Myth: Psoriasis Treatments Should Not Be Used During Pregnancy
It is likely that dermatologists will encounter female patients with psoriasis who are pregnant or wish to become pregnant during the course of their psoriasis treatment. Earlier this year Porter et al evaluated several psoriasis therapies and discussed their safety for patients with psoriasis during pregnancy. Because psoriasis is a risk factor for adverse pregnancy outcomes, control of disease prior to and during pregnancy may optimize maternal and fetal health, according to the authors. As a result, they outlined the following treatment recommendations:
- Consider anti–tumor necrosis factor (TNF) α agents over IL-12/IL-23 and IL-17 inhibitors.
- Anti–TNF-α agents can be used during the first half of pregnancy.
- Longer-term use of anti–TNF-α agents during pregnancy can be considered depending on psoriasis disease severity.
- If biologic therapy is required during pregnancy, use certolizumab because it does not cross the placenta in significant amounts; etanercept also may be a reasonable alternative.
- Babies born to mothers who are continually treated with biologic agents should not be administered live vaccinations for at least 6 months after birth due to the increased risk of infection; inactive vaccinations can be administered according to Centers for Disease Control and Prevention guidelines.
- Breastfeeding by mothers currently treated with anti–TNF-α agents is generally considered safe.
- Cotreatment with methotrexate and a biologic agent should be avoided.
However, the National Psoriasis Foundation guidelines for treating psoriasis in pregnant or breastfeeding women advise that topical treatments are the first choice of treatment, particularly moisturizers and emollients. Limited use of low- to moderate-potency topical steroids appears to be safe, but women should avoid applying topical steroids to the breasts. Second-line treatment is narrowband UVB phototherapy; if narrowband UVB is not available, use broadband UVB. Breastfeeding women should avoid psoralen plus UVA. The foundation also advises that systemic and biologic drugs should be avoided while pregnant or breastfeeding unless there is a clear medical need. Childbearing women should avoid oral retinoids, methotrexate, and cyclosporine due to a link to birth defects. A useful table of US Food and Drug Administration–approved psoriasis treatments and their category for use by pregnant and breastfeeding women is available online. Specifically, drugs that should absolutely be avoided in this patient population include acitretin, methotrexate, and tazarotene.
For some patients, discontinuing therapy may not be practical. Dermatologists should be prepared to weigh the risks and benefits of treatment to advise patients appropriately. According to Dr. Jeffrey M. Weinberg’s pearls for treating psoriasis in pregnant women in Cutis, “Most biologic therapies are pregnancy category B. We still use these drugs with caution in the setting of pregnancy. If a pregnant patient does wish to continue a biologic therapy, close monitoring and enrollment in a pregnancy registry would be good options.”
More research is necessary; however, pregnant women often are excluded from clinical trials. Therefore, adverse outcomes should be reported to registries such as the Organization of Teratology Information Specialists or others sponsored by drug manufacturers, which will aid in understanding the effects of psoriasis treatments in pregnant and breastfeeding women.
The treatment of psoriasis in pregnancy should be approached in a thoughtful manner. While we always want to minimize therapeutic interventions in pregnant individuals, we also want to maintain control of a disease such as psoriasis. As outlined in this article, there is good amount of flexibility in terms of therapies available to us. It is important to discuss the situation carefully, including the benefits and risks, with the patient and the obstetric professionals, in order to design the optimal regimen for each individual.
—Jeffrey M. Weinberg (New York, New York)