Management of psoriasis in pregnancy

Psoriasis management tree based on comorbidity

Psoriasis, a common chronic inflammatory skin disorder, encompasses various subtypes, including guttate, pustular, erythrodermic, and the most common type, plaque psoriasis. Irrespective of the subtype, psoriasis can manifest with multisystemic presentations, including psoriatic arthritis, metabolic disorders, cardiovascular disease, malignancies, chronic kidney disease (CKD), psychiatric illness, and inflammatory bowel disease (IBD). Many comorbidities and concomitant conditions must be considered when selecting the most appropriate therapy for a patient (Kaushik et al., 2019 and Monks et al., 2021) . Ongoing clinical trials and the development of new therapeutic targets contribute to the continuous improvement of available treatment options. Given the dynamic landscape of therapies, particularly when managing complex patients with multiple comorbidities, dermatologists are constantly challenged with the task of adeptly tailoring treatments to each psoriasis patient. This article systematically reviews the current evidence, presenting it as an updated Psoriasis Decision Tree to assist physicians in selecting tailored treatment options.

Oversight and Management of Women with Psoriasis in Childbearing Age

Psoriasis is a complex disease with many associated comorbidities, all of which have a negative impact on a patient's personal, social, and sexual life. There are some unique considerations in the effects of this disease among women. The average age of diagnosis in women with psoriasis is 28 years, and this onset corresponds to the fertile life of women. There is conflicting information about the effects of psoriasis on female fertility. Some studies suggest that this condition's associated comorbidities, personal behaviors, and reduced ovarian reserve, especially due to chronic inflammation, affect women's fertility. Another possible reason women with psoriasis are less likely to become pregnant is that their sexual intercourse frequency decreases after the condition's onset. The available information on the effects of pregnancy on women with psoriasis is limited. According to current evidence, most women will experience an improvement in their skin condition. Studies show that patients with moderate-to-severe psoriasis are more prone to experience pregnancy complications. The management of pregnant and lactating women with psoriasis is also difficult, as the safety profile of commonly used drugs in patients with psoriasis is not entirely known.

Pregnancy and neonatal outcomes in women with immune mediated inflammatory diseases exposed to anti-tumor necrosis factor-α during pregnancy: A systemic review and meta-analysis

BACKGROUND

Anti-TNFα is increasingly used as treatment for immune mediated inflammatory diseases (IMID), such as inflammatory bowel disease (IBD), rheumatoid arthritis (RA) and psoriasis (PS). However, the impact of anti-TNFα during pregnancy on mother and newborn is under debate. This requires a sound knowledge of the effects of this treatment on pregnancy and neonatal outcomes.

OBJECTIVES

To assess pregnancy and neonatal outcomes after anti-TNFα therapy during pregnancy in women with IMID, specifically IBD, RA and PS.

METHODS

We performed a systematic review and meta-analysis of 39 studies assessing pregnancy and neonatal outcomes of women with IMID exposed to anti-TNFα agents during pregnancy. We used a random-effects model to determine pooled outcome measures.

RESULTS

An increased risk of preterm births (OR 1.45, 95% CI = 1.16 to 1.82, p = 0.001) and infections in newborns (OR 1.12, 95% CI = 1.00 to 1.27, p = 0.05)) was seen for women in the combined group of IMID exposed to anti-TNFα compared to diseased controls. Specifically for IBD patients exposed to anti-TNFα, the risk was increased for preterm birth (OR 1.66, 95% CI = 1.14 to 2.42, p = 0.009), and low birth weight (OR 1.49, 95% CI = 1.01 to 2.20, p = 0.047) compared to diseased controls. Combined data from studies of women with RA and PS, showed no increased risk for adverse pregnancy outcome after exposure to anti-TNFα. Most children of mothers with IMID received vaccination according to national vaccination schemes and only minor adverse events were reported.

CONCLUSION

Exposure to anti-TNFα agents during pregnancy is associated with increased risk of preterm birth and infections in newborns of women with IMID compared to diseased controls. The risk of preterm birth and low birth weight was increased in women with IBD specifically. The increased risk of infections in newborns underlines the importance of vaccination, which seems to be safe in children exposed to anti-TNFα. Delay of vaccination is therefore unnecessary in these children. These data may aid in balancing the continuing anti-TNFα therapy versus the risk of adverse pregnancy outcomes.

