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Pruritic urticarial papules and plaques of pregnancy (PUPPP) is the most commonly diagnosed pregnancy-specific dermatosis. It presents with intense pruritus and can be difficult to manage, which encourages mothers to look to social media for camaraderie and advice.
This study aimed to characterize the sources and thematic content of Instagram posts in order to define influential groups of users. Our goal was to determine the status of online discourse surrounding PUPPP and elucidate any potential space for health care provider intervention via creation of Instagram accounts dedicated to information dissemination for patient populations.
Three hashtag categories were selected (#PUPPP, #PUPPPs, and #PUPPPrash), and the top public posts from each were analyzed and organized by source and by thematic content. The numbers of likes and comments were also recorded.
Among the top 150 posts in each hashtag category, only 428 posts in total were eligible for this analysis. Majority (316/428, 73.8%) of posts were created by mothers who experienced PUPPP. These posts were testimonial accounts in nature. A small fraction of posts (14/428, 3.3%) were generated by physician accounts. Posts from blogs with extensive followings garnered the most attention in the form of likes and comments.
Mothers experiencing PUPPP comprised the majority of accounts posting under the hashtags selected. The most common themes included pictures of the rash and personal testimonies. Posts under blog posts received the most likes and comments on average. There is space for physician and health care specialists to improve their social media presence when it comes to discourse surrounding PUPPP. Patients are seeking out communities on social media, like Instagram, in order to have questions answered and obtain advice on management. Accounts with large followings tend to have more likes and more comments, which encourages information dissemination and awareness. Thus, we suggest that physicians create content and potentially partner with blog-type accounts to improve outreach.
Pruritic urticarial papules and plaques of pregnancy (PUPPP) is the most common pregnancy-specific dermatosis affecting about 1 in 200 pregnancies [
Typically, the eruptions begin on the abdomen and can spread to the thighs, arms, and buttocks, with onset occurring typically in the third trimester [
Social media has taken the spotlight in recent years as a tool for human interaction, which has changed how we learn from and engage with peers. Particularly within younger generations that grew up with internet access, it is increasingly common to find that people turn to social media for information and advice. A recent survey found that 72% of people reported turning to the internet to look up health information within the last year [
Social media has become a way for patients with various unique conditions to post and find camaraderie with others who have similar afflictions, including during pregnancy [
PUPPP is a lesser publicized affliction, and thus, its discussion is not common in the public arena despite its relatively high prevalence in pregnant and postpartum mothers [
Using the Instagram app, hashtag-based key terms were searched and identified (n=3; #PUPPP, #PUPPPs, and #PUPPPrash). Note that capitalization does not make a difference on the app hashtag search function; thus, “#PUPPP” yields the same result as “#puppp.”
The top 150 posts from each tag were selected for analysis from all public posts. To be included in the study, the picture’s caption had to include information or opinions regarding PUPPP. We excluded posts that were considered private because they would not be readily accessible to the public when using Instagram’s search function. We excluded posts that had irrelevant material (ie, posts about puppies that were tagged within the #puppp thread and posts that did not include content regarding PUPPP) or were repeat tags (ie, posts tagged in the #puppp and #puppps categories). With these criteria, two of the tag categories yielded fewer than 150 posts that qualified for the study.
Each post was assigned exclusively to a category based on source. The categories included the following: (1) mother, (2) physician/health care provider, (3) health care organization, (4) company/product, and (5) blog/blogger (
Characterization of the thematic content of each post was then determined by the team. Thematic content was categorized nonexclusively, meaning that each post could be assigned to more than one category based on image content as well as accompanying caption content. These categories included the following: (1) testimony, (2) educational information, (3) picture of PUPPP rash, (4) therapy advice & guidance, (5) blog post, and (6) product promotion (
Stratification methodology of Instagram posts that met the inclusion criteria.
Post source categories (exclusive assignment)a | Thematic content categories (nonexclusive assignment)a |
1. Mother | 1. Testimony |
2. Physician/health care provider | 2. Educational information |
3. Health care organization | 3. Picture of PUPPPb rash |
4. Company/product | 4. Therapy advice & guidance |
5. Blog/blogger | 5. Blog post |
|
6. Production promotion |
aIndividual posts could be placed exclusively in one category based on their source but were nonexclusively categorized by content of the post.
bPUPPP: pruritic urticarial papules and plaques of pregnancy.
The numbers of comments and endorsements or “likes” were recorded for each post after the characterization process. The average numbers of likes and comments were then calculated within each tag category.
As of November 23, 2020, there were 2100 posts tagged with #PUPPP, 599 posts tagged with #PUPPPs, and 189 posts tagged with #PUPPPrash, which were publicly available on Instagram (totaling 2888 posts).
After determining which posts were eligible for study, 150 were included under #PUPPP, 141 were included under #PUPPPs, and 137 were included under #PUPPPrash (totaling 428 posts).
