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Women of childbearing age with psoriasis require pregnancy friendly treatment plan
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As half of all pregnancies go unplanned, patients and providers must understand the implications of therapeutic options in all women with psoriasis who are sexually active, whether or not they plan to start a family, according to researchers.
“There is also a need for better information of [health care professionals] with respect to therapeutic options for women of reproductive age, particularly in light of the increasing safety data available for biologic therapies, and for the establishment of formal treatment guidelines,” Alice B. Gottlieb, MD, PhD, of the department of dermatology at Icahn School of Medicine at Mount Sinai, and colleagues wrote.
In women, a diagnosis of psoriasis and therapy commencement often coincide with peak reproductive years. Most patient with psoriasis (88%) who plan to become pregnant sought advice from the internet and only 21% consulted their physician, based on National Psoriasis Foundation survey results.
Previous studies have reported a 22% lower likelihood of pregnancy among women with psoriasis, whereas a 2016 study found no clear evidence of an increased risk for adverse pregnancy outcomes in this population.
“However, certain studies have found a link between disease activity and pregnancy complications or adverse pregnancy outcomes,” Gottlieb and colleagues wrote. “An increased risk of gestational diabetes, gestational hypertension, preeclampsia and emergency cesarean delivery was reported in women with [psoriasis].”
Additionally, the researchers added that pregnancy outcome data for women with psoriatic arthritis is even more limited. An increase in gestational hypertension and preeclampsia was identified in a 2017 study. However, a Swedish study from 2018 did not identify a difference in the adjusted OR of preeclampsia, gestational diabetes and stillbirth between groups.
Discontinuation of biologic treatment before pregnancy or during the first trimester coincides with significant disease worsening during pregnancy and postpartum, but no significant changes were reported in a small number of patients who continued biologic therapy beyond the first trimester, according to the study.
Nursing mothers are prone to nipple pain due to dermatitis and the development of new psoriasis plaques. As for topical therapies, the use of class 1 corticosteroids on the nipples should be avoided, according to researchers. Moreover, psoralen and UVA therapy is contraindicated during pregnancy.
“Psoriasis and psoriatic arthritis management before, during and after pregnancy is highly important to achieve optimal outcomes for both mothers and infants,” Gottlieb and colleagues wrote.
Oral treatments such as oral psoralen, methotrexate and acitretin should be avoided in pregnancy because they have been linked to teratogenic effects.
As for biologic therapies, “the Fc-free anti-TNF certolizumab pegol (CZP) [Cimzia, UCB] is the only biologic agent with clinical trial data in its label supporting potential use in both pregnancy and breastfeeding or chronic inflammatory disease,” they wrote.
Humira (adalimumab, AbbVie) and Enbrel (etanercept, Amgen) were updated to allow potential use during pregnancy, while it is understood that they may cross the placenta, according to researchers.
However, Stelara (ustekinumab, Janssen) and Cosentyx (secukinumab, Novartis) are typically avoided during pregnancy as a precautionary measure, due to the lack of data on use in pregnant women.
Researchers added that biologics are considered for use while breastfeeding.
As the onset of psoriasis in women often coincides with prime reproductive years, specific treatment challenges must be addressed and handled adequately, according to researchers. – by Abigail Sutton
Disclosures: Gottlieb reports she is a consultant, advisory board member and/or speaker for AbbVie, Allergan, Avotres Therapeutics, Beiersdorf, Bristol-Myers Squibb, Celgene, Dermira, Eli Lilly, Incyte, Janssen, Leo, Novartis, Reddy Labs, Sun Pharmaceutical Industries, UCB Pharma and Xbiotech. Gottlieb also reports receiving research/educational grants from Boehringer Ingelheim, Incyte, Janssen, Novartis and Xbiotech. Please see the study for all other authors’ relevant financial disclosures.
Perspective
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Junko Takeshita, MD, PhD, MSCE
Treatment of psoriatic disease among women of childbearing potential requires special considerations and discussions with patients in order to minimize their disease burden while also maximizing safety for a future child. This review provides a comprehensive summary of management considerations for women of childbearing age with psoriasis or psoriatic arthritis before, during, and after pregnancy including data on pregnancy outcomes, expectations for psoriasis activity, and specific treatment recommendations. While most pregnant women experience improvement or stabilization of their skin disease during pregnancy, this is not always the case and, thus, sometimes therapies beyond the specific topical treatments that are thought to be safe need to be considered. Narrowband ultraviolet B phototherapy remains the therapy of choice for more severe psoriasis during pregnancy. However, there are increasing data to support the relative safety of certain biologics, particularly tumor necrosis factor inhibitors, for treatment of psoriatic disease when necessary. Specifically, certolizumab is the favored biologic to use during pregnancy due to its inability to cross the placenta and little to no transfer to breast milk. Data on the safety of other biologics during pregnancy are sparse. Ultimately, a careful discussion of the risks and benefits of psoriasis treatment options before, during, and after pregnancy between each patient and her medical provider is necessary to decide upon the best course of psoriasis management during this critical time.
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