Quick Answer: Syphilis can mimic PUPPP during pregnancy and is often missed. If your rash spreads beyond the belly, involves your palms, or is paired with fatigue or swollen lymph nodes, request a syphilis test immediately, it’s treatable, and early treatment protects your baby.
It Starts with an Itch, But the Story Gets More Complicated
Pregnancy rashes are common. Stretching skin, hormonal shifts, immune system changes, all prime conditions for itching, redness, and hives. PUPPP (pruritic urticarial papules and plaques of pregnancy) is one of the most frequent diagnoses, affecting about 1 in 150 pregnancies. But here’s the problem: PUPPP is a diagnosis of exclusion, not confirmation. That means doctors often give the label when they don’t think it’s anything else. And sometimes, they’re wrong.
In 2023, the CDC reported a record-breaking rise in congenital syphilis in the United States, with a 254% increase over the previous five years. One of the key drivers? Missed diagnoses in pregnant people. Specifically, misattributing syphilitic rashes to conditions like eczema, allergic dermatitis, and yes, PUPPP.
“It looked like a heat rash at first,” said one anonymous account published in a maternal health journal. “I was seven months along. My OB said not to worry. But my midwife, thank God, said to run a full panel just in case. That’s when they found it. Syphilis. I had no idea.” She was treated in time, but her baby still needed evaluation after birth. Many aren’t so lucky.
The Overlap That Confuses Doctors, And Delays Care
So how does this happen? Why do trained clinicians mistake a potentially fatal infection for something hormonal?
First: the rash. Both PUPPP and syphilis can produce itchy red bumps. Both can start in the third trimester. Both can cause discomfort across the abdomen. But that’s where the similarities end, and where clinical vigilance matters. A 2022 review in the Journal of Clinical Dermatology found that in 18% of pregnant women diagnosed with syphilis, their rash was originally misclassified as “pregnancy-related dermatosis.” In half of those cases, no STD test was ordered until late in the third trimester, or not at all.
That’s a catastrophic delay. Congenital syphilis, passed from mother to fetus, can cause preterm birth, stillbirth, neurological damage, and organ failure. And yet, its earliest symptom in the birthing parent, an unexplained rash, is still too often brushed off.
| Feature | PUPPP | Syphilis |
|---|---|---|
| Onset Timing | Late third trimester (week 35+) | Anytime during pregnancy, often 2nd trimester |
| Itch Location | Starts on stretch marks, belly only | Spreads to palms, soles, trunk, scalp |
| Associated Symptoms | No systemic symptoms | May include fever, fatigue, swollen nodes |
| Visual Appearance | Hive-like, red papules, often linear | Spots, scaling, may involve mucosa |
| Treatment | Topical steroids, resolves postpartum | Penicillin injection required |
Figure 1. Comparison of PUPPP and syphilis rash during pregnancy. This table highlights key clinical differences and reinforces the need for diagnostic testing, not assumption.
Shame, Silence, and Why Syphilis Gets Missed
Let’s talk about shame. It’s one of the biggest barriers to proper testing in pregnancy, not just for patients, but providers, too. If you tell your OB you’ve only had one partner and no recent STI concerns, they might think, “No need to test again.” But syphilis doesn’t care about assumptions. It doesn’t need new partners. It doesn’t even need penetrative sex in some cases. Skin-to-skin contact, oral sex, or a dormant infection from years ago can all flare up during pregnancy when the immune system shifts.
And here’s the stigma-laced part: many pregnant people don’t want to admit they may be at risk. They fear judgment. Or they assume they were tested early on, and don’t realize that re-testing in the third trimester is not just smart, but sometimes essential, especially in areas with rising rates.
In fact, the CDC now recommends third-trimester re-screening for all pregnant individuals in high-incidence regions, regardless of self-reported risk. Yet compliance varies by state, by provider, by system. And lives hang in the balance.
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If You’re Pregnant and Itchy, Here’s What to Say, and What to Ask For
Picture this: you’re in your OB’s exam room, fidgeting in the paper gown because your skin’s on fire again. You show them the rash. You say it’s itchy, spreading, weird. They nod. “Looks like PUPPP.” End of story. But it doesn’t have to be. This is the moment where your voice can change everything. The simplest ask, “Can we just run a syphilis test to be safe?”, can prevent one of the most devastating outcomes in modern maternal medicine: congenital syphilis.
You don’t have to know how syphilis works. You don’t need a medical degree. All you need is the understanding that a rash that doesn’t behave like textbook PUPPP should be tested, not assumed. And if your provider resists? Ask why. Ask what else it could be. Ask what tests they’ve run and which they haven’t. It’s not confrontation, it’s collaboration. It’s protecting you and your baby.
Let’s be clear: syphilis is treatable. One intramuscular shot of penicillin, done early enough, can stop the transmission. That’s it. It’s not your fault. It’s not shameful. And the idea that only “certain people” get it? Dangerous garbage. Anyone can contract it. What matters is catching it before it spreads, especially across the placenta.