Certolizumab Pegol: A Review in Moderate to Severe Plaque Psoriasis

Certolizumab pegol (Cimzia^®) is a PEGylated, Fab'-only, recombinant humanized antibody against TNF-α. Subcutaneous certolizumab pegol is indicated for the treatment of various immune-mediated inflammatory diseases (IMIDs), including moderate to severe plaque psoriasis. In pivotal phase III trials in adults with moderate to severe plaque psoriasis, significantly more patients receiving certolizumab pegol 200 mg or 400 mg once every 2 weeks than placebo recipients achieved a ≥ 75% reduction in PASI score (PASI75 responder) and a PGA score of clear/mostly clear with a ≥ 2 point improvement from baseline (PGA0/1 responder) at week 12 (CIMPACT) or 16 (CIMPASI-1 and -2). In CIMPACT, certolizumab pegol 400 mg once every 2 weeks was superior to etanercept (highest recommended dosage) at 12 weeks, with certolizumab pegol 200 mg once every 2 weeks demonstrating non-inferiority, but not superiority, to etanercept. The clinical benefits of certolizumab pegol were maintained during the maintenance phase (to week 48) and the open-label extension phase of these trials. Certolizumab pegol is unique among the biologics, with the absence of an Fc fragment conferring pharmacokinetic advantages; most notably, its minimal transfer across the placenta, and low relative infant dose during breastfeeding in conjunction with its low oral bioavailability. Certolizumab pegol was generally well tolerated and no new safety signals were identified in these phase III trials, which complements its established safety profile in other IMIDs. Certolizumab pegol is a useful option for the treatment of moderate to severe plaque psoriasis and provides an important treatment option for women of childbearing age, for whom there are limited options available.

Autoimmune Hepatitis: Tolerogenic Immunological State During Pregnancy and Immune Escape in Post-partum

The maternal immune system engages in a fine balancing act during pregnancy by simultaneously maintaining immune tolerance to the fetus and immune responses to protect against invading organisms. Pregnancy is an intricately orchestrated process where effector immune cells with fetal specificity are selectively silenced. This requires a sustained immune suppressive state not only by expansion of maternal Foxp3+ regulatory T cells (Tregs) but also by leaning the immune clock toward a Th2 dominant arm. The fetus, known as a semi-allograft or temporary-self, leads to remission of autoimmune hepatitis during pregnancy. However, this tolerogenic immune state reverts back to a Th1 dominant arm, resulting in post-partum flare of AIH. Various hormones play a significant role in endocrine-immune axis during pregnancy. The placenta functions as a barrier between the maternal immune system and the fetus also plays a pivotal role in creating a tolerogenic environment during pregnancy. We review the evidence of immune tolerance during pregnancy and immune escape at post-partum period, focusing on patients with autoimmune hepatitis.

Management of Plaque Psoriasis With Biologic Therapies in Women of Child-Bearing Potential Consensus Paper

BACKGROUND

Plaque psoriasis (PsO) is a chronic inflammatory disease that often presents at peak reproductive age in women of child-bearing potential (WOCBP). With the emergence of biologic therapies to treat PsO, guidance on disease management in WOCBP is needed to inform treatment decisions before, during, and after pregnancy.

OBJECTIVES

To develop a practical, up-to-date consensus document, based on available evidence and expert opinion where evidence was lacking, in order to guide both Canadian and international clinicians treating PsO in WOCBP.

METHODS

A panel of 9 Canadian dermatologists with extensive clinical experience managing PsO reviewed the relevant literature from the past 25 years in 3 key domains: overview of PsO in WOCBP and clinical considerations, treatment considerations, and postpartum considerations. The structured literature search focused on WOCBP treated with TNF-alpha inhibitors (adalimumab, certolizumab, etanercept, golimumab, infliximab), IL-23 inhibitors (guselkumab, risankizumab, tildrakizumab), IL-12/23 inhibitors (ustekinumab), and IL-17 inhibitors (brodalumab, ixekizumab, secukinumab). This literature review, along with clinical expertise and opinion, was used to develop concise and clinically relevant consensus statements to guide practical management of PsO in WOCBP. Experts voted on the statements using a modified Delphi process and prespecified agreement cut-off of 75%.

RESULTS AND IMPLICATIONS

After review, discussion, and voting on 19 draft consensus statements at an in-person meeting and remotely, 12 consensus statements were approved by the expert panel. The statements presented here will guide healthcare providers in practical disease management using biologic therapies for the treatment of PsO in WOCBP.

Drug discontinuation in pregnant women with psoriasis: The PSO-MOTHER cohort study

PURPOSE

To analyse the drug use pattern in women with psoriasis before, during and after pregnancy.

