Oral Contraceptive Pills and Psoriasis: Safety Profile
Oral contraceptive pills (OCPs) are safe to use in patients with psoriasis, with no evidence of disease exacerbation or significant adverse interactions with psoriasis treatments, though strict contraception is mandatory when using systemic psoriasis therapies. 1
Direct Evidence on OCPs and Psoriasis
The available evidence demonstrates no causal relationship between OCP use and psoriasis outcomes:
Large cohort data from the Oxford Family Planning Association study (17,032 women followed long-term) found no increased risk of hospital referral for psoriasis among OCP users compared to non-users. 2
Hospital referral for psoriasis was actually associated with smoking (approximately twofold increased risk), not with oral contraceptive use. 2
Among various skin disorders studied, only eczema/dermatitis showed a modest association with current OCP use (relative risk 1.6), but psoriasis specifically showed no such relationship. 2
Critical Context: OCPs as Contraception During Psoriasis Treatment
The primary concern regarding OCPs in psoriasis patients relates to their use as contraception when systemic therapies are prescribed, not to any direct OCP-psoriasis interaction:
Absolute Contraception Requirements
All commonly used systemic psoriasis agents are absolutely contraindicated in pregnancy and require rigorous contraception. 1
Methotrexate: Contraception required during treatment and for at least one menstrual cycle after stopping in women; causes spermal abnormalities in men wishing to father children. 1
Retinoids (etretinate): Teratogenic potential persists for approximately two years after stopping treatment due to body storage; requires contraception for at least one month before treatment, during treatment, and for at least two years after stopping. 1
PUVA photochemotherapy: Contraception required throughout treatment. 1
Cyclosporin, hydroxyurea, azathioprine: All require contraception during use. 1
Clinical Application in Practice
The American Academy of Dermatology guidelines illustrate this principle through a case presentation:
A 25-year-old woman with psoriasis planning conception within one year was appropriately using OCPs while managing her disease. 1
The clinical priority was controlling psoriasis before conception, with OCPs serving as essential contraception during this treatment period. 1
Treatment planning must account for the patient's reproductive timeline, particularly with agents like retinoids that require extended washout periods. 1
Risk Stratification by Treatment Type
Topical Therapy Only (BSA <5%)
- No contraception concerns specific to psoriasis treatment. 1
- OCPs can be used freely without psoriasis-related considerations. 2
Systemic Therapy Candidates (BSA ≥5% or refractory disease)
- Absolute requirement for effective contraception before initiating treatment. 1
- OCPs represent an appropriate contraceptive method in this context. 1
- Written instructions must be provided to patients regarding teratogenicity risks. 1
Biologic Therapies in Reproductive-Age Women
- TNF-α inhibitors (particularly certolizumab pegol) are preferred in women planning pregnancy due to minimal placental permeability. 3
- Certolizumab pegol is recommended first-line for pregnant patients requiring treatment. 3
- Other biologics (secukinumab, ustekinumab) should be discontinued when planning pregnancy. 3
Common Pitfalls to Avoid
Do not withhold OCPs from psoriasis patients based on unfounded concerns about disease worsening - large-scale epidemiologic data refute this association. 2
Do not prescribe systemic psoriasis therapies to women of childbearing age without confirming reliable contraception - this represents a critical safety requirement, not a suggestion. 1
Do not assume all contraceptive methods are equivalent - when using retinoids, the two-year post-treatment contraception requirement necessitates highly reliable methods. 1
Do not overlook male patients - methotrexate causes spermal abnormalities and is contraindicated in men wishing to father children. 1
Monitoring Considerations
When OCPs are used as contraception during systemic psoriasis therapy:
- No additional monitoring is required specifically for the OCP-psoriasis interaction. 2
- Standard monitoring protocols for the systemic agent apply (e.g., weekly CBC and liver function tests for methotrexate, blood pressure and creatinine for cyclosporin). 1
- Pregnancy testing should be performed before initiating teratogenic agents. 1