Psoriasis in those planning a family, pregnant or breast‐feeding. The Australasian Psoriasis Collaboration

Abstract

The Australasian Psoriasis Collaboration has reviewed the evidence for managing moderate to severe psoriasis in those who are pregnant or are breast-feeding, or planning a family. The severity of the psoriasis, associated comorbidities and specific anti-psoriasis treatment, along with other exposures, can have a deleterious effect on pregnancy outcomes. Psoriasis itself increases the risk of preterm and low birthweight babies, along with spontaneous and induced abortions, but no specific birth defects have been otherwise demonstrated. The baseline risk for a live born baby to have a major birth defect is 3%, and significant neuro-developmental problem is 5%. In Australia, pregnant women with psoriasis are more likely to be overweight or obese, depressed, or smoke in their first trimester, and are also less likely to take prenatal vitamins or supplements. Preconception counselling to improve maternal, pregnancy and baby health is therefore strongly encouraged. The topical and systemic therapies commonly used in psoriasis are each discussed separately, with regards to pregnancy exposure, breast-feeding and effects on male fertility and mutagenicity. The systemic therapies included are acitretin, adalimumab, apremilast, certolizumab, ciclosporin, etanercept, infliximab, ixekizumab, methotrexate, NBUVB, prednisone, PUVA, secukinumab and ustekinumab. The topical therapies include dithranol (anthralin), calcipotriol, coal tar, corticosteroids (weak, potent and super-potent), moisturisers, salicylic acid, tacrolimus, and tazarotene. As a general recommendation, effective drugs that have been widely used for years are preferable to newer alternatives with less foetal safety data. It is equally important to evaluate the risks of not treating, as severe untreated disease may negatively impact both mother and the foetus.

Psoriasis and pregnancy in the biologic era, a feared scenario. What do we do now?

“…It should be stated that first line systemic treatments used in moderate–severe psoriasis are contraindicated during pregnancy. These include retinoids (acitretin), classified as category X (there is clear evidence of abnormalities or fetal risk); methotrexate within category D (proven fetal risk), cyclosporine classified as category C (potential benefits may warrant its use despite potential risks) (Rademaker et al, ), and biologic agents are classified as category B.…”

Practical compendium for psoriasis management

“…*Long history of use of topical CCS indicates their safety. It is better to keep the amount used for mild potent <100 g/week, for midpotent and potent <50 g/week and for super potent 30 g/week (Koh, Tian, & Oon, ; A. Nast et al, ; Rademaker et al, ). **Folic acid supplement is essential since UVB lowers folic acid levels and might cause neural tube defects in the fetus (Elmets, Lim et al, ).…”

“…Neonates born to mothers receiving anti‐TNF‐α are immunocompromised for 3–6 months therefore live vaccines (e.g., Rota, MMR, BCG) should not be given (Amatore et al, ; Rademaker et al, ).…”

“…For men planning conception phototherapy, conventional therapy as acitretin and cyclosporine, along with biologics are safe to be used, the only drug recommended to be stopped before conception by 3 months is methotrexate (Menter et al, ; Rademaker et al, ).…”

Autoimmunity and autoimmune co‐morbidities in psoriasis

“…The biologicals are applicable in both paediatric and elderly patients, in patients undergoing haemodialysis and patients with perioperational circumstances . They are also used in pregnant women, although their safety warrants further evaluation . Switching of biologicals is recommended for patients with primary failure, secondary failure and infusion reactions …”