METHODS

All children born (2009-2016) in a central Italian region (Lazio) to mothers with a diagnosis of psoriasis were identified. Drug use patterns (biologicals, systemic, and topical), and discontinuation and switching of drug therapies before, during, and after pregnancy were studied. Findings were compared with data from a population exposed to similar drug therapies (eg, antirheumatic drugs).

RESULTS

Among 3499 deliveries by women affected by psoriasis, 1876 (53.6%) were diagnosed with this condition before the Last Menstrual Period (LMP). Of these, 525 (27.9%) had at least one drug prescription for psoriasis therapy during 6 months before LMP. For each class of drugs considered, there was a general decrease in its use during pregnancy. Considering the two trimesters preceding LMP and the three trimesters of pregnancy, the following percentages of prescriptions were observed: from 10.5% to 0% for biologicals, 7.2% to 2.5% for the conventional systemic drugs, and 51.1% to 9.4% for the topical treatments. After delivery, previous treatments were resumed. Similar results were observed for rheumatoid arthritis, a chronic condition.

CONCLUSIONS

Majority of drugs come with warnings regarding potential embryo-fetotoxicity, which might play a role in the decision to continue treatments during pregnancy. According to our study pregnancy appears to have a significant influence on drug prescriptions of different pharmacological treatments for psoriasis.

The unforeseen during biotechnological therapy for moderate-to-severe psoriasis: How to manage pregnancy and breastfeeding, infections from Mycobacterium tuberculosis, hepatitis B virus, hepatitis C virus, and HIV, surgery, vaccinations, diagnosis of malignancy, and dose tapering

The use of biotechnological therapies for moderate-to-severe psoriasis is ever-expanding and it is becoming increasingly more frequent to encounter different unforeseen events during their use, such as fertile patients becoming pregnant and breastfeeding, development of infections due to personal habits like tuberculosis, hepatitis B virus, hepatitis C virus, or HIV, scheduling of surgical procedures, need of vaccinations, development of malignancy, and evaluation of dose tapering. As any clinician may experience at least one of these unexpected events, it should be good practice to know how to manage them. Thus, a practical analysis has been proposed in this study.

Management of psoriasis in pregnancy - a review of the evidence to date

The onset of psoriasis collides with women’s reproductive timeframe, and pregnancy brings challenges to its treatment. Indeed, the health of both mother and foetus must be considered. When choosing to treat pregnant women affected by psoriasis with pharmacological therapy, it is important to be aware of all possible options and their repercussions. Although there are several pharmacological therapies available, pregnancy brings ethical concerns and any pharmacological approach must be well thought out. The data available in humans are limited, and further investigation on this matter is needed. Within biological therapies, certolizumab pegol has recently been identified as a promising approach during pregnancy because it has been shown to have no late active placental transfer and no clear signs of foetal harm. This article aims to review the impact of psoriasis during pregnancy, how the disease can be managed pharmacologically during this period according to the available armamentarium, and the possible effects of the therapeutic options for the mother and the foetus.

Japanese guidelines for the management and treatment of generalized pustular psoriasis: The new pathogenesis and treatment of GPP

Generalized pustular psoriasis (GPP) is a rare disease characterized by recurrent fever and systemic flushing accompanied by extensive sterile pustules. The committee of the guidelines was founded as a collaborative project between the Japanese Dermatological Association and the Study Group for Rare Intractable Skin Diseases under the Ministry of Health, Labour, and Welfare Research Project on Overcoming Intractable Diseases. The aim of the guidelines was to provide current information to aid in the treatment of patients with GPP in Japan. Its contents include the diagnostic and severity classification criteria for GPP, its pathogenesis, and recommendations for the treatment of GPP. Since there are few clinical trial data with high levels of evidence for this rare disease, recommendations by the committee are described in the present guidelines.

Choosing First-Line Biologic Treatment for Moderate-to-Severe Psoriasis: What Does the Evidence Say?

