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

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.

Small Molecules in the Management of Psoriasis and Psoriatic Arthritis

Psoriasis is a common chronic, immune-mediated inflammatory skin disease associated with various comorbidities. Managing psoriasis is often challenging as the therapy is decided based on the area of the disease, associated comorbidities and impairment in quality of life, besides the patient's preference. Making progress in the development of new molecules that can be used topically or orally, effectively controlling the disease with minimal side effects and providing long-lasting remissions are the needs of the hour. Recent developments in understanding the complexities of the pathogenesis of psoriasis have resulted in the reinforcement of treatment modalities, leading to the evolution of various biologics and small-molecule inhibitors. In comparison with biologics, both patients and treating physicians prefer small molecules for various reasons such as avoiding injections and side effects that are associated with biologics biologics. Moreover small molecules are economical than biologics. Newer small molecules, both topical and oral, are promising additions to the therapeutic arsenal in the management of psoriasis in the future.

Family Planning Concerns Among Women With Psoriasis: A Descriptive, Cross-Sectional, Multicenter Study

BACKGROUND AND OBJECTIVE

A significant proportion of women of childbearing age have psoriasis. The aim of this study was to examine family planning concerns in this population.

MATERIAL AND METHODS

Observational, descriptive, cross-sectional, multicenter study conducted between March 2020 and October 2021. We collected sociodemographic data and analyzed responses to a family planning questionnaire administered to women aged 18 to 45 years with plaque psoriasis who were candidates for systemic treatment.

RESULTS

We studied 153 patients (mean [SD] age, 35.4 [8.0] years; mean disease duration, 16.7 years) being treated at 11 Spanish hospitals. Overall, 38.4% of women were considered to have moderate to severe psoriasis by their physicians; perceived severity ratings were significantly higher among women. Psoriasis affected the women's desire to become pregnant or led to their delaying pregnancy in 1 in 3 respondents. They were concerned that their condition might worsen if they had to discontinue or switch treatment or that the treatment might harm the baby. Approximately half of the women had not received family planning counseling from their physicians, and this was more likely to be the case among never-pregnant women. Women on biologic therapy (58.7%) had better psoriasis control and a better quality of life than women on other treatments. Their sexual health was also less affected.

CONCLUSIONS

Women with psoriasis have numerous family planning concerns, which in some cases can lead them to delay pregnancy or affect their desire to become pregnant. Dermatologists need to receive better training regarding family planning in women with psoriasis so that they can provide their patients with more and better information.

[Translated article] Family Planning Concerns Among Women With Psoriasis: A Descriptive, Cross-Sectional, Multicenter Study

BACKGROUND AND OBJECTIVE

A significant proportion of women of childbearing age have psoriasis. The aim of this study was to examine family planning concerns in this population.

MATERIAL AND METHODS

Observational, descriptive, cross-sectional, multicenter study conducted between March 2020 and October 2021. We collected sociodemographic data and analyzed responses to a family planning questionnaire administered to women aged 18 to 45 years with plaque psoriasis who were candidates for systemic treatment.

RESULTS

We studied 153 patients (mean [SD] age, 35.4 [8.0] years; mean disease duration, 16.7 years) being treated at 11 Spanish hospitals. Overall, 38.4% of women were considered to have moderate to severe psoriasis by their physicians; perceived severity ratings were significantly higher among women. Psoriasis affected the women's desire to become pregnant or led to their delaying pregnancy in 1 in 3 respondents. They were concerned that their condition might worsen if they had to discontinue or switch treatment or that the treatment might harm the baby. Approximately half of the women had not received family planning counseling from their physicians, and this was more likely to be the case among never-pregnant women. Women on biologic therapy (58.7%) had better psoriasis control and a better quality of life than women on other treatments. Their sexual health was also less affected.

CONCLUSIONS

Women with psoriasis have numerous family planning concerns, which in some cases can lead them to delay pregnancy or affect their desire to become pregnant. Dermatologists need to receive better training regarding family planning in women with psoriasis so that they can provide their patients with more and better information.

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.

