INFORMATION FOR WOMEN WHO HAVE PSORIASIS WHILE PREGNANT OR BREASTFEEDING
What is psoriasis?
Psoriasis is a skin disorder that is characterized by an overabundance of cells called keratinocytes. This causes plaques on the skin, elevated thick scaly areas which itch. This happens because of inflammation in the surface and deep layers of the skin. The inflammation occurs not only in the skin, but also in other body tissues. The severity of effects and the particular types of body tissues that are affected varies, resulting in several different types of psoriasis.
The most common type is called plaque psoriasis, which usually begins on the back side of elbows, knees and back, but also can develop anywhere on the skin. Another type of psoriasis is called psoriatic arthritis, which is characterized by arthritis in various joints. This type of psoriasis is more common in people with more severe skin disease and often also involves the nails.
Psoriasis is one of many conditions that can complicate pregnancy, because it usually begins in young adulthood and is a chronic condition, a condition that persists for a very long time, often throughout life.
How common is psoriasis during pregnancy?
Psoriasis is a very common condition, estimated to exist in about 2, possibly 3, percent of the human population. The disease can develop at any age, but most frequently makes its appearance in what epidemiologists call a bimodal age peak. One peak occurs in those aged 15-30 years, while the other peak is at 50-60 years of age. In women, the average age at diagnosis is 28 years, which makes psoriasis a fairly common disease in women who are pregnant and nursing. In fact, an estimated 65,000-107,000 babies are born to women with psoriasis every year. 9,000-15,000 of these women suffer from moderate to severe disease.
Along with adding its own particular effects on the body, pregnancy also can modify the severity of psoriasis. Roughly 55 percent of pregnant women with psoriasis find that their symptoms get better during pregnancy, whereas 23 percent find that the condition worsens, and 21 percent notice little change. Things often get worse in the post-partum period, the weeks following delivery, when 40-90 of patients experience a worsening of the disease. Additionally, 10-30 percent of psoriasis patients suffer from psoriatic arthritis. Its thought that pregnancy, or delivery of the baby could actually act as a triggering factor for articular disease.
How is psoriasis diagnosed?
Diagnosis of psoriasis begins with a patient history that details the course of progression of skin plaques and symptoms in other organs, such as joints. After a physical examination that highlights the skin and joints, physicians go through workup that includes a skin biopsy, and looks at various immunological factors and other agents in blood samples. For patients with arthritic symptoms and signs, radiographs (X-rays) and other imaging tests are also important.
Does psoriasis cause problems during pregnancy?
Pregnancy exacerbates psoriasis and triggers flare ups in roughly 23 percent of psoriatic pregnant women. Worsening symptoms can affect up to 90 percent during the post-partum period, and flare ups can involve expansion of the usual skin conditions to include arthritis. Pregnant women with psoriasis also have an elevated risk of other diseases, many of which can cause long-term problems. These conditions include type 2 diabetes mellitus, heart disease, obesity, and metabolic syndrome.
Does psoriasis during pregnancy cause problems for the baby?
Psoriasis varies greatly in its severity, and studies are not clear on whether mild cases can have negative consequences on the outcome of pregnancy. When it comes to moderate and severe psoriasis, on the other hand, accumulating evidence from research studies suggests that the condition can damage blood vessels in the placenta, leading to pregnancy loss (spontaneous abortions) and low birth weight (LBW).
What to consider about taking medications when you are pregnant or breastfeeding:
- The risks to yourself and your baby if you do not treat the psoriasis. These can be significant for those with moderate to severe psoriasis
- The risks and benefits of each medication you use when you are pregnant
- The risks and benefits of each medication you use when you are breastfeeding
What should I know about using medication to treat psoriasis during pregnancy?
For treatment of moderate and severe cases of psoriasis and psoriatic arthritis, a category of medications known as biological agents have become very popular. These agents consist of antibodies and protein factors that modify immune system activity and other body processes. Research has not provided a clear answer on the safety of biological agents during pregnancy and breastfeeding, but there is significant concern, supported by some study results, that that a developing baby or newborn could be harmed.
One group of biological agents that have come under scrutiny, because they may be harmful during pregnancy and lactation yet are extremely effective against psoriasis, are TNF-a inhibitors. These drugs consist of antibodies, with names such as certolizumab, infliximab, and others ending in mab, which stands for monoclonal antibody. Despite the concerns, in some cases, these drugs can be appropriate during pregnancy on the grounds that disease flare ups represent a greater risk. Other agents that are given systemically (inside the body) include methotrexate and cyclosporine, and these are also thought to be dangerous to a developing baby or a nursing child.
Another treatment category is called phototherapy, in which patients are exposed to ultraviolet light after taking a medication that sensitizes the skin cells to the light. One such photosensitizing medication is called tazarotene. As with the biological agents, there is also concern regarding the safety of the light sensitizing drugs, tazarotene in particular, but the level of concern is slightly less compared with the biological agents.
Finally, there are topical treatments, agents that are applied to the skin. Many of these contain steroids these are, in fact, the main psoriasis treatment. But some topical treatments contain other classes of agents that fight psoriasis through other mechanisms. One example is vitamin D analogs. Topical agents are very useful in mild to severe psoriasis and represent the safest treatment during pregnancy and lactation, but they may not be adequate for severe cases and flare ups.
Who should NOT stop taking medication for psoriasis during pregnancy?
Pregnant women with severe psoriasis and psoriatic arthritis may need to continue with medications at some level throughout pregnancy, despite concerns about risk to the developing baby. However, physicians can tweak dosages and change medications in order to minimize the risks.
What should I know about choosing a medication for my psoriasis during pregnancy?
Each class of medications has benefits and drawbacks, and psoriasis typically presents a clinical dilemma. Whenever possible, your doctor will try to control your psoriasis using topical treatments alone.
You may find Pregistrys expert reports about the individual medications to treat psoriasis here. Additional information can also be found in the sources listed at the end of this report.
What should I know about taking a medication for my psoriasis when I am breastfeeding?
Use of topical medications while breastfeeding can be safe, if you are careful. If you choose this option, you must be very careful to keep ointments and cream far away from the ar
eas on the breast that contact the infant while he is nursing. Biological agents and many other systemic agents should be avoided during lactation. If your psoriasis flares up after delivery, or it is so severe that you require TNF-a inhibitors, then do not breastfeed.
What alternative therapies besides medications can I use to treat my psoriasis during pregnancy?
Warm baths, skin emollient, weight loss, alcohol and smoking cessation, and stress management can be helpful, but their effectiveness is limited compared with medications.
What can I do for myself and my baby when I have psoriasis during pregnancy?
Work with your doctors to find an optimal balance between medications and symptom severity. If your psoriasis is mild to moderate, you may be able to prevent flare ups using topical corticosteroids or other topical medications in combination with non-drug treatments such as warm baths and stress management. If topical medication alone proves inadequate, your doctor may advise adding phototherapy and keeping the dosing of photosensitizing agents at a minimum, especially as delivery approaches. Similarly, if biological agents needed to be added, those too can be kept at a minimum and tapered off as delivery approaches.
Resources for psoriasis in pregnancy:
For more information about psoriasis during and after pregnancy, contact http://www.womenshealth.gov/ (800-994-9662 [TDD: 888-220-5446]) or check the following links: