I. Introduction

Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP) is an uncommon skin condition that affects some women during the late stages of pregnancy. This rash is characterized by intensely itchy, red bumps or hives that typically appear on the abdomen and can spread to other parts of the body. While harmless to the mother and baby, PUPPP rash can cause significant discomfort and distress.1

Carrying twins is a unique and often demanding experience for expectant mothers. In addition to the physical challenges associated with carrying multiple babies, twin pregnancies can also increase the risk of certain complications, including PUPPP rash. As the body undergoes significant hormonal changes and the skin stretches to accommodate the growing babies, the likelihood of developing this itchy rash may be higher in twin pregnancies.2

II. Understanding PUPPP Rash

PUPPP rash, also known as polymorphic eruption of pregnancy, is a type of dermatosis that typically appears in the third trimester or immediately after childbirth. It is characterized by intensely itchy, red bumps or hives that can range in size from small papules to larger plaques. The rash often starts on the abdomen and can spread to other areas, such as the thighs, buttocks, and arms.3

The primary symptom is intense itching, which can be severe enough to disrupt sleep and daily activities. The rash itself may appear as small, raised bumps or welts, or it may form larger, confluent plaques. The affected skin may appear red, inflamed, and sometimes scaly. In some cases, the rash may also be accompanied by a burning sensation or mild skin discoloration.4

The exact cause of PUPPP rash is not well understood, but it is believed to be related to a combination of factors, including hormonal changes, stretching of the skin, and an underlying predisposition or genetic component. Certain risk factors may increase the likelihood of developing PUPPP rash, such as:

1. First-time pregnancy
2. Multiple pregnancies (twins or triplets) 5
3. Excessive weight gain during pregnancy
4. Excessive stretching of the abdomen
5. Family history of PUPPP rash or other skin conditions

PUPPP rash is typically diagnosed based on its clinical appearance and the timing of its onset during pregnancy. Your healthcare provider may perform a physical examination and review your medical history to rule out other potential causes of the rash, such as allergic reactions or other skin conditions. In some cases, a skin biopsy may be performed to confirm the diagnosis and exclude other possibilities.6

III. PUPPP Rash in Twin Pregnancy

While the overall incidence of PUPPP rash is low, occurring in approximately 1 in 160 to 1 in 300 pregnancies, the risk is significantly higher in twin pregnancies. Some studies suggest that the incidence of PUPPP rash in twin pregnancies may be as high as 1 in 20 to 1 in 50 cases.7

During pregnancy, the body undergoes significant hormonal changes, including increased levels of oestrogen, progesterone and other hormones. These hormonal fluctuations can contribute to the development of PUPPP rash by altering the skin's sensitivity and ability to stretch. In twin pregnancies, the increased demand for hormones to support the growth and development of two babies may further exacerbate these changes, potentially increasing the risk of developing PUPPP rash.8

In addition to the hormonal changes associated with carrying multiple babies, twin pregnancies are often accompanied by other factors that can increase the risk of PUPPP rash. These include:

1. Excessive stretching of the abdomen to accommodate two babies.
2. Higher likelihood of excessive weight gain
3. Increased skin tension and stress on the abdomen

Managing PUPPP rash in a twin pregnancy can present unique challenges. Additionally, the risk of complications and potential impact on the babies' health and development must be carefully monitored. Balancing the need for effective treatment while ensuring the safety of both the babies is a key consideration for healthcare providers.

IV. Managing PUPPP Rash in Twin Pregnancy

1. Self-care tips

While there is no definitive cure for PUPPP rash, there are several self-care strategies that can help alleviate symptoms and provide relief:

• Avoid hot baths or showers, as they can exacerbate itching.
• Apply cool compresses or take lukewarm baths with colloidal oatmeal or baking soda to soothe the skin.
• Wear loose, breathable clothing to minimise skin irritation.
• Use gentle, fragrance-free moisturisers to hydrate the skin and reduce dryness.
• Practise stress-reduction techniques, as stress can worsen itching.12. Home remedies

In addition to self-care measures, some home remedies may provide temporary relief from PUPPP rash symptoms:

• Aloe vera gel can help soothe and moisturise the skin.
• Calamine lotion or menthol-based creams can provide a cooling sensation and reduce itching.
• Applying cold, damp compresses or taking cool baths can help alleviate discomfort.
• Avoiding harsh soaps, detergents, and scratching can prevent further irritation.2