Differential Expression of Estrogen-Responsive Genes in Women with Psoriasis

In women, the flow of psoriasis is influenced by each phase of a woman’s life cycle. According to previous findings, significant changes in the levels of sex hormones affect the severity of the disease. Aim: The aim of this study was to identify the estrogen-responsive genes that could be responsible for the exacerbation of psoriasis in menopausal women. Methods: Skin samples of lesional skin donated by psoriasis patients (n = 5) were compared with skin samples of healthy volunteers (n = 5) using liquid chromatography–tandem mass spectrometry (LC–MS/MS). The set of differentially expressed proteins was subjected to protein ontology analysis to identify differentially expressed estrogen-responsive proteins. The expression of discovered proteins was validated by qPCR and ELISA on four groups of female participants. The first group included ten psoriasis patients without menopause; the second included eleven postmenopausal patients; the third included five healthy volunteers without menopause; and the fourth included six postmenopausal volunteers. Moreover, the participants’ blood samples were used to assess the levels of estradiol, progesterone, and testosterone. Results: We found that the levels of estradiol and progesterone were significantly lower and the levels of testosterone were significantly higher in the blood of patients compared to the control. The protein ontology analysis of LC–MS/MS data identified six proteins, namely HMOX1, KRT19, LDHA, HSPD1, MAPK1, and CA2, differentially expressed in the lesional skin of female patients compared to male patients. ELISA and qPCR experiments confirmed differential expression of the named proteins and their mRNA. The genes encoding the named proteins were differentially expressed in patients compared to volunteers. However, KRT19 and LDHA were not differentially expressed when we compared patients with and without menopause. All genes, except MAPK1, were differentially expressed in patients with menopause compared to the volunteers with menopause. HMOX1, KRT19, HSPD1, and LDHA were differentially expressed in patients without menopause compared to the volunteers without menopause. However, no significant changes were found when we compared healthy volunteers with and without menopause. Conclusion: Our experiments discovered a differential expression of six estrogen-controlled genes in the skin of female patients. Identification of these genes and assessment of the changes in their expression provide insight into the biological effects of estrogen in lesional skin. The results of proteomic analysis are available via ProteomeXchange with identifier PXD021673.

Awareness and Expectations Surrounding Family Planning and Pregnancy Among Danish Patients with Chronic Inflammatory Disease of the Skin or Joints: Results from an Online Survey

Background

Patients with chronic inflammatory diseases (CIDs) may encounter challenges in their family planning journey. Here, we report on the access to family planning and pregnancy (FPP) information and the concerns among patients in Denmark with CIDs.

Methods

Patients aged 18–50 years with CIDs participated in an online survey. Patients were recruited through patient advocacy groups and were asked to report information on their diagnosis, concerns related to FPP and perceptions of access to FPP information. Descriptive statistics were applied.

Results

Of the eligible respondents, 368 had rheumatological diagnoses (rheumatoid arthritis, psoriatic arthritis, juvenile idiopathic arthritis or axial spondyloarthritis; mean age 40 years; 83% women, 17% men) and 95 had dermatological diagnoses (psoriasis or psoriatic arthritis; mean age 38 years; 67% women, 33% men). Approximately 70% of all patients reported seeking FPP information from patient advocacy groups; 57% of both cohorts used the internet as information sources; and 73% and 42% of rheumatological and dermatological cohorts used their hospital and specialist doctor, respectively. Despite this, 58% and 67% of patients with rheumatological and dermatological diagnoses reported limited or no access to FPP information, with > 70% of dermatological patients of early/mid-reproductive age reporting a lack of access to this information. Overall, 68% of patients with rheumatological and 73% with dermatological diagnoses had biological children, amongst whom 24% and 18%, respectively, indicated their disease affected the number of children they ultimately decided to have. The most frequent FPP concerns among patients who did not want any/more biological children were disease worsening, heredity and taking care of the child.

Conclusions

Despite awareness of available sources of FPP information, patients expressed experiencing a feeling of limited access to information and having concerns that affect key decisions regarding FPP. The results of this survey highlight a need for improved and more standardised FPP information for patients with CIDs in Denmark.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40744-021-00348-2.