An advanced understanding of the pathogenesis of psoriasis has led to the development of multiple therapeutic options for moderate-to-severe psoriasis. Tumor necrosis factor inhibitors, ustekinumab, interleukin-17 inhibitors, and guselkumab (an interleukin-23 inhibitor recently approved for psoriasis) are commercially available biologic agents for psoriasis. Evidence from clinical trials provides pertinent information regarding the safety and efficacy of biologic agents for psoriasis, which should be integrated into clinical decision making. However, disease presentations, disease severity, and comorbid conditions can complicate the choice of initial treatment, which underscores the importance of providing personalized therapy for patients with psoriasis. Furthermore, each biologic agent offers unique benefits and limitations for the treatment of patients with psoriasis. Here, evidence-based recommendations are presented and discussed regarding first-line biologic therapy options for patients with psoriasis and distinct comorbid conditions or patient-related factors. We discuss the comorbid conditions of psoriatic arthritis, multiple sclerosis, congestive heart failure, inflammatory bowel disease, hepatitis B, and latent tuberculosis. Moreover, we describe treatment recommendations for distinct patient populations with psoriasis, including pediatric patients with psoriasis and patients with psoriasis of childbearing potential and nursing.

New Insights into the Management of Patients with Autoimmune Diseases or Inflammatory Disorders During Pregnancy

The treatment of autoimmune diseases remains a serious problem. Current therapies can lead to adverse effects in patients. One of the most vulnerable patient groups is pregnant women. It has been reported that different autoimmune diseases have a certain trend during pregnancy and after delivery which could be explained by maternal immune responses. Better management of pregnant women with autoimmune diseases or inflammatory disorders could be achieved by linking such alterations in immune responses and governed immune responses in different autoimmune disorders while considering various reports of autoimmune conditions during pregnancy. This study considers changing the T helper cells (Th1) and Th2 balance and suggests some new approaches for the better management of autoimmune diseases in pregnant women based on immune responses. Additionally, the possible role of Th17, alterations in some selected autoimmune diseases including rheumatoid arthritis (RA), multiple sclerosis (MS), psoriasis, systemic lupus erythematosus (SLE), atopic dermatitis (AD), asthma and pemphigus during pregnancy, and possible associated mechanisms are discussed.

Psoriasis and adverse pregnancy outcomes: a systematic review of observational studies

Psoriasis is a chronic inflammatory disorder with significant physical and psychological sequelae. The majority of individuals experience disease onset in early adult life - for women this often occurs during their reproductive years. While some autoimmune diseases have been shown to affect pregnancy outcomes adversely, such a relationship has not been well studied in psoriasis. We searched PubMed, Embase and the Cochrane database for published articles examining psoriasis and adverse pregnancy outcomes, and included observational studies and clinical trials evaluating direct measures of maternal and fetal morbidity and mortality. Four of the nine included articles reported a statistically significant increase in the risk of at least one outcome, including spontaneous abortion, caesarean delivery, low birth weight, macrosomia, large-for-gestational age, and a composite outcome consisting of both prematurity and low birth weight. However, these associations were not always consistent across studies. Overall, there was no clear evidence of increased adverse outcomes in pregnant women with psoriasis.

Treatment of psoriasis and psoriatic arthritis during pregnancy and breastfeeding

Psoriasis is a chronic inflammatory disease that affects primarily the skin and joints, with a worldwide incidence of 2-3%. Fifty percent of patients are women, most still diagnosed during childbearing years. Currently,the estimate is that up to 107 thousand deliveries are performed annually in women with psoriasis, a percentage of them in women with moderate to severe disease. Fetal risks in pregnant women with psoriasis derive both from maternal disease and the medications used to control the illness. The purpose of this review is to study the effect of the main drugs used in the treatment of psoriasis and psoriatic arthritis during pregnancy and lactation, with particular focus on disease-modifying anti-rheumatic biological drugs, biological therapies, immunobiologics or biologics.

A multileveled approach in psoriasis assessment and follow-up: A proposal for a tailored guide for the dermatological practice

BACKGROUND

Psoriasis is a complex and heterogeneous disease resulting from interactions between genetic, immunological, and environmental factors. To make the most optimal treatment decision, the dermatologist must therefore have a detailed overview of the patient's history and lifestyle.

OBJECTIVES

We sought to offer an overview of the various relevant aspects in clinical dermatological assessment of psoriasis patients, emphasizing the importance of a multidisciplinary and integrated clinical approach.

METHODS

We gathered information on psoriasis management and developed a tailored checklist covering all health-related aspects associated with psoriasis.

RESULTS

Demographics, personal and family history were elaborately described as well as drug history to discuss how they affect psoriasis management. Relevant patient information such as the vaccination status or cardiovascular profile were included in the checklist as well and treatment recommendations were adapted and updated in accordance with evidence-based literature. This checklist also emphasizes the importance of drug surveillance, proper follow-up and specialist referral, and why the dermatologist needs to address these health-related aspects when assessing psoriasis patients, going beyond optimal skin care.

