What to do for a pregnant patient with psoriasis who is responding to butyrate (butyric acid) treatment?

Management of Psoriasis in Pregnancy Responding to Butyrate

If your pregnant patient with psoriasis is responding well to topical butyrate (hydrocortisone butyrate), continue this treatment throughout pregnancy as topical corticosteroids are the safest and most appropriate first-line therapy for psoriasis during pregnancy. 1, 2, 3

Rationale for Continuing Butyrate Treatment

• Topical corticosteroids, including hydrocortisone butyrate, are considered safe during pregnancy and represent first-line therapy for pregnant women with limited psoriasis 2, 3
• The FDA drug label for hydrocortisone butyrate states that topical corticosteroids should be used during pregnancy "only if the potential benefit justifies the potential risk to the fetus," but emphasizes avoiding extensive use, large amounts, or prolonged periods 1
• Animal studies with hydrocortisone butyrate showed fetal effects only at systemic doses far exceeding typical topical application (2× maximum therapeutic human dose), and no topical embryofetal development studies showed teratogenicity at clinically relevant doses 1

Practical Application Guidelines

• Limit application area and duration: Avoid using hydrocortisone butyrate extensively on large body surface areas, in excessive amounts, or continuously for prolonged periods during pregnancy 1
• Use the minimum effective amount: Apply only to affected areas with the least amount compatible with maintaining disease control 1
• Prefer low- to moderate-potency formulations: The National Psoriasis Foundation Medical Board recommends low- to moderate-potency topical steroids as first-line therapy in pregnancy, though your patient is already responding to butyrate 3

When to Consider Alternative or Additional Therapies

If the patient's psoriasis worsens or butyrate becomes insufficient:

• Second-line option: Narrowband UVB phototherapy is the consensus second-line treatment for pregnant women with psoriasis not adequately controlled by topicals 3
• For moderate-to-severe disease: If topical therapy and UVB fail, cyclosporine (2.5-5 mg/kg daily) has increasing safety evidence in pregnancy and should be considered before other systemics 4, 5, 3
• Biologic consideration: TNF-α inhibitors, particularly certolizumab pegol, may be used with caution in severe cases, though this represents a significant escalation from topical therapy 3, 6

Critical Safety Monitoring

• Monitor for signs of HPA axis suppression if using butyrate on large body surface areas, though this is rare with appropriate topical use 1
• Ensure the patient understands to avoid occlusive dressings unless specifically directed, as this increases systemic absorption 1
• Document the extent of body surface area treated and frequency of application at each visit 1

Common Pitfalls to Avoid

• Do not discontinue effective topical therapy unnecessarily: Many patients and providers become overly cautious about any medication during pregnancy, but topical corticosteroids have decades of safe use data 2, 3
• Do not switch to systemic therapy prematurely: The risk-benefit ratio strongly favors continuing topical therapy when it is effective, as systemic agents carry greater fetal risks 2, 3
• Do not use high-potency corticosteroids on facial or intertriginous areas: These locations have increased absorption and higher risk of skin atrophy 7

Postpartum Planning

• Topical corticosteroids are compatible with breastfeeding, though caution should be exercised and application to breast areas should be avoided 1
• If disease control was marginal during pregnancy with topicals alone, plan for potential escalation postpartum when more treatment options become available 3