1. Topical treatments

In cases where self-care and home remedies are insufficient, your healthcare provider may recommend topical treatments to manage PUPPP rash symptoms:

• Topical corticosteroid creams or ointments can reduce inflammation and itching.
• Calamine lotion or menthol-based creams can provide temporary relief from itching.
• Antihistamine creams or lotions may help alleviate itching and skin irritation.3

1. Oral medications

For more severe or persistent cases of PUPPP rash, oral medications may be prescribed:

• Oral antihistamines can help reduce itching and prevent further skin irritation.
• Corticosteroid tablets or injections may be used for short-term relief of severe symptoms.
• Oral antifungal medications may be prescribed if a secondary fungal infection develops.4

1. Other therapies

In some cases, additional therapies may be recommended to manage PUPPP rash and its symptoms. These include:

• Phototherapy (exposure to specific wavelengths of light) can help reduce inflammation and itching.
• Cool water baths or wet dressings can provide temporary relief and hydration.
• Transcutaneous electrical nerve stimulation (TENS) may be used to alleviate itching.[5]

While PUPPP rash is harmless to the mother and babies, some potential risks and complications should be considered:

1. Severe itching can lead to sleep disruption, anxiety, and decreased quality of life.
2. Excessive scratching can cause skin damage, increasing the risk of infection.
3. In rare cases, PUPPP rash may be a sign of an underlying condition, such as cholestasis of pregnancy, which requires prompt medical attention.6

V. Coping Strategies for Patients

PUPPP rash can take a significant toll on a woman's emotional and mental well-being, particularly during the already challenging experience of a twin pregnancy. The constant itching, discomfort, and visible skin changes can contribute to feelings of stress, anxiety, and depression. It is important to acknowledge and address these psychological impacts to ensure overall well-being.7

Building a strong support network can be invaluable for women dealing with PUPPP rash during a twin pregnancy. This may include:

1. Emotional support from partners, family members, and friends
2. Joining online support groups for women with PUPPP rash or twin pregnancies
3. Seeking counselling or therapy to cope with the psychological effects.

In addition to medical interventions, making certain lifestyle adjustments can help manage PUPPP rash symptoms and improve overall well-being:

1. Practising stress-reduction techniques, such as meditation, yoga, or deep breathing exercises
2. Ensuring adequate rest and sleep to reduce fatigue and irritability.
3. Maintaining a well-balanced diet rich in nutrients and hydration
4. Engaging in light exercise, as recommended by your healthcare provider, to promote circulation and reduce stress 8

VI. Pregnancy and Postpartum Considerations

In most cases, PUPPP rash does not directly affect the progression of pregnancy or the health of babies. However, the severe itching and discomfort associated with the rash can contribute to increased stress levels and fatigue, which may indirectly impact the overall well-being of the mother and babies. 1

PUPPP rash typically resolves within a few weeks after childbirth, as the hormonal changes and skin stretching subside. However, in some cases, the rash may persist or worsen temporarily during the postpartum period. It is important to continue monitoring the condition and seek medical attention if the rash does not improve or if new symptoms develop.2

While PUPPP rash is a temporary condition, some women may experience prolonged skin discoloration, scarring, or residual itching after the rash has resolved. In rare cases, PUPPP rash may recur in subsequent pregnancies or be associated with an increased risk of developing other skin conditions, such as eczema or psoriasis.3

VII. Seeking Medical Advice

It is essential to consult your healthcare provider if you experience any of the following:

1. Severe or worsening itching that disrupts sleep or daily activities
2. Signs of infection, such as fever, pus or warmth in the affected areas
3. Excessive bleeding, cracking, or peeling of the skin
4. Symptoms that persist or worsen after childbirth 4

During your prenatal appointments, do not hesitate to ask your healthcare provider questions to better understand your condition and available treatment options. Some questions you may want to ask include:

1. What are the potential causes of PUPPP rash?
2. Are there any specific risk factors or concerns related to my twin pregnancy?
3. What treatment options are safe and effective for managing PUPPP rash during pregnancy?
4. Are there any potential risks or complications I should be aware of?
5. How can I best manage the itching and discomfort at home?
6. When should I seek immediate medical attention?5

