What are the safest treatment options for managing psoriasis in a pregnant woman?

Psoriasis Management in Pregnancy

For pregnant women with psoriasis, low- to moderate-potency topical corticosteroids are the safest first-line treatment for localized disease, while narrowband UVB phototherapy is the preferred systemic option for moderate-to-severe disease that fails topical therapy. 1

Treatment Algorithm by Disease Severity

Localized Psoriasis (First-Line)

• Low- to moderate-potency topical corticosteroids are the safest and most appropriate first-line treatment for localized psoriasis in pregnancy. 1
• Topical calcipotriene can be used with caution during pregnancy, though it should only be prescribed when potential benefits justify potential fetal risks. 2
• The maternal and fetal no-effect exposures for calcipotriene in animal studies (43.2 μg/m²/day in rats, 17.6 μg/m²/day in rabbits) exceed expected human systemic exposure (0.13 μg/m²/day) from dermal application. 2

Moderate-to-Severe Psoriasis (Second-Line)

• Narrowband UVB phototherapy is the first-line systemic treatment for pregnant patients with moderate-to-severe psoriasis who have failed topical therapies. 1
• Narrowband UVB has no known teratogenic effects and is considered the safest systemic approach during pregnancy. 1
• Treatment is administered 3-5 times per week, with initial dosing based on skin type (130-400 mJ/cm²), increasing by 10% for treatments 1-20. 1
• Most patients require approximately 30 treatments to achieve noticeable response. 1
• Genital shielding should be used routinely during phototherapy. 1

Severe Refractory Disease (Rescue Therapy)

• Cyclosporine may be regarded as rescue therapy for pregnant patients with severe psoriasis unresponsive to topical and phototherapy options. 1
• Starting dose is 2.5 mg/kg/day divided twice daily, used for short 3-4 month interventional courses to minimize fetal exposure. 1
• Cyclosporine is pregnancy category C and may cause lower birth weight and shorter pregnancy duration, though it appears not to be teratogenic. 3, 4
• Benefits to maternal health outweigh potential fetal risks when deciding to use systemic therapy for severe refractory disease. 1

Biologic Therapy Considerations

• TNF-α inhibitors (adalimumab, etanercept, infliximab) may be used with caution when disease severity necessitates treatment and other options have failed. 1
• Most pregnancies reported in women taking biologics at conception and during pregnancy have had successful outcomes. 1
• Certolizumab pegol is recommended as first-line biologic treatment in pregnant patients due to minimal placental permeability. 5
• Maternal IgG (and therefore biologics) is actively transferred to the fetus during second and third trimesters, with unknown impact on fetal development. 1
• For patients receiving infliximab during pregnancy, infusions should be avoided after 30 weeks if possible due to its relatively long half-life and evidence of placental crossing. 1

Absolutely Contraindicated Treatments

Category X Medications

• Methotrexate is absolutely contraindicated during pregnancy as it is a known teratogen and mutagen that can cause fetal death or teratogenic effects. 1, 3
• Acitretin is absolutely contraindicated during pregnancy due to severe teratogenic effects, and women must avoid pregnancy for at least 3 years after discontinuing therapy. 3, 6
• Tazarotene topical is contraindicated during pregnancy and should be discontinued immediately if pregnancy is recognized. 1
• Apremilast has insufficient safety data and should not be used during pregnancy. 1

Critical Safety Precautions

Biologic Therapy Timing

• Biologic agents should be avoided or discontinued in advance so the fetus is free of medication during the critical period of development in the first 12 weeks. 1
• Effective contraception is strongly recommended for patients receiving biologic therapy. 1

Infant Vaccination Restrictions

• 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

Alcohol Avoidance with Cyclosporine

• Ethanol must not be ingested by female patients of childbearing potential during treatment with cyclosporine or for 2 months after cessation, as concurrent ingestion of cyclosporine and ethanol can form etretinate with significantly longer elimination half-life. 4

Essential Counseling Points

• Controlling severe or unstable psoriasis is important to maintain maternal health. 1
• Consultation with obstetrics, particularly high-risk maternal-fetal medicine, is recommended when considering systemic therapy. 1
• Careful pregnancy monitoring in moderate-to-severe psoriasis is required given high risk of complications including pregnancy-induced hypertensive disorders, low birth weight for gestational age, and gestational diabetes. 7