Psoriasis during pregnancy: characteristics and important management recommendations

Abstract

The treatment of psoriasis in pregnant women can be challenging. Psoriasis generally improves during pregnancy; however, many pregnant patients still require treatment. In treating pregnant patients, the benefits of treatment and risks to the mother and the fetus must be considered. For localized psoriasis, topical corticosteroids are the treatment of choice. Other topical agents that are approved for the treatment of psoriasis, such as topical tar products and topical tazarotene, should be avoided during pregnancy because of unclear risks of teratogenicity. For moderate-to-severe psoriasis, ultraviolet B phototherapy is preferred. Despite limited safety data, biologics are favored over other systemic medications when needed. While there are new treatment options for psoriasis, there is limited information on the safety of medications during pregnancy.

Keywords:

• acitretin
• apremilast
• coal tar
• corticosteroid
• cyclosporine
• etanercept
• infliximab
• methotrexate
• pimecrolimus
• pregnancy
• psoriasis
• salicylic acid
• secukinumab
• tacrolimus
• therapy
• ustekinumab

Financial & competing interests disclosure

The Center for Dermatology Research is supported by an unrestricted educational grant from Galderma Laboratories, LP. S Feldman is a speaker for Janssen and Taro. He is a consultant and speaker for Galderma, Stiefel/GlaxoSmithKline, Abbott Labs, Leo Pharma Inc. S Feldman has received grants from Galderma, Janssen, Abbott Labs, Amgen, Stiefel/GlaxoSmithKline, Celgene and Anacor. He is a consultant for Amgen, Baxter, Caremark, Gerson Lehrman Group, Guidepoint Global, Hanall Pharmaceutical Co. Ltd, Kikaku, Lilly, Merck & Co Inc, Merz Pharmaceuticals, Mylan, Novartis Pharmaceuticals, Pfizer Inc, Qurient, Suncare Research and Xenoport. He is on the advisory board for Pfizer Inc. S Feldman is the founder and holds stock in Causa Research, and holds stock and is majority owner in Medical Quality Enhancement Corporation. He receives Royalties from UpToDate and Xlibris. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Key issues

• Psoriasis usually improves during pregnancy, possibly due to the hormonal influences of estrogen, progesterone and glucocorticoids and their effects on the immune system.

• Overall, the data on the safety of psoriasis mediations in pregnancy are sparse.

• Treatment of psoriasis for pregnant patients with mild disease is similar to that of non-pregnant patients, with topical corticosteroids and vitamin D analogs being first-line options.

• For pregnant patients with inverse psoriasis, topical calcineurin inhibitors are good options, given their lack of risk of atrophy/striae.

• Systemic absorption of topical medications is usually minimal, so there is little concern over systemic side effects with limited use.

• Localized phototherapy is a good option in patients with localized disease who do not feel comfortable using topical medications.

• Moderate-to-severe psoriasis is more challenging to treat due to teratogenicity concerns with many of the systemic medications and a relative lack of safety data in pregnancy, though ultraviolet B phototherapy offers a good first-line option.

• The biologics seem to be safe, but a more comprehensive pregnancy disease registry will allow us great reassurance regarding their use in pregnant women.

Notes