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

Psoriasis is a chronic immunologic disease involving inflammation that can target internal organs, the skin, and joints. The peak incidence occurs between the age of 30 and 40 years, which overlaps with the typical reproductive period of women. Because of comorbidities that can accompany psoriasis, including metabolic syndrome, cardiovascular involvement, and major depressive disorders, the condition is a complex one. The role of hormones during pregnancy in the lesion dynamics of psoriasis is unclear, and it is important to resolve the implications of this pathology during pregnancy are. Furthermore, treating pregnant women who have psoriasis represents a challenge as most drugs generally prescribed for this pathology are contraindicated in pregnancy because of teratogenic effects. This review covers the state of the art in psoriasis associated with pregnancy. Careful pregnancy monitoring in moderate-to-severe psoriasis vulgaris is required given the high risk of related complications in pregnancy, including pregnancy-induced hypertensive disorders, low birth weight for gestational age, and gestational diabetes. Topical corticosteroids are safe during pregnancy but effective only for localised forms of psoriasis. Monoclonal antibodies targeting cytokines specifically upregulated in psoriasis, such as ustekinumab (IL-12/23 inhibitor), secukinumab (IL-17 inhibitor) can be effective for the severe form of psoriasis during pregnancy. A multidisciplinary team must choose optimal treatment, taking into account fetal and maternal risks and benefits.

An updated guide in the management of psoriasis for every practitioner

BACKGROUND

Psoriasis is one of the most common chronic cutaneous skin disorders, having genetic and immunological components. It is currently unknown what exactly triggers it, or how far reaching are the etiological factors, although great strides have been made in uncovering the pathophysiological cascade. Presently, there is a wide diversity of treatment methods for psoriasis, yet not all are applicable for each patient. Selection of both drug and dosage depends on both the knowledge and experience of the treating dermatologist and also on the specific characteristics of each patient. Therefore, the treating physicians should be made aware of the management possibilities, their advantages and their side effects.

METHODS

We have performed a non-systematic literature review on the current treatment methods for psoriasis. We have included the studies, articles, and prescription information that provided the most relevant information regarding each therapeutic agent. Afterward, we divided the treatment methods according to delivery and illustrated the management protocols for adult, paediatric, and pregnant patients.

DISCUSSION AND CONCLUSIONS

Current therapies are divided into topical drugs, phototherapy, systemic and biological agents. Topical therapies and phototherapy are generally the first and second line of management respectively, being typically effective in treating mild to moderate forms of psoriasis. On the other hand, the chronic moderate to severe forms usually benefit from systemic drugs, whereas biologic agents are reserved for severe or unremitting cases, especially those suffering from psoriatic arthritis. Also of importance is the understanding of the pathophysiological mechanisms in psoriasis and how the selected drugs interfere in the pathological cascade. Furthermore, physicians should be able to recommend the appropriate therapy not only for adults but also for paediatric and pregnant patients as well. In the following manuscript, we present an updated version of these management options, alongside their indications, posology and most common side effects, a guide that may be useful for every practitioner in this field.

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.

Maternal and Neonatal Outcomes in Pregnant Women with Psoriasis and Psoriatic Arthritis: A Systematic Review and Meta-Analysis

OBJECTIVE

Psoriasis and psoriatic arthritis (PsA) are inflammatory diseases that affect women in their reproductive years. We aimed to investigate whether maternal psoriasis and PsA are associated with adverse pregnancy outcomes.

METHODS

We searched multiple electronic databases from inception to 3 August 2020, and reference lists of selected articles. Observational studies reporting at least one pregnancy outcomes in women with psoriasis or PsA with a comparator of general population or healthy subjects were included. Data were pooled by random-effects models and expressed as odds ratio (OR) and 95% confidence interval (CI).