Regular prenatal care is crucial for monitoring the health and well-being of both the mother and babies during a twin pregnancy. Attending all scheduled appointments allows your healthcare provider to closely monitor the progression of the pregnancy, identify potential complications, and provide prompt treatment and support if needed.6

VIII. Conclusion

PUPPP rash is an uncommon but potentially distressing skin condition that can affect women during the late stages of pregnancy, particularly in cases of multiple gestations like twin pregnancies. While harmless, the intense itching and discomfort associated with PUPPP rash can significantly impact a woman's quality of life and overall well-being.7

Effective management of PUPPP rash in twin pregnancies may involve a combination of self-care strategies, home remedies, topical treatments, oral medications and, in severe cases, other therapies. Building a strong support network, practiSing stress-reduction techniques and making lifestyle adjustments can also help alleviate symptoms and promote overall well-being.8

If you are experiencing symptoms of PUPPP rash during your twin pregnancy, it is crucial to seek prompt medical attention and support. Your healthcare provider can help diagnose the condition, recommend appropriate treatment options, and provide guidance on managing the rash and its associated discomfort.

Remember, you are not alone in this journey. Reaching out to support groups, counsellors, or trusted friends and family members can provide the much-needed emotional support and coping strategies during this challenging time.

While PUPPP rash is a well-known condition, ongoing research efforts are necessary to better understand its underlying causes, risk factors, and potential long-term implications. As our knowledge of this condition grows, more effective prevention and treatment strategies may emerge, improving the overall experience for expectant mothers, particularly those carrying multiple babies. Additionally, continued research into the unique challenges and considerations of twin pregnancies will help healthcare providers better support and care for women facing these circumstances.

By fostering awareness, promoting early intervention, and encouraging open communication between patients and healthcare providers, we can work towards improving the management of PUPPP rash and ensuring the best possible outcomes for mothers and their babies.

REFERENCES:

1. Chourouk, Chouk., Noureddine, Litaiem. Pruritic Urticarial Papules And Plaques Of Pregnancy. (2021).
2. Priya, Jain., Merlin, Mary, James. PUPPP: Demonstration of Deranged Liver Enzymes during Pregnancy. International Journal of Nursing, (2018). doi: 10.24321/2455.9318.201747
3. Elling, Sv., McKenna, P., FC, Powell. Pruritic urticarial papules and plaques of pregnancy in twin and triplet pregnancies. Journal of The European Academy of Dermatology and Venereology, (2000). doi: 10.1046/J.1468-3083.2000.00026.X
4. Ji, Won, Byun., Bo, Hee, Yang., Sung, Hyub, Han., Hee, Jin, Song., Hyeon, Sook, Lee., Gwang, Seong, Choi., Jeonghyun, Shin. Two Cases of Pruritic Urticarial Papules and Plaques of Pregnancy in the Postpartum. Journal of Clinical Dermatology, (2010).
5. Lisa, M., Cohen., Eleanor, L., Capeless., Paul, A., Krusinski., Mary, E., Maloney. Pruritic urticarial papules and plaques of pregnancy and its relationship to maternal-fetal weight gain and twin pregnancy.. Archives of Dermatology, (1989). doi: 10.1001/ARCHDERM.1989.01670230076012
6. Frank, C., Powell. Parity, polypregnancy, paternity, and PUPPP.. Archives of Dermatology, (1992). doi: 10.1001/ARCHDERM.1992.01680210131028
7. Jeffrey, P., Callen., Ruth, Hanno. Pruritic urticarial papules and plaques of pregnancy (PUPPP): A clinicopathologic study. Journal of The American Academy of Dermatology, (1981). doi: 10.1016/S0190-9622(81)70101-4
8. Liliana, Oropeza, Chávez., Ángel, Sánchez, Tinajero., José, Arturo, Martínez, Orozco., Eduardo, Becerril, Vargas., Alfredo, Dolores, De, la, Merced., Danna, Patricia, Ruiz, Santillán., Andrea, Iraís, Delgado, Cueva., Nestor, Alvarado, Peña. A 34-Year-Old Woman with a Diamniotic Dichorionic Twin Pregnancy Presenting with an Erythematous and Papular Skin Rash Associated with SARS-CoV-2 Infection.. American Journal of Case Reports, (2021). doi: 10.12659/AJCR.929489