Testing Early Changes Everything, Here’s the Proof
We’re not just fear-baiting here. TThe data is very clear. The Centers for Disease Control and Prevention said in a 2022 report that almost 89% of congenital syphilis cases could have been stopped if people had been tested and treated sooner. That's not just a number; it's a baby who was born with damaged organs that didn't have to be. It’s a NICU stay that could have been avoided. It’s a parent asking themselves, “What if I had pushed harder at that appointment?”
When testing happens early, ideally during the first prenatal panel, and again before 28 weeks, outcomes improve drastically. Add a third-trimester re-screen for those with new symptoms or known exposure, and risk drops even further. Yet a 2023 study in JAMA Pediatrics found that fewer than 60% of high-risk pregnancies received a third-trimester re-screen. That’s a gap we can close, with your voice, your vigilance, and your right to know what’s going on with your body.
This isn’t about blame. It’s about empowerment. About shifting the narrative from “how did this happen?” to “what can I do now?”
| Recommended Action | Timing | Why It Matters |
|---|---|---|
| Initial syphilis screening | First prenatal visit (before 12 weeks) | Detects existing infection before fetal exposure |
| Re-screen if rash or symptoms appear | Anytime during pregnancy | Catches infections acquired or reactivated after initial test |
| Routine third-trimester screening (CDC recommended) | Weeks 28–32 | Protects against late-pregnancy transmission |
| Post-treatment follow-up | One month after treatment | Confirms treatment success and non-transmission |
| Partner testing and treatment | Immediately if exposed | Prevents reinfection and protects the entire household |
Figure 2. Timing and impact of syphilis testing and treatment in pregnancy. This roadmap is lifesaving, not just preventive.
How to Talk to Your Partner Without Shame or Fear
This is the part no one prepares you for: telling your partner. Maybe you’re monogamous. Maybe it’s complicated. Maybe you haven’t had sex in weeks. It doesn’t matter. What matters is honesty, and safety, and getting everyone on the same page. “There’s a chance I have syphilis,” doesn’t mean, “You cheated,” or “I cheated.” It means, “I love our baby enough to make sure we’re okay.”
Use whatever language makes you feel powerful. “The rash might not be pregnancy-related, I’m getting tested just in case.” “Syphilis rates are up. I just want to rule it out.” “They said it’s probably nothing, but I’d rather know.” These are truth-telling tools, not accusations. You don’t owe anyone guilt. You owe your body care. Your baby safety. And your relationship clarity.
If you need support, some clinics and telehealth services will notify partners anonymously. No names, just facts. “Someone you’ve been intimate with tested positive for syphilis. Please get tested.” That’s it. No shame. No drama. Just health, delivered with dignity.
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When You Test Positive: What Happens Next
Let’s say it is syphilis. Deep breath. Here’s what happens: you’ll likely get a single dose of penicillin G benzathine, injected into the muscle of your buttock. It stings. But it works. Within days, your body begins clearing the infection. Your baby is monitored, but if caught early enough, no damage occurs. That’s the goal. And if it’s later in pregnancy, you may need more doses, ultrasounds, or neonatal evaluation. Still treatable. Still manageable. Still not the end of your story.
You’ll get follow-up testing at one, three, and six months postpartum to ensure you’re in the clear. Your provider may test your partner. Your baby may receive a blood test, a spinal tap, or antibiotics after birth. These are safety nets, not punishments. And then it’s over. You move forward. You hold your baby. You breathe again.
That’s what timely testing gives you: a plan. A path. Peace of mind.
It’s Not “Just a Rash” When It Could Be Syphilis
Marisol got lucky. Her midwife was persistent. She got tested. She got treated. Her baby arrived healthy. But not everyone gets that story. Some are dismissed. Some are too afraid to ask. Some never even know syphilis is on the table. Let this be your sign: the rash matters. The timing matters. You matter. Don’t wait for it to go away on its own. Don’t accept “just hormones” if your gut says otherwise. Don’t settle for assumptions when answers are one test away.
If your head keeps spinning, peace of mind is one test away. Order a discreet syphilis rapid test kit here and take control from home.
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FAQs
1. Can a syphilis rash really look like a normal pregnancy rash?
Absolutely, and that’s the scary part. Syphilis is the master of disguise, especially during pregnancy. It doesn’t always show up as a sore or something dramatic, it can look like harmless bumps or patches, especially when your skin’s already changing. One day it’s on your belly, the next it’s creeping down your thighs. That’s why people, and sometimes doctors, write it off as “just PUPPP.” But if it’s not staying in the belly zone, or you’re noticing it on your palms or soles? That’s your sign to get tested, no matter what anyone says.
2. I’ve only been with one person, how could I have syphilis?
This is one of the most common, and most heartbreaking, questions we hear. The truth? STDs don’t care about your relationship status. Syphilis can lie dormant for months, even years, and show up during pregnancy because your immune system is working differently. You could’ve had it before you even met your current partner. Or they could have had it without knowing, no cheating required. The point is, this isn’t about blame. It’s about getting answers and keeping you and your baby safe.
