Itching in Pregnancy


Written by : Dr.M.D.Mazumdar, MD

Itching in pregnancy is not uncommon. More than 20% of all pregnant women suffer from itching at some time or the other during pregnancy.

Pregnancy is a period of various changes - immunologic, metabolic and hormonal. This makes the pregnant women susceptible to various changes in the skin which can be both physiologic and pathologic.

Itching all over the body may be mild and manageable. But in some women, it can be severe enough to affect sleep and quality of life. It can be so severe as to cause depression or worsen already present depression.

In most cases, itching is due to simple dryness of the skin. Dryness occurs due to stretching of the skin over the enlarging uterus in the abdomen. Dryness and itching is also most common over the breasts, thighs, hips and buttocks. In other parts of the body, skin dryness can be due to stretching of the skin due to fat deposits under the skin.

Causes of Itching in Pregnancy

There are some causes of itching in pregnancy which are specific to pregnancy alone:

1. Pruritic urticarial papules and plaques of pregnancy (PUPPP). Also known as polymorphic eruption of pregnancy (PEP), toxemia of pregnancy, or prurigo of pregnancy.

2. Intrahepatic cholestasis of pregnancy. Also called idiopathic jaundice of pregnancy, obstetric cholestasis, and pruritus gravidarum

3. Pemphigoid gestationis

4. Atopic eruption of pregnancy. This condition includes prurigo of pregnancy, pruritic folliculitis of pregnancy, and eczema in pregnancy.

On this page, we will be discussing PUPPP.

Pruritic urticarial papules and plaques of pregnancy (PUPPP)

About 1 in 200 women develop PUPPP. It usually starts in the third trimester, the itching increasing as the pregnancy progresses. Some women however may begin to show early signs in the second trimester. PUPPP is characterised by a hive like rash with multiple small, red, itchy bumps on the skin. The itchiness is severe enough to affect the sleep and general life of the pregnant woman.

Itching due to PUPPP starts on the abdomen and gradually spreads to the thighs, legs and arms. In some women it may even occur in large plaques on the back and buttocks. It usually does not occur on the face. In fact, it is uncommon above the abdomen area. It is rare for PUPPP to cause itching of the hands and feet.

Severe itching of the soles and hands can be due to Intrahepatic Cholestasis of Pregnancy (ICP) and cna be potentially dangerous to the baby.

PUPPP does not cause risk to mother or child. Some babies may show a mild PUPPP rash at childbirth which soon disappears spontaneously.

Causes of PUPPP:

The exact cause of PUPPP is not known.

1. Stretching of the Skin: The most commonly accepted theory suggests that it occurs due to overstretching of the skin in some women. As the abdomen enlarges to accommodate the growing uterus, the skin stretches. The stretching of the skin causes damage to the connective tissues like the elastin and collagen fibres. The subsequent irritation and inflammation sets up an autoimmune reaction which causes the rash and the intense itching. The tearing of the elastin fibres also leads to the formation of stretch marks.

Women who carry large babies or in whom the abdomen is distended due to twins or hydramnios are more likely to suffer from PUPPP.

This theory for the occurance of PUPPP is supported by the fact that :-

- The rash and itching starts within the stretch marks and then spreads out.

- Occurs when the skin stretches most - usually in the last trimester and more so in the last five weeks.

- The risks of developing PUPPP is more in triplet pregnancy (14% than in twin pregnancies 2.9%). The skin stretches more in a women carrying triplets.

2. Inflammatory Reaction: Another cause of PUPPP is believed to be due to an inflammatory reaction to fetal cells circulating in the maternal blood. This theory is supported by the fact that fetal cells disappear from the maternal blood within the first few weeks of childbirth. In most cases, PUPPP also decreases and disappears in the same time period. In some women however, a mild PUPPP may linger for 4-6 weeks.

3. Genetic Cause: Another theory suggests that it is genetic in nature and comes from the father's side of the family. So, itching due to PUPPP may develop if the paternal aunts also had the condition during pregnancy.

