State-of-the-Art Review of Pregnancy-Related Psoriasis

A guide to prescribing systemic treatments for psoriasis during pregnancy, breastfeeding and in those trying to conceive: what does the current evidence suggest?

Psoriasis is a common inflammatory skin condition with an estimated prevalence of 1.5% in the UK. Its management has evolved rapidly over the past 15 years as our understanding of its pathogenesis has progressed. Treatment initiation often overlaps with peak reproductive years, posing specific therapeutic challenges for individuals hoping to conceive. Certain systemic agents are well established to be teratogenic during pregnancy, such as methotrexate and acitretin, but data on newer drug classes for psoriasis remain limited. This literature review evaluated recent data on the systemic agents for psoriasis, explicitly considering the context of male and female fertility, pregnancy and breastfeeding. Our goal was to equip clinicians with an accessible, concise summary of up-to-date evidence to help them educate patients and facilitate informed, shared decision-making aligned with their reproductive health.

Risk Factors for Psoriasis Flares: A Narrative Review

Psoriasis is a chronic inflammatory cutaneous disease with multifactorial pathogenesis involving both genetic and environmental factors as well as the innate and acquired immune response. Several triggering factors may exacerbate or worsen the disease. In this context, we performed a review manuscript with the aim of investigating current literature on psoriasis risk factors, also showing possible mechanisms by which they act on psoriasis. Globally, risk factors can be divided in classic risk factors (eg, mechanical stress, infections and dysbiosis of the skin, common drugs, environment and pollution, lifestyle, psychological stress, hormonal and metabolic alterations) which have long been known to be responsible for worsening and/or reoccurrence of psoriatic manifestations, and emerging risk factors (eg, biological drugs, immunotherapy for oncologic disease, Covid-19, and vaccines) defined as those newly identified risk factors. Accurate patient information and monitoring of risk factors as well as planned follow-ups may help to prevent and treat the worsening of psoriasis and consequently improve the quality of life of psoriatic patients.

Clinical pharmacokinetics and pharmacodynamics of topical non-biological therapies for psoriasis patients

INTRODUCTION

Psoriasis is a chronic inflammatory cutaneous disease that causes patients psychosocial distress. Topical therapies are utilized for mild-to-moderate disease and for more severe disease in conjunction with systemic therapies. Topical corticosteroids are a cornerstone of treatment for psoriasis, but long-term use can cause stria and cutaneous atrophy and as well as systemic side effects such as topical steroid withdrawal. Non-steroidal topical therapies tend to be safer than topical corticosteroids for long-term use.

AREAS COVERED

We conducted a literature review on the pharmacokinetic (PK) and pharmacodynamic (PD) properties of topical therapies for psoriasis. We discuss how the PK and PD characteristics of these therapies inform clinicians on efficacy and toxicity when prescribing for patients.

EXPERT OPINION

Topical corticosteroids, used intermittently, are very safe and effective. Long-term, continuous use of topical corticosteroids can cause systemic side effects. Several generic and newly approved non-steroidal options are available, but no head-to-head studies compare the effectiveness of the generics (vitamin D analogs, tacrolimus, pimecrolimus) against the newer therapies (roflumilast, tapinarof). Patients often do not respond to topical therapies due to poor adherence to treatment regimens. For patients resistant to topical treatment, phototherapy or systemic therapy may be an option.

Current and emerging prospects in the psoriatic treatment

Psoriasis is an autoimmune chronic disorder that causes inflammation and a scaly epidermis. The exact pathogenesis of the disease is not known yet. According to the studies, psoriasis is considered an immune-mediated disease. Until now it is believed that genetic and environmental factors are responsible for the disease. There are many comorbidities associated with psoriasis which increases difficulties as patients in some cases get addicted to drugs, alcohol, and smoking which reduces their quality of life. The patient may face social ignorance or suicidal thoughts which may arise in the patient's mind. Due to the undefined trigger of the disease, the treatment is not fully established but by considering the severe impact of the disease researchers are focusing on novel approaches for successful treatment. which has succeeded to a large extent. Here we review pathogenesis, problems faced by psoriatic patients, the need for the development of new treatments over conventional therapies, and the history of psoriatic treatments. We thoroughly focus on emerging treatments like biologics, biosimilars, and small molecules which are now showing more efficacy and safety than conventional treatments. Also, this review article discusses novel approaches which are now in research such as drug repurposing, treatment by stimulation of the vagus nerve, regulation of microbiota, and autophagy for improving disease conditions.

Allergic Contact Cell-Mediated Hypersensitivity in Psoriasis: A Narrative Minireview

The dysfunctionality of the protective skin barrier in psoriasis allows easier cutaneous penetration of various contact haptens; thus, such patients can develop allergic contact hypersensitivity as a comorbidity. Both skin conditions involve T-cell-mediated mechanisms. Dermatologists and allergists should consider assessing allergic contact cell-mediated hypersensitivity in selected psoriasis patients, especially those with palmoplantar psoriasis and who are refractory to topical treatments, and in patients with psoriasis, with or without arthritis, treated with biologics that present skin lesions clinically suggestive of contact dermatitis.

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.

Maternal and neonatal outcomes of births to women with psoriasis: a population-based cohort of 13 million births

PURPOSE

Psoriasis is a common auto-immune disease affecting the skin and joints for which the current literature remains limited and contradictory in the context of pregnancy. The purpose of our study was to evaluate the association between psoriasis in pregnancy and maternal and newborn outcomes.

METHODS

A population based retrospective cohort study was conducted using the 1999-2015 United States' Healthcare Cost and Utilization Project Nationwide Inpatient Sample. ICD-9 codes were used to identify delivery admissions to women with or without psoriasis, as well as maternal and fetal outcomes. Adjusting for baseline characteristics, multivariate logistic regression models were performed to estimate the effects of psoriasis on maternal and newborn outcomes.

RESULTS

The cohort consisted of 3737 women with psoriasis, among a total of 13,792,544 pregnancy admissions in US hospitals between the years 1999 and 2015, for a period prevalence of 27.1 cases per 100,000 pregnant women. Psoriasis was associated with preeclampsia, OR 1.4 (95% CI 1.2-1.6), gestational diabetes, 1.27 (1.13-1.42), myocardial infarction, 13.4 (3.3-54.6), chorioamnionitis, 1.3 (1.0-1.6), delivery by cesarean section, 1.2 (1.1-1.3), anemia, 1.74 (1.18-2.57), and requiring blood transfusions, 1.4 (1.0-1.8). Their newborns were at higher risk of being born preterm, 1.2 (1.1-1.4), congenital anomalies, 1.7 (1.2-2.4), and intra-uterine growth restriction, 1.5 (1.2-1.7).

CONCLUSION

Women with psoriasis and their newborns appear more prone to adverse outcomes of pregnancy. It would be prudent for these women to be followed closely during pregnancy by their obstetrical caregiver and dermatologist. Further investigation is warranted regarding the management of psoriasis during pregnancy.