Limited data exist for psoriasis treatment in pregnant women

Clinicians treating pregnant women who have psoriasis have limited data to guide treatment decisions, according to a review.

“Robust safety data often are lacking for the use of topical and systemic agents to treat psoriasis in pregnancy,” Kelsey S. Flood, MD, of the department of dermatology at the University of Cincinnati, and colleagues wrote. “Professional society guidelines on the use of systemic agents in pregnancy vary among dermatology, gastroenterology and rheumatology organizations.”

The review included findings for topical agents, phototherapy, oral medications, biologics and small-molecule inhibitors.

While topical steroids are generally considered “reasonable,” clinicians are encouraged to consider “potency, formulation, area of application and use of occlusion,” according to the findings.

Women in the first trimester may experience orofacial cleft with topical steroid exposure, while calcipotriene may be associated with vitamin D toxicity. Topical tacrolimus likely does not carry the risk for preterm birth or low birthweight associated with oral tacrolimus. Limited data are available for anthralin and coal tar, although first-trimester use of coal tar is not recommended, according to Flood and colleagues.

Phototherapy may be used as second-line therapy. While psoralen in UVA therapy is contraindicated in pregnancy due to its mutagenic properties, UVB therapy has not shown any risk to the fetus or delivery process.

Turning to oral medications, methotrexate and systemic retinoids are both contraindicated for pregnant women. Pregnancy should be avoided for 3 years after acitretin use. Data for apremilast in pregnancy, however, are insufficient. Moreover, the picture for oral steroids is complicated, with some studies showing premature birth, low birthweight and congenital abnormalities, while others failing to demonstrate any such associations. Outcomes for cyclosporine are “not well described,” while “limited data are available for Janus kinase inhibitors,” Flood and colleagues wrote.

Regarding biologics and small-molecule inhibitors, the authors suggested that despite limited data in pregnancy, safety findings for many of these drugs are “encouraging.”

Due to the placental transport of IgG antibodies, the authors suggested that the infants of women taking biologics may be immunosuppressed in the first months of life. However, this finding remains unconfirmed.

Small studies have linked biologic therapies with spontaneous or induced abortions but no congenital abnormalities, but the researchers added that tumor necrosis factor inhibitors are generally considered “reasonable.”

Clinicians should be aware that adalimumab, infliximab and golimumab are associated with active transplacental transport, but that this is “substantially less” with certolizumab and etanercept.

“Our understanding of treatment of psoriasis in pregnancy is limited as a consequence of regulations surrounding clinical trials and inadequate detection of pregnancies in registries,” Flood and colleagues wrote. “Further efforts are necessary to better understand the relationship between psoriasis and pregnancy and how to manage pregnant women with psoriasis.”