The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA

Skin Disorders of Pregnancy

This is from Anne Frye's book, Holistic Midwifery.

"...late in the first pregnancy, a woman gets an itchy pimply skin eruption presenting with edema and redness on her abdomen and in her stretch marks.  These lesions can also enlarge to include the thighs, buttocks and upper arms.  No laboratory test abnormalities are noted.  They are not harmful and will disappear postpartum.  The newborn may also have these lesions, but they are presumably benign."

Seems to indicate PUPPP is likely only in a first pregnancy, though surely there are exceptions.  For comparison's sake, here's info on several other possibilities, all from Holistic Midwifery:

*Pruigo gestationis (rare):  "These benign lesions appear as raw, itchy, non-blistering papules that are limited to the extensor surfaces of the arms and legs.  They usually appear during the second half of pregnancy.  They are small, 1 to 2 mm. papules that are distributed symmetrically.  Lesions appearing between 25 and 29 weeks are more itchy than those appearing later.  Calamine lotion usually relieves the symptoms."

*Papular dermatitis of pregnancy (rare):  "This rare rash consists of an eruption of highly itchy hives over the entire skin surface, with the appearance of 3 to 8 new lesions daily.  Lesions are 3 to 5 mm. in diameter, consisting of a central raised area covered with a bloody crust 1 to 2 mm. in diameter; they do not occur in clusters and may appear anywhere on the body... The rash may appear at any time during gestation and almost always vanishes after the birth, but may recur in subsequent pregnancies.  All women with this condition have been found to have elevated urinary Chorionic Gonadotropin, (from 25,000 to 500,000 units).  A 27% fetal mortality is reported, although no reason for these deaths is given.  In women treated with corticosteroids, no fetal deaths occurred. (Gabbe, et. al., 1991)"

Maybe one test you could inform your doc you'd like to have done.  :)  If your Chorionic Gonadotropin levels are normal, you don't have papular dermatitis and would not need to worry about the validity of the claimed 27% mortality rate.

*Toxemic rash of pregnancy (rare): "A rash consisting of red, elevated itching hives appears on the skin of the abdomen.  It has no relationship to metabolic toxemia; no pathologic data are available."

She doesn't give any more info on diagnosing or treating this one.

*Intrahepatic cholestasis of pregnancy (ICP) and its milder form, pruritis gravidarum: "...are the most common forms of jaundice in pregnancy.  ICP begins anytime after the 12th week of pregnancy and clears within 48 hours after birth.  Women who have taken high estrogen oral contraceptives are at more risk.  Although not hazardous to the mother, according to some studies the rate of prematurity and fetal distress is increased.  Bio-technical physicians may prescribe cholestyramine, 12 to 16 grams per day, to control itching, tapering the dose to 8 to 10 g per day as symptoms subside.  This may cause malabsorption of fat soluble vitamins and a prolonged prothrombin time; which can be monitored and reated with vitamin K to prevent hemorrhage.  ICP may recur in successive pregnancies."  More on this one condition from Anne Frye's book, "Understanding Diagnostic Tests in the Childbearing Year,":  "This aggravating condition of pregnancy involves generalized body itching of the trunk, extremities, palms, soles, and scalp.  Symptoms are usually worse at night and in the early morning.  Insomnia, fatigue, and mental disturbances may accompany being up all night, itching.  Jaundice may or may not occur after 3 or more weeks.  This condition is relatively common in some populations and often affects those of Mediterranean, Chilean, and Scandanavian descent.  It typically presents in the third trimester; rarely earlier.  It appears to be caused by swelling and blockage of the bile drainage ducts in the liver, resulting in a back-up of liver enzymes."  She goes on to say that when ICP is present, alkaline phosphatase levels are elevated, as well as serum bilirubin levels and serum bile acid levels.  She does mention that some studies have linked ICP to increased fetal distress (higher rates of meconium staining, preterm labor, etc.), but other studies have found no such relationship.

*Pruritis gravidarum (rare):  "This type of itching is unique to pregnancy and is the result of the elevated estrogen and progesterone levels which are thought to interfere with the liver's ecretion of bile salts.  The reported incidence is 0.02% to 2.4%.  Liver supporting herbs such as Dandelion root or Yellow Dock root can help the liver do its job.  Onset is usually in the third trimester with severe generalized itching.  There are no lesions but the skin may be abraded due to scratching.  In the most severe cases jaundice will be noted.  Lab tests of liver function are usually normal or mildly elevated."

For the itching, she recommends adding unrefined olive oil to the diet, applying castor oil to the skin nightly (hey, it's better than drinking it! <s>), avoiding mineral oil based skin products, increasing intake of vitamin A & D rich foods, taking oatmeal baths, and massaging yogurt into the skin.

My thinking, for what it's worth, is that it'd be prudent to check out the urinary Chorionic Gonadotropin, just to rule out papular dermatitis. Then just monitor yourself and tune in, eat well, and support your liver.  As long as you feel well, you may have a stressed liver but it's pretty obviously keeping up with the increased demands of pregnancy.

To make a long post longer <g>, here's what Frye says in "Understanding Diagnostic Tests..." regarding taking care of your liver in pregnancy:

"Be sure the diet is adequate and exposure to environmental pollutants and the ingestion of food additives is minimal."

* Choline - a B vitamin, found in lecithin, egg yolk, liver, brewer's yeast, and wheat germ.  She recommends a daily supplement of at least 500 mg, but AVOID those with picolinate as they can stress your kidneys.  It's important that you take the choline WITH a B-complex vitamin, because prolonged supplementation with choline alone can lead to a B12 deficiency.

* Spring dandelion root tincture - a good liver tonic, but if it's too strong, try fall dandelion root.  If even that causes liver tenderness, etc., switch to yellow dock.

* Eliminate things that stress your system, like drugs, alcohol, stimulants, coffee, caffeine, white sugar, cigarettes... she even mentions regular meats from the supermarket, which are often full of antibiotics and hormones.  She says organic meats are best, followed by kosher or Islamic butchered meats.  Find a good butcher.  <s>

* Eat more unrefined olive oil, beets, dark green leafies, and fresh lemon juice... all of these are gentle and support the liver.

* Decrease the saturated fats in your diet

* Use plain yogurt as a lotion to help stop itching, or even as a bath (!)... she suggests homemade yogurt for such a large-scale operation.  ;)  You put anywhere from a quart to a gallon of yogurt in the tub and then fill it with water.  Or you can just use cornstarch, 1 cup or more to a tub of water, or oatmeal (Aveeno bath, or just plain rolled oats in a piece of cloth tied to the faucet as you fill the tub).

* Avoid the regular prescription-type vitamins and iron, which have tons of dyes, synthetic vitamins, and constipation-causing, hard-to-assimilate iron.   A natural prenatal vitamin from a health food store is better, and any iron supplement that is causing constipation "should be discontinued immediately."