Review of treatment options for psoriasis in pregnant or lactating women: From the Medical Board of the National Psoriasis Foundation

Background: Treating psoriasis in pregnant and lactating women presents a special challenge. For ethical reasons, prospective randomized control trials have not been conducted in this patient population although these patients do encounter new-onset psoriasis in addition to flares and may require treatment throughout their pregnancies. Objective: Our aim was to arrive at consensus recommendations on treatment options for psoriasis in pregnant and lactating women. Methods: The literature was reviewed regarding all psoriasis therapies in pregnant and lactating women. Results: Topical therapies including emollients and low-to moderate-potency topical steroids are first-line therapy for patients with limited psoriasis who are pregnant or breast-feeding. The consensus was that second-line treatment for pregnant women is narrowband ultraviolet B phototherapy or broadband ultraviolet B