Signs and Symptoms:

PUPPP starts as intense itchiness within the stretch marks. Since stretch marks occur mainly on the abdomen, itchiness is also severe on this region. Stretch marks and itchiness may also occur on the breasts, hips, thighs and buttocks. The itchiness develops into a rash which consists of clusters of small pink or red pimple like spots which are particularly itchy.

The irritation and itchiness increases at night. It can be severe enough to interfere with sleep and make the pregnant woman miserable and fatigued the next day.

The clusters enlarge and may join together to form large reddish papules and plaques. The lesion may be surrounded by a halo in the early stages - this is more apparent in fair skinned women.

Small blisters containing clear fluid may form around the rash.

Red streaks and scratch marks may be seen on the abdomen due to the uncontrollable itching

The rash and itchiness increases as the pregnancy progresses and is worst in the last five weeks of pregnancy.

Risk Factors to develop PUPPP

Some women are more prone to develop the itchiness characterizing PUPPP.

- Women in their first Pregnancy.

- Women with diabetes since that can cause the baby to be larger than normal with more stretching of the skin. Diabetes may be gestational diabetes or a previously present diabetes.

- Hypertension can increase the risks of developing PUPPP.

- Twin Pregnancy or Triplet pregnancy can cause excessive stretching of the skin.

- Excessive weight gain is another risk factor for PUPPP

- Caucasian women are more likely to get PUPP. The whiter the skin, the more the chances of getting PUPPP.

- For some reason, women carrying a male fetus is more at risk of getting PUPPP.

Tests for PUPPP

There is no definite test to diagnose PUPPP. But certain tests need to be done to rule out other causes of itching in pregnancy.

- Complete blood count

- Liver Function tests to rule out Cholestatic jaundice of pregnancy

- Comprehensive metabolic panel for metabolic diseases which can also cause itching in pregnancy

- Serum Cortisol - high cortisol levels can cause itching of the skin

- Serum HCG levels - HCG levels will be high in twin pregnancy.

- Ultrasound to check for twin pregnancy

- Blood tests for the blood sugar level. Diabetes increases the risks of PUPPP

- Skin biopsy does not show any specific changes in PUPPP so it is usually unnecessary. But it may be carried out to differentiate it from other, more serious skin conditions which may affect pregnancy such as pemphigoid gestationis and pustular psoriasis.

Treatment:

Treatment is aimed at alleviating the symptoms. PUPPA or itching in pregnancy due to PUPPP clears up spontaneously after childbirth. It cannot be cured completely during the pregnancy.

Some steps which can be taken to prevent itching:

- Keeping cool can prevent itching. Wearing loose, cotton clothes in natural fibres can help air movement around the body and control itching to some extent.

- The skin should be well moisturised with a good oil such as coconut oil or almond oil. Cocoa butter is also helpful. Moisturisers that contain retinol, salicylic acid, vitamin A, tropic acid, and retinyl palmitate should be avoided.

- Harsh soaps should be avoided. The body should be washed instead with moisturising emollient soap substitutes which are unscented . Baby soaps are quite effective in this regard.

- Oats or oat milk are natural anti-itching substances. A handful of oats added to the bathwater or rubbing the body with oats wrapped in a small piece of cloth can be helpful.

- Patting the skin dry is better than rubbing - rubbing the skin with a towel after a bath can trigger off a bout of itching.

- Spraying the body from time to time with a cool mist is a good method of keeping cool.

- Scented cosmetics should be avoided. Cosmetics which are specially formulated for sensitive skin is better.

- Being out in the sun should be avoided as much as possible. The heat can trigger heat rash and more itching.

- Calamine lotion contains ingredients which can control itching. It can be applied all over the body.

- Aloe vera is a good moisturiser to use.

- If these steps do not help, application of a mild 1% steroid cream may be necessary in some women.

- Some women may even need to be prescribed anti-histaminic or steroid tablets to control the acute itching.

- Rarely, labour may need to be induced early since childbirth will cause PUPPP to clear up spontaneously.

Prognosis: PUPPP clears up within the first few weeks after childbirth. Some babies may be born with a mild form of PUPPP but this too clears up spontaneously in the first few days after bith.

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