What are the guidelines for conception in a woman with psoriasis treated with methotrexate (MTX), and what are the alternative treatments for psoriasis during pregnancy?

From the Guidelines

Methotrexate should be discontinued at least 3 months before attempting pregnancy due to its potential to cause birth defects, as recommended by the joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management of psoriasis with systemic nonbiologic therapies 1. When a woman stops taking methotrexate, psoriasis will likely flare again, as the medication treats symptoms but doesn't cure the underlying condition. Some key points to consider:

• The critical period for methotrexate's teratogenic effects appears to be within the first 6 to 8 weeks of pregnancy 1.
• Women planning pregnancy should work with both their dermatologist and obstetrician to create a safe transition plan.
• During pregnancy, safer alternatives for managing psoriasis include:
  • Topical corticosteroids (low to medium potency)
  • Moisturizers
  • Narrowband UVB phototherapy
  • Topical calcipotriene, tacrolimus, or pimecrolimus may be used in limited areas if necessary
• Biologics like certolizumab pegol might be considered for severe cases under specialist guidance, as it has minimal placental transfer.
• Lifestyle modifications such as stress reduction, avoiding triggers, gentle skin care, and maintaining a healthy diet can also help manage symptoms. Regular follow-ups with both dermatology and obstetrics are essential to monitor both psoriasis control and pregnancy health, adjusting treatments as needed throughout pregnancy and postpartum periods.

From the FDA Drug Label

Methotrexate can cause fetal death or teratogenic effects when administered to a pregnant woman. Pregnancy should be avoided if either partner is receiving methotrexate; during and for a minimum of three months after therapy for male patients, and during and for at least one ovulatory cycle after therapy for female patients.

Methotrexate and Pregnancy:

• A woman should avoid getting pregnant while taking methotrexate and for at least one ovulatory cycle after stopping the therapy.
• If she stops taking methotrexate, psoriasis may occur again as methotrexate is used to treat the condition.

Alternative Treatments for Psoriasis during Pregnancy:

• No alternative treatments are mentioned in the provided drug labels.
• However, it is essential to consult a physician to discuss the best course of treatment for psoriasis during pregnancy, as the labels do not provide information on alternative therapies 2 2.

From the Research

Methotrexate and Pregnancy

• Methotrexate is a commonly used medication for treating psoriasis, but it is not recommended during pregnancy due to its potential teratogenic effects 3.
• Women who are planning to get pregnant should stop taking methotrexate at least one month before conception, but the exact timing may vary depending on individual circumstances.
• It is essential to consult a healthcare provider for personalized advice on stopping methotrexate and planning a pregnancy.

Risk of Psoriasis Relapse

• Stopping methotrexate may lead to a relapse of psoriasis symptoms, as the medication helps to control the disease 4.
• The risk of relapse varies from person to person, and it is crucial to monitor the condition closely after stopping methotrexate.
• Alternative treatments may be necessary to manage psoriasis symptoms during pregnancy.

Alternative Treatments for Psoriasis during Pregnancy

• Phototherapy, such as narrowband UVB (NB-UVB) or psoralen plus UVA (PUVA), can be a safe and effective alternative for treating psoriasis during pregnancy 5, 6, 7.
• Topical corticosteroids, calcipotriene, and other topical treatments may also be used to manage mild to moderate psoriasis symptoms during pregnancy.
• It is essential to consult a healthcare provider to determine the best course of treatment for psoriasis during pregnancy, as some medications may not be suitable.