different remedies I tried to cope with my case of PUPPP. In the end, it was gel ice packs, mentholated anti-itch lotions, dandelion root extract and steroids that worked for me. To every woman out there suffering, remember that you are NOT alone, and this will NOT last forever. Keep those fingernails trimmed short and try your hardest not to itch. Slather yourself in ultra-hydrating lotion at least twice a day (this is especially important right after you shower), and make sure you drink extra fluids throughout the day. Moisturized skin is happy skin.