Posts in all three tags were placed into one of five designated categories for characterization of the source. Overall, we found that the majority of posts available were created and shared by those who identified themselves as mothers (316/428, 73.8%), followed by blogs (58/428, 13.6%), companies (28/428, 6.5%), physicians or health care providers (14/428, 3.3%), and health care organizations (12/428, 2.8%) (
Post source categorization.
Tag category | Post source, n (%) | ||||
Mothers | Health care organizations | Physicians and health care providers | Companies | Blogs | |
#PUPPP (N=150) | 134 (89.3%) | 9 (6.0%) | 7 (4.7%) | 0 (0%) | 0 (0%) |
#PUPPPs (N=141) | 132 (93.6%) | 1 (0.7%) | 0 (0%) | 8 (5.7%) | 0 (0%) |
#PUPPPrash (N=137) | 50 (36.5%) | 2 (1.5%) | 7 (5.1%) | 20 (14.6%) | 58 (42.3%) |
Overall (N=428) | 316 (73.8%) | 12 (2.8%) | 14 (3.3%) | 28 (6.5%) | 58 (13.6%) |
In all categories, except for #PUPPPrash, mothers themselves were the predominant posters of content regarding PUPPP. In #PUPPPrash, the largest portion of content and discussion involved blogs (58/137, 42.3%), most of which were identified as “maternity lifestyle blogs” where women share experiences, advice, and information regarding pregnancy and motherhood to their followers (
Only 14 posts came from health care providers overall, seven of which were from physicians licensed with an MD (Doctorate in Medicine) or DO (Doctorate in Osteopathic Medicine) medical degree (
#PUPPP had the majority of posts from accounts deemed as “health care organizations,” such as a public account, @skincancerderminstitute, a dermatology clinic. Nine of the 12 posts coming from health care organizations were in this tag group. Other organizations represented were centered on pregnancy and women’s health.
The “companies” category, which we defined as any account tied to a business that advertised a product or service that they themselves sell and/or provide for financial gain, was most prominent in the #PUPPPrash category, comprising 14.6% (20/137) of all posts analyzed (
All posts were categorized nonexclusively into six categories based on the content in the image or the caption associated with the image.
By and large, the category “testimony” comprised a majority of the posts across all three tag groups. Out of all 428 posts, 309 (72.2%) were classified as a “testimony” based on the content within the caption provided by the poster. This meant that 72.2% of all posts contained personal accounts and anecdotes from mothers who had experienced PUPPP during one or more of their pregnancies (
Analysis of thematic content of posts in each tag category and overall (N=428).
Themea | Tag category | |||
#PUPPP, n | #PUPPPs, n | #PUPPPrash, n | Across all tags, n (%) | |
Testimony | 91 | 94 | 124 | 309 (72.2%) |
Education | 20 | 8 | 1 | 29 (6.8%) |
Therapy advice | 10 | 14 | 5 | 29 (6.8%) |
Blog post | 0 | 11 | 89 | 100 (23.4%) |
Production promotion | 15 | 23 | 5 | 43 (10.0%) |
Picture of rash | 58 | 55 | 115 | 228 (53.3%) |
aPosts were nonexclusively categorized, that is, each post could be tallied in more than one of the six themes represented.
Posts were given a designation under the category “education” if they provided objective and factual medical information about PUPPP. Posts in this category, for example, included infographics, diagrams, and other texts that would provide information to moms about what PUPPP is, what the symptoms are, and what standard treatment includes, and/or provide epidemiological information. A popular fact included frequently in educational posts was that about 1 in 150 to 200 women will be affected by PUPPP [
Overall, 228 (53.3%) posts contained a picture of a rash directly. Pictures of a rash included an exposed abdomen with signs of PUPPP. Within the PUPPPrash tag, one picture of one blogger’s rash was reposted 78 times with a copied caption. In the PUPPP and PUPPPs groups, pictures were all personal, meaning they were of the user’s own rash.
Another important finding was that 100 of the 428 (23.4%) posts were from an account that advertised being a blog (
Therapy advice included posts in which accounts offered advice on which over-the-counter products or home remedies worked best for the poster’s PUPPP. These posts only comprised 6.8% (n=29) of all posts.
Lastly, product promotion included posts in which a specific product or service was advertised for financial gain by the poster. These posts included products, such as herbal soap bars, creams, and essential oils, designed to help with the symptoms of PUPPP. These posts could have links to the vendor’s Instagram page or website for consumers to purchase products directly. Product promotion posts comprised 10.0% (43/428) of all posts and were more represented in the PUPPPs group followed by the PUPPP group (
The number of likes was recorded for each post during analysis, and the average was calculated for each subsection. The highest average number of likes was found in the PUPPPrash tag with 2371.52. The same category also resulted in the highest average number of comments of 34.34 (
Likes and comments broken down by tag category.
