What psoriasis treatments are contraindicated during pregnancy?

Psoriasis Treatments Contraindicated During Pregnancy

Acitretin and methotrexate are absolutely contraindicated during pregnancy due to their severe teratogenic effects, while cyclosporine should be used with caution only when benefits outweigh risks. 1, 2

Contraindicated Treatments

Acitretin

• Acitretin is FDA pregnancy category X (highly unsafe during pregnancy) and is absolutely contraindicated during pregnancy 3
• Causes severe fetal malformations including meningomyelocele, meningoencephalocele, multiple synostoses, facial dysmorphia, syndactyly, absence of terminal phalanges, cardiovascular malformations, and alterations of the skull and cervical vertebrae 1
• Women must avoid pregnancy for at least 3 years after discontinuing acitretin therapy due to its long elimination half-life and potential conversion to etretinate 3, 1
• Alcohol consumption during or within 2 months after acitretin therapy must be avoided as it promotes conversion to etretinate, which has a much longer half-life (168 days) 3, 1
• Women of childbearing potential should never receive acitretin due to these severe risks 3, 1

Methotrexate

• Methotrexate is absolutely contraindicated during pregnancy as it can cause fetal death or teratogenic effects 3, 2
• Women of childbearing potential must have pregnancy excluded before starting methotrexate and use reliable contraception during therapy 3, 2
• Both men and women must avoid pregnancy during methotrexate therapy and for at least 3 months after discontinuation for men and at least one ovulatory cycle for women 2
• Methotrexate is also contraindicated during breastfeeding due to potential serious adverse reactions in infants 2

Use with Caution During Pregnancy

Cyclosporine

• Cyclosporine is pregnancy category C; studies have reported lower birth weight and shorter pregnancy duration in transplant patients, although it appears not to be teratogenic 3
• Caution should be exercised when considering cyclosporine in pregnant patients, and it should only be used when the potential benefit justifies the potential risk to the fetus 3
• Mothers receiving cyclosporine should not breastfeed 3

Considerations for Treatment Selection During Pregnancy

• For women planning pregnancy, systemic biologic therapies may be considered as safer alternatives to traditional systemic agents, though individual risk-benefit assessment is necessary 3
• Topical therapies are generally considered first-line treatment for psoriasis during pregnancy, though some topical retinoids should also be avoided 4
• When selecting treatments for women of childbearing potential, physicians must consider the risk of unplanned pregnancy and the teratogenic potential of medications 3

Common Pitfalls to Avoid

• Failing to counsel women about the 3-year contraception requirement after discontinuing acitretin 3, 1
• Neglecting to warn patients about alcohol consumption during and after acitretin therapy, which can convert acitretin to long-lasting etretinate 3, 1
• Assuming that lower doses of contraindicated medications are safe during pregnancy 1, 2
• Inadequate contraception counseling for both male and female patients on methotrexate 2
• Overlooking the need for pregnancy testing before and during treatment with contraindicated medications 3, 1

By understanding these contraindications and following proper guidelines, healthcare providers can help ensure the safety of pregnant women with psoriasis while effectively managing their disease.