RESULTS

Overall, 16 studies were included in the meta-analysis. The pooled analyses showed pregnant women with psoriatic diseases have significantly higher risk of adverse maternal outcomes compared with general population (caesarean delivery: 1.33 (1.17-1.52); preterm birth: 1.32 (1.15-1.52); (pre)eclampsia: 1.28 (1.14-1.43); gestational diabetes: 1.19 (1.10-1.30); gestational hypertension: 1.30 (1.18-1.44). However, no statistically increased risks of fetal complications were observed in women with psoriatic diseases (small for gestational age: 1.02 (0.93-1.11); low birth weight: 1.15 (0.93-1.42); congenital malformations: 1.03 (0.93-1.14); Apgar score <7: 1.07 (0.81-1.39); neonatal mortality: 1.13 (0.90-1.43); stillbirth: 1.19 (0.95-1.50)). Subgroup analysis found similar results in women with either psoriasis or PsA regarding maternal outcomes and the magnitude of risk estimates seems to be greater in PsA though without statistical difference.

CONCLUSIONS

Pregnant women with psoriasis and PsA have excess risk of adverse maternal events, but not adverse neonatal events. Close monitoring of the mothers' clinical status before and during pregnancy is decidedly required in daily practice.

The use of biological drugs in psoriasis patients prior to pregnancy, during pregnancy and lactation: a review of current clinical guidelines

Introduction

Information on the possibility of using biological drugs in psoriasis patients planning to conceive, patients who are pregnant or during lactation is limited.

Aim

Presenting recommendations published in clinical guidelines regarding the use of biological drugs – adalimumab, brodalumab, certolizumab pegol, etanercept, guselkumab, infliximab, ixekizumab, risankizumab, secukinumab, tildrakizumab, and ustekinumab, by psoriasis patients in the period of planning pregnancy, during pregnancy or during lactation.

Material and methods

The paper was based on a comprehensive review of over 40 websites of HTA agencies, dermatological associations worldwide and medical databases (PubMed, Embase), the objective of which was to identify clinical guidelines relating to biological treatment of women of childbearing potential, published after 2018, which used GRADE – a system for rating the quality of a body of evidence.

Findings

Certolizumab pegol is recommended in women who are planning to conceive. Furthermore, guidelines indicate other TNF-α inhibitors as possible treatment. Certolizumab pegol is also recommended as first-line treatment in pregnant patients. Furthermore, for trimesters 2 and 3, guidelines allow using other TNF-α inhibitors. Treatment with secukinumab and ustekinumab should be discontinued when planning pregnancy or when pregnancy was diagnosed. Biological treatment during pregnancy and lactation (continuation or initiation of treatment) can be used only after an analysis of risks and benefits has been conducted.

Conclusions

TNF-α inhibitors seem to be the safest and most researched biological drugs used in psoriasis treatment of patients planning to conceive, during pregnancy or lactation. Given its non-existent or minimal placental permeability, most likely the safest alternative is certolizumab pegol.

Use of biologic therapies for psoriasis during pregnancy and long-term outcomes of exposed children: A 14-year real-life experience at a tertiary center in Turkey and review of the literature

Data regarding the use of biologic therapies for psoriasis during pregnancy are scarce with even more limited knowledge about the long-term safety of in utero exposure. We retrospectively evaluated nine pregnancies in six women with psoriasis who were exposed to biologic therapies between 2006 and 2019 in our psoriasis clinic, a tertiary referral center in Turkey. Pregnancy outcomes included the delivery of seven healthy babies without any complications, one elective abortion, and one ectopic pregnancy. All exposed children, aged between 14 months and 13 years (median age: 4.0 years), showed normal growth and neuropsychological development without immunodeficiencies, allergies, malignancies or other diseases. Based on up-to-date collective data in the literature and our real-life clinical experience presented here, exposure to biologic therapies during pregnancy for psoriasis does not seem to be associated with adverse pregnancy or neonatal outcomes. Our results are also reassuring with respect to long-term outcomes of exposed children, but need to be confirmed through further large prospective studies. Nevertheless, use of biologic therapies during late pregnancy, particularly during the third trimester, should be reserved for high-need patients with psoriasis and definitely requires a delicate risk/benefit balance on a case-by-case basis.