What are the treatment options for psoriasis in pregnancy that is not responding to butyrate (sodium butyrate)?

Treatment Options for Psoriasis in Pregnancy Not Responding to Butyrate

For pregnant patients with psoriasis unresponsive to butyrate, escalate to topical corticosteroids (low- to moderate-potency) combined with narrowband UVB phototherapy as second-line treatment, reserving cyclosporine or TNF-α inhibitors for severe, refractory disease after careful risk-benefit discussion. 1, 2, 3

First-Line Safe Options During Pregnancy

Topical Therapies

• Low- to moderate-potency topical corticosteroids are the safest and most appropriate first-line treatment for localized psoriasis in pregnancy that has failed butyrate 1, 2, 4, 3
• Emollients and moisturizers should be used liberally as adjunctive therapy to maintain skin barrier function 3
• Avoid high-potency topical steroids on large body surface areas due to potential systemic absorption 1

Important caveat: Topical tazarotene, anthralin, and coal tar products should be avoided during pregnancy due to unclear teratogenic risks 1, 4

Phototherapy as Second-Line

• Narrowband UVB phototherapy is the preferred treatment for moderate-to-severe psoriasis in pregnancy when topical therapies fail 2, 4, 3
• Broadband UVB can be used if narrowband UVB is unavailable 3
• Phototherapy is considered safe throughout all trimesters with no documented fetal harm 2, 4

Systemic Therapy for Severe Refractory Disease

When Systemic Treatment Becomes Necessary

The decision to use systemic therapy should be made when:

• Psoriasis is severe or rapidly worsening despite topical therapy and phototherapy 2, 5
• Disease significantly impacts maternal health and quality of life 1
• Benefits to maternal health outweigh potential fetal risks 2, 5, 3

Cyclosporine: Preferred Systemic Option

• Cyclosporine may be regarded as a rescue therapy for pregnant patients with severe psoriasis unresponsive to topical and phototherapy options 2, 5, 3
• Increasing evidence supports relative safety of cyclosporine during pregnancy, though it should be used with caution 2, 5
• Cyclosporine does not appear to be teratogenic based on transplant literature, though fetal monitoring is essential 2, 3

Biologic Therapy: Use With Caution

• TNF-α inhibitors (adalimumab, etanercept, infliximab) may be used with caution when disease severity necessitates treatment and other options have failed 1, 2, 5, 3
• Most pregnancies reported in women taking biologics at conception and during pregnancy have had successful outcomes 1
• Evidence about biologic safety comes primarily from rheumatological and inflammatory bowel disease populations, not psoriasis specifically 1
• Maternal IgG (and therefore biologics) is actively transferred to the fetus during second and third trimesters, with unknown impact on fetal development 1

Critical consideration: The risk of fetal abnormalities with biologics has not been adequately studied and cannot be quantified 1

Specific Biologic Timing Strategy

• If biologics are necessary, consider stopping after 16 weeks gestation to minimize third-trimester fetal exposure 1
• Infants born to mothers receiving biologics beyond 16 weeks gestation should not receive live vaccines until 6 months of age (including rotavirus and BCG) 1

Absolutely Contraindicated Medications

Never use during pregnancy:

• Methotrexate (known teratogen and mutagen) 1, 5, 3
• Acitretin (known teratogen) 5, 3
• Apremilast (insufficient safety data) 1

Clinical Decision Algorithm

1. Failed butyrate → Low- to moderate-potency topical corticosteroids + emollients 1, 3

2. If inadequate response or moderate-to-severe disease → Add narrowband UVB phototherapy 2, 4, 3

3. If severe/refractory disease threatening maternal health → Consider cyclosporine as rescue therapy 2, 5, 3

4. If cyclosporine contraindicated or ineffective → TNF-α inhibitors with careful counseling about unknown fetal risks 1, 2, 5, 3

Essential Counseling Points

• Controlling severe or unstable psoriasis is important to maintain maternal health 1
• The risk-benefit discussion must be individualized based on disease severity, prior pregnancy outcomes, and patient preferences 1
• Consultation with obstetrics, particularly high-risk maternal-fetal medicine, is essential when considering systemic therapy 1, 3
• Document all pregnancy exposures in safety registries for future evidence generation 1

Common Pitfalls to Avoid

• Do not assume all psoriasis medications are equally dangerous - there is a hierarchy of safety with topical steroids and UVB being safest 2, 4, 3
• Do not withhold necessary treatment for severe disease - uncontrolled severe psoriasis may pose greater maternal risk than carefully selected systemic therapy 1, 2
• Do not forget to counsel about live vaccine avoidance in neonates if biologics were used beyond 16 weeks gestation 1
• Do not use salicylic acid before UVB phototherapy as it decreases efficacy through a filtering effect 1