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

Exposure to biologic therapy before and during pregnancy in patients with psoriasis: Systematic review and meta-analysis

Biologicals have transformed the management of severe disease phenotypes in psoriasis and are often prescribed in women of childbearing age. However, information on safety of biologicals in pregnancy are lacking. We conducted a systematic review and meta-analysis aimed to describe the characteristics and pregnancy outcomes in women with psoriasis exposed to biologics within 3 months before or during pregnancy, and to estimate the pooled prevalence of spontaneous, elective and total abortions, and congenital malformations in their newborns. Bibliographic searches were performed in the PubMed, Embase, Scopus and Web of Science databases up to 14 April 2022. No restrictions on sample size or publication date were applied. Review performance complied with PRISMA guidelines, and two reviewers assessed randomized controlled trials and nonrandomized studies reporting pregnancy outcomes in women exposed to biologics indicated for psoriasis during the pre-gestational and/or gestational period. Studies focusing on rheumatologic or gastroenterological immune-mediated inflammatory diseases were excluded. Regardless of data heterogeneity, a random-effects model was used to pool prevalence estimates. We included 51 observational studies, involving 739 pregnancies exposed to approved biologics for psoriasis. Administration was mostly (70.4%) limited to the first trimester, and the most common drug was ustekinumab (36.0%). The estimated prevalence of miscarriage was 15.3% (95% confidence interval [CI] 12.7-18.0) and elective abortions, 10.8% (95% CI 7.7-14.3). Congenital malformations occurred in about 3.0% (95% CI 1.6-4.8) of live births exposed to biologics during pregnancy. Altogether, exposure to biologics for psoriasis during pregnancy and/or conception does not seem to be associated with an increased risk of miscarriage/abortion or congenital malformations, showing similar rates to the general population. These results suggest that biologic drugs are safe and pose an acceptable risk to the foetuses/neonates.

Impact of Psoriasis and Hidradenitis Suppurativa in Pregnancy, a Systematic Review

Psoriasis and hidradenitis suppurativa (HS) are chronic inflammatory skin diseases that frequently develop in young women. The aim of this study is to evaluate how hidradenitis suppurativa and psoriasis impact women desiring to conceive, and their influence on fertility and gestation. A systematic review of articles dating from January 2015 to April 2021 was performed using the Scopus (Elsevier) database. The search terms were (psoriasis and (birth or pregnancy or fertility)) and ((hidradenitis suppurativa or acne inversa) and (birth or pregnancy or fertility)). The search was limited to human data. Systematic reviews, case reports, clinical practice guidelines, expert consensus and conference papers were excluded. The impact of HS on pregnancy includes an impaired desire for pregnancy, a decrease in fertility, the worsening of the disease during pregnancy and potential adverse events during pregnancy. Moreover, the pregnancy might imply a change on the treatment of HS. The impact of psoriasis on pregnancy includes a decrease in fertility, potential adverse events during pregnancy and an unpredictable evolution of the disease. Moreover, the pregnancy might imply a change on the treatment of psoriasis, although biologic therapies do not appear to increase the risk of adverse events. In conclusion, both HS and psoriasis have an impact on pregnancy. A decrease of fertility has been reported. Moreover, both diseases have an unpredictable evolution during pregnancy. Pregnant women who are under biologic therapy do not seem to have a higher rate of adverse events. Treatment of both conditions is usually halted during pregnancy since scientific evidence about their safety is not conclusive, or teratogenic risk has been proven.

Infliximab for the treatment of recalcitrant generalized pustular psoriasis of pregnancy: Report of a challenging case

Pustular psoriasis of pregnancy (PPP), also known as impetigo herpetiformis, is a rare gestational dermatosis that may induce life-threatening complications for both the mother and fetus. Treatment of recalcitrant generalized PPP may be challenging as available therapeutic options are limited. We herein present a 24-year-old pregnant woman with generalized PPP accompanied by high fever, fatigue, leukocytosis, and elevated levels of serum acute phase reactants. The patient was resistant to a combination treatment of high-dose cyclosporine (7.5 mg/kg/d, peroral), systemic methylprednisolone (1 mg/kg/d, intramuscular), and empirical antibiotherapy. However, she dramatically improved with infliximab (5 mg/kg, intravenous infusion), which was introduced at week 28 of pregnancy. Even within 24 hours after the first infusion of infliximab, pustular lesions began to regress with a rapid decline in fever. Following the third infusion, clearance of pustular lesions with a slight erythema was observed. Serum levels of leukocytes and acute phase reactants returned to normal. There were no adverse events related to infliximab therapy. At 40 weeks, the patient gave birth to a healthy baby. Our experience reported herein suggests that infliximab may serve as a rapidly acting, highly effective, and well-tolerated "rescue" therapy in recalcitrant generalized PPP, which poses a big therapeutic challenge for clinicians.