3. What if my OB just brushes it off and doesn’t test me?
Then it’s time to advocate like hell. Politely, firmly, whatever works for you, but don’t back down. You can say, “I know it might be nothing, but with everything going on, I’d really like to rule out syphilis.” That’s not paranoia. That’s being smart. And if they still say no? You don’t need permission to take care of yourself. Go to a sexual health clinic. Order a discreet at-home test. Do what you need to do. Your body, your baby, your rules.
4. How fast does syphilis treatment work during pregnancy?
Fast, and thank goodness for that. The standard treatment is a penicillin injection, and if caught early, it can start clearing the infection within days. In many cases, that single dose is enough to protect your baby from any harm. The key is timing. The earlier in pregnancy you treat it, the lower the risk of complications. Even if it’s caught later, treatment still works, it just might mean more monitoring for your little one after birth.
5. Is the syphilis rash itchy like PUPPP, or not?
Sometimes yes, sometimes no, and that’s what makes it so tricky. PUPPP is usually itchy and stays confined to stretch-mark zones. Syphilis? It might itch. It might not. It might flake, scale, or just... linger. If you’re noticing a rash that’s weirdly symmetrical, or spreading to places PUPPP shouldn’t go, like your palms, soles, or mouth, it’s worth asking for a test. Especially if it doesn’t fade with creams or oatmeal baths.
6. Will my baby be okay if I had syphilis during pregnancy?
In most cases, yes, *if* you get treated in time. That’s the silver lining. The body’s resilience, paired with medical care, is powerful. Babies exposed to syphilis in utero are monitored closely, and many are completely fine if the infection was caught and treated before delivery. If it’s found too late, they might need treatment too, possibly even before you leave the hospital. It’s scary, but it’s not a death sentence. It’s a situation with a solution.
7. Can I get tested for syphilis without going to a clinic?
Yep. You have options. You can go to a local sexual health center, ask your OB to re-run your panel, or, if the thought of sitting in a waiting room makes your skin crawl, order an at-home syphilis test. Same science, same blood-based detection, just shipped discreetly to your door. And if that gives you the peace of mind you need to sleep tonight? That’s worth everything.
8. I feel so embarrassed even thinking about this, am I overreacting?
Not even a little. You’re doing what people with power do: you’re asking questions, getting informed, and protecting your health. Pregnancy comes with enough uncertainty already. Add a weird rash, conflicting advice, and rising STD rates? You’re not overreacting. You’re acting with love, for yourself and for your baby. That’s not shameful. That’s fierce. And we’re right here with you.
9. Does PUPPP ever affect the palms or soles like syphilis does?
Nope. PUPPP typically remains confined to areas with stretch marks, mostly the belly, thighs, and buttocks. If your rash spreads to hands, feet, or scalp, especially with systemic symptoms like fatigue or swollen nodes, syphilis must be ruled out.
10. Is syphilis testing included in all pregnancy panels?
It should be included in the first prenatal panel, but not all providers re-test in the third trimester, even when guidelines recommend it. Always ask if it was done, and whether repeat screening is needed based on your symptoms or local outbreak status.
You Deserve Answers, Not Assumptions
This isn’t about being paranoid. It’s about being prepared. No one expects an STD to show up during pregnancy, especially not one that masquerades as a common rash. But here we are. With syphilis rates rising, misdiagnoses mounting, and preventable complications still happening, the most radical thing you can do is ask a simple question: “Can we rule out syphilis?”
You’re not being dramatic. You’re being smart. You’re protecting your future child. You’re advocating for the care you deserve, without shame, without apology, without hesitation. And you don’t have to wait for a clinic to take you seriously. This at-home combo test kit checks for the most common STDs discreetly and quickly, because your peace of mind shouldn't depend on someone else's assumptions.
How We Sourced This Article: We combined current guidance from leading medical organizations with peer-reviewed research and lived-experience reporting to make this guide practical, compassionate, and accurate. In total, around fifteen references informed the writing; below, we’ve highlighted six of the most relevant and reader-friendly sources. Every external link in this article was checked to ensure it leads to a reputable destination and opens in a new tab, so you can verify claims without losing your place.
Sources
2. CDC - Congenital Syphilis Fact Sheet
3. Planned Parenthood - Understanding Syphilis
4. Sexually Transmitted Infections Treatment Guidelines, 2021 | CDC
5. Sexually Transmitted Infections Treatment Guidelines, 2021 – Workowski et al. | PubMed
About the Author
Dr. F. David, MD is a board-certified infectious disease specialist who works to stop, diagnose, and treat STIs. He blends clinical precision with a no-nonsense, sex-positive approach and is committed to expanding access for readers in both urban and off-grid settings.
Reviewed by: Dr. Andrea Kline, OB-GYN | Last medically reviewed: September 2025
This article is for informational purposes and does not replace medical advice.