Tag category | Mean number of endorsements | Range for the number of likes | Mean number of comments | Range for the number of comments |
#PUPPP | 50.53 | 0-458 | 10.46 | 0-65 |
#PUPPPs | 67.39 | 1-1452 | 8.57 | 0-46 |
#PUPPPrash | 2371.52 | 4-38,350 | 34.34 | 0-389 |
The PUPPPrash group had the highest average number of likes but also had the largest range of likes from 4 to 38,350. This category had 10 posts with more than 10,000 likes and 32 posts with between 1000 and 9999 likes. No other category had a post with more than 10,000 likes. PUPPPrash also had the largest average number of comments per post with a range of 0 to 389 (
Of note, the PUPPPrash category also had the highest concentration of blog accounts (
The presence of PUPPP on the social media app Instagram is significant yet small in comparison to the estimated number of pregnancies affected each year. With a little under 3000 posts available to the public on the popular app and around 3.7 million births in the United States annually, there appears to be a gap in discourse surrounding this common dermatosis [
Interestingly, the overwhelming majority of posts came from mothers who were affected by the rash. These posts tended to contain testimonial captions and frequently included pictures of the mother’s own rash. Based on caption analysis, most of these testimonial posts were intended to bring awareness to a condition that is considered “embarrassing” by many moms. Posts would include candid accounts of the mothers’ experiences with combating PUPPP. Posts like this help to normalize the discourse and make others feel more comfortable discussing their rash with their followers. Some moms even included pictures of their exposed rash. These vulnerable pictures could put others at ease if the rash looks similar to their own. Overall, these testimonial posts really highlight the community’s honesty with PUPPP and willingness to share their experiences for the benefit of others.
The amount of posts coming from health care professionals made up a small fraction of the sample (14/428, 3.3%). As a potential space for physicians to impact the public beyond their clinical domain, this analysis has made it apparent that there is room for improvement on the part of physicians to guide online discussion. Only 14 of all 428 posts were from professional health care providers, and only seven of those were from physicians (
The posts that this study found to garner the most attention, in the form of likes and comments, were blog posts, although they made up only 23.4% (100/428) of the posts across all three investigated tags. Some of these posts gained tens of thousands of likes and hundreds of comments. The blog accounts that many of these “high-earning” posts came from boasted large followings, which may have been a contributing factor for the greater interaction of these posts than posts from any one mother. This makes sense given that Instagram’s algorithm puts pictures from accounts you follow into one’s home feed. Therefore, the more followers an account has, the more interaction its posts will receive. Many of the blogs that earned the most likes were advertised as maternity blogs, and the posts dealt with topics and issues for expecting mothers as well as new mothers. It is possible that mothers who have experienced complications during their pregnancy seek out and follow pregnancy-specific blogs on Instagram in the hope of finding camaraderie and reassurance in their peers and influential users.
Several limitations became apparent during our analysis. First, Instagram has introduced a new policy that does not allow the general public to view all available posts. Currently, there is a disclaimer when one searches any given hashtag that states not all of the most recent posts will show up on the content feed. This is part of a new initiative by social media companies to stop the spread of misinformation.
On Instagram, we are not able to definitively determine the age or gender of the person posting the content as this information is not distributed by each user’s account. This limited our analysis particularly when looking at the posts coming from mothers affected by PUPPP. Access to the demographic information of the mothers would have given us a better idea of what audience characteristics are better represented on Instagram.
There is future potential for a similar study to analyze the content of the comment sections. Previous studies have demonstrated that examining user comments on social media can provide an in-depth view of questions and concerns brought up by patients [
Other studies could be designed with this paradigm in order to examine other lesser known medical conditions in all specialties. It could be interesting to investigate some more “taboo” conditions as well in order to see how willing online users would be to ask about them behind the comfort and convenience of the keyboard rather than in person to their physician.
This study demonstrated that there is a considerable presence on Instagram of the most common dermatosis specific to pregnancy, PUPPP. We were able to examine this common skin condition of pregnancy through the unique lens of publicly available Instagram content. Through the use of hashtags on the popular social media app, we found that mothers with PUPPP readily expressed their experiences, asked questions, and shared advice with their followers. At times, these moms would even share their opinions on various treatments and therapies as well and generate dialogue among one another.
Importantly, there are very few physicians actively posting clinically valid information about the rash, which could address many of the questions and concerns that these mothers pose online. Health care professionals, such as dermatologists and obstetricians, should be aware of this social media presence and consider increasing their influence on applications since a high number of patients turn to internet communities for support.
One suggestion we propose is for physicians to increase their social media presence by creating public professional accounts that display their credentials [
The spread of misinformation has also become a topic of discussion in recent years as social media has become a dominant forum for peer conversation [
In a time where we have immediate access to any information through the internet, misinformation is rampant and physicians work hard to dispel concerns that patients bring in with them to the examination room. We suggest that clinicians build up their social media presence to offer legitimate responses and medical information to patients looking for quick answers before their next doctor’s appointment.
pruritic urticarial papules and plaques of pregnancy
None declared.