What treatment options are available for a pregnant patient with psoriasis that is not responding to topical steroids (corticosteroids) and butyrate (short-chain fatty acid)?

Treatment of Psoriasis in Pregnancy Unresponsive to Topical Steroids and Butyrate

For pregnant patients with psoriasis failing topical corticosteroids and butyrate, narrowband UVB phototherapy is the first-line systemic approach, and if this fails or is impractical, cyclosporine should be used as rescue therapy for severe disease. 1, 2

First-Line Systemic Treatment: Narrowband UVB Phototherapy

• Narrowband UVB (NB-UVB) is the preferred first-line systemic treatment for pregnant patients with moderate to severe psoriasis who have failed topical therapies. 1
• NB-UVB has no known teratogenic effects and should be considered the safest systemic approach during pregnancy. 1
• Treatment is administered 3-5 times per week, with dosing based on skin type starting at 130-400 mJ/cm² and increasing by 10% of the initial dose for treatments 1-20. 1
• Most patients require approximately 30 treatments to achieve noticeable response, with clearance typically occurring after 30-40 treatments. 1
• Pregnancy is explicitly not a contraindication to UVB therapy. 1

Critical Phototherapy Considerations

• Do not use salicylic acid before UVB phototherapy as it decreases efficacy through a filtering effect. 2
• Genital shielding should be used routinely during phototherapy to avoid potential effects on the fetus. 1
• The face should be covered unless psoriatic lesions are present, as facial lesions respond to lower UV doses. 1

Second-Line: Cyclosporine as Rescue Therapy

When phototherapy fails, is unavailable, or disease severity necessitates more aggressive intervention, cyclosporine is the recommended rescue therapy. 2, 3

Cyclosporine Dosing in Pregnancy

• Start at 2.5 mg/kg/day divided twice daily (1.25 mg/kg BID). 3
• Maintain this dose for at least 4 weeks before considering dose escalation. 3
• If inadequate response after 4 weeks, increase by approximately 0.5 mg/kg/day at 2-week intervals to a maximum of 4 mg/kg/day. 3
• Most patients show clinical improvement within 2 weeks, with satisfactory control achieved in 12-16 weeks. 3
• Use only for short 3-4 month interventional courses during pregnancy to minimize fetal exposure. 1

Cyclosporine Safety Profile in Pregnancy

• Cyclosporine is FDA Pregnancy Category C—it may cause lower birth weight and shorter pregnancy duration but appears not to be teratogenic. 4, 3
• Increasing evidence supports its relative safety during pregnancy when used for severe refractory disease. 2, 5
• The drug is embryo- and fetotoxic only at maternally toxic doses (0.8 times transplant doses in rats, 5.4 times in rabbits). 3
• In 116 reported pregnancies with cyclosporine exposure, the main concerns were premature birth (47%) and low birth weight, not congenital malformations (only 7 malformations in 116 pregnancies). 3
• Benefits to maternal health outweigh potential fetal risks when deciding to use cyclosporine for severe refractory psoriasis in pregnancy. 2

Monitoring Requirements for Cyclosporine

• Measure blood pressure and serum creatinine before treatment and every 2 weeks during the first 3 months, then monthly. 3
• Decrease dose by 25-50% if serum creatinine rises ≥25% above pretreatment level. 3
• Discontinue if dose reduction does not control abnormalities or if adverse events are severe. 3
• Monitor for hypertension, which is a common adverse effect requiring dose adjustment or discontinuation. 3

Third-Line: TNF-α Inhibitors (Use with Extreme Caution)

• TNF-α inhibitors (adalimumab, etanercept, infliximab) may be considered only when disease severity absolutely necessitates treatment and both phototherapy and cyclosporine have failed. 2
• Most pregnancies in women taking biologics at conception and during pregnancy have had successful outcomes. 2
• Critical caveat: Maternal IgG (and therefore biologics) is actively transferred to the fetus during the second and third trimesters with unknown impact on fetal development. 2
• Infants born to mothers receiving biologics beyond 16 weeks gestation should not receive live vaccines (including rotavirus and BCG) until 6 months of age. 2

Absolutely Contraindicated Treatments

• Methotrexate is absolutely contraindicated—it is a known teratogen and mutagen causing fetal death or severe malformations. 2, 4
• Acitretin is absolutely contraindicated—it causes severe fetal malformations and requires 3 years of contraception after discontinuation. 4
• Apremilast has insufficient safety data and should not be used during pregnancy. 1, 2

Essential Counseling and Multidisciplinary Approach

• Controlling severe or unstable psoriasis is important to maintain maternal health, which itself affects fetal outcomes. 2
• Consultation with high-risk maternal-fetal medicine is recommended when considering systemic therapy beyond phototherapy. 2
• The risk-benefit discussion must address disease severity, prior pregnancy outcomes, and the specific risks of each treatment option. 2
• Mothers receiving cyclosporine should not breastfeed due to drug presence in breast milk. 3

Common Pitfalls to Avoid

• Do not escalate to systemic therapy without first attempting adequate trials of topical corticosteroids (low to moderate potency) and phototherapy. 2
• Do not use cyclosporine for extended periods—limit to 3-4 month courses to minimize fetal exposure and maternal toxicity. 1
• Do not assume all topical steroids failed equally—ensure adequate potency and application frequency were used before declaring topical therapy ineffective. 2
• Do not delay treatment of severe psoriasis out of excessive caution—uncontrolled severe maternal disease poses its own risks to pregnancy outcomes. 2, 6