CONCLUSIONS

Our comprehensive overview can be used as a consultation checklist for good clinical practice in psoriasis patient management and aid in treatment decision.

Psoriasis: female skin changes in various hormonal stages throughout life--puberty, pregnancy, and menopause

Psoriasis is one of the most prevalent immune mediated skin diseases worldwide. Despite the large prevalence in both men and women, the pathogenesis of this disease has not yet been fully clarified. Nowadays, it is believed that psoriasis is most likely a T helper Th1/Th17 induced inflammatory disease. Stressful life situations are known to cause flare-ups and psoriasis activity may be linked to stress from major life events. We know that stress greatly affects both the hormone and immune systems and that there are many different hormonal phases throughout a woman's lifetime. The severity of psoriasis may fluctuate or be influenced by each phase and this relationship can be seen as disease frequency seems to peak during puberty, postpartum, and menopause when hormone levels fall, while symptoms improve during pregnancy, a state when hormone levels are increased.

[Chronic inflammatory and autoimmune mediated dermatoses during pregnancy. Course and prognosis for mother and child]

Chronic inflammatory dermatoses during pregnancy can take varying courses in mother and child. The dominant Th2-response characteristic for pregnancy may explain why atopic eczema or lupus erythematosus may deteriorate while psoriasis vulgaris may improve. In contrast, impetigo herpetiformis frequently shows a severe course. Lupus erythematosus and other autoantibody-triggered dermatoses like pemphigus vulgaris pose an increased risk for the child because of placental transfer of autoantibodies with specific skin changes or systemic manifestations of the disease as well as placental insufficiency, growth retardation and premature birth. Such risks are not associated with linear IgA dermatosis. A severe pityriasis rosea during the first 20 weeks of pregnancy may lead to an increased risk of abortion or premature delivery. Early diagnosis and individually adjusted therapy of skin diseases is mandatory to avoid any risk for mother or child.

Management of rheumatic diseases during pregnancy

Systemic rheumatic diseases commonly affect women during the childbearing years. Many women with these diseases may be contemplating pregnancy or discover an inadvertent pregnancy, leading to concerns regarding medication use, changes in disease activity during pregnancy, safety of lactation, and future ability to care for a child given the presence of chronic illnesses. There are outstanding reviews that summarize the safety and use of immunosuppressive medications during pregnancy. However, in addition to medication use, providers need to be aware of the available data regarding fertility, pregnancy outcomes, delivery, and lactation issues that may be specific to individual diseases. Optimally, women should plan pregnancies to occur around times of disease quiescence, several months after potentially teratogenic medications have been discontinued. The course of the underlying rheumatic disease during pregnancy is variable, and there are no specific clinical or laboratory variables that consistently predict disease improvement or worsening during pregnancy. Recent data suggest that increased disease activity in women with most autoimmune diseases during pregnancy may lead to increased risk of premature delivery, low-birth-weight infants, and other adverse pregnancy outcomes. Arthritis involving the cervical spine and hips may impact delivery and must be considered by both obstetricians and obstetric anesthesiologists. Data are mixed regarding the impact of breastfeeding on underlying autoimmune diseases; the choice to continue breastfeeding is a personal decision.

Prolactin--a novel neuroendocrine regulator of human keratin expression in situ

The controls of human keratin expression in situ remain to be fully elucidated. Here, we have investigated the effects of the neurohormone prolactin (PRL) on keratin expression in a physiologically and clinically relevant test system: organ-cultured normal human hair follicles (HFs). Not only do HFs express a wide range of keratins, but they are also a source and target of PRL. Microarray analysis revealed that PRL differentially regulated a defined subset of keratins and keratin-associated proteins. Quantitative immunohistomorphometry and quantitative PCR confirmed that PRL up-regulated expression of keratins K5 and K14 and the epithelial stem cell-associated keratins K15 and K19 in organ-cultured HFs and/or isolated HF keratinocytes. PRL also up-regulated K15 promoter activity and K15 protein expression in situ, whereas it inhibited K6 and K31 expression. These regulatory effects were reversed by a pure competitive PRL receptor antagonist. Antagonist alone also modulated keratin expression, suggesting that "tonic stimulation" by endogenous PRL is required for normal expression levels of selected keratins. Therefore, our study identifies PRL as a major, clinically relevant, novel neuroendocrine regulator of both human keratin expression and human epithelial stem cell biology in situ.