PUPPP rash during pregnancy

By trimester

Weeks 1–13

1st trimester

PUPPP almost never shows up this early, so new itching now is more likely just normal skin stretching. Mention any rash or itching to your provider anyway, especially if it's on your palms and soles.

Weeks 14–27

2nd trimester

PUPPP is still uncommon in the second trimester and usually waits for the third. Cholestasis can start now though, so if itching with no rash shows up on your palms and soles, especially at night, tell your provider the same day.

Weeks 28–birth

3rd trimester

This is when PUPPP typically appears: itchy red bumps starting in your belly's stretch marks. A bumpy, visible rash points to PUPPP and isn't dangerous, but itching with no rash you can see, especially on your palms and soles and worse at night, points to cholestasis and needs same-day bile acid testing.

What does the evidence show for PUPPP rash?

• PUPPP usually starts as small, itchy red bumps right inside your belly's stretch marks, and it's far more common if you're carrying twins or triplets than if you're carrying one baby. 1
• It's most common in first-time pregnancies in the third trimester, and it usually settles down with a topical steroid cream and an antihistamine for the itch. 2
• PUPPP is harmless for you and your baby, and the rash typically clears up within about six weeks after delivery. 3
• Cholestasis feels completely different: intense itching with no rash at all, often worst on your palms and soles and worse at night. 4
• A simple bile acid blood test confirms cholestasis, and national guidance flags levels of 100 micromoles per liter or higher as the point where stillbirth risk rises enough to change delivery plans. 5

When should I call my provider about PUPPP rash?

Itching with no visible rash, especially if it is worse at night or concentrated on your palms and soles, is a different pattern from PUPPP and points toward cholestasis, which needs a same-day bile acid blood test since levels of 100 micromoles per liter or higher are linked to a higher risk of stillbirth. A rash that appears earlier than the third trimester, involves your belly button, or develops blisters is also a different pattern from typical PUPPP and is worth prompt evaluation, since it can point to pemphigoid gestationis, a rarer autoimmune skin condition that can look similar. Consult your healthcare provider the same day for either pattern rather than assuming it is ordinary PUPPP. Whatever the pattern, any symptom that feels beyond your usual range is a reason to call: obstetric teams expect these questions and would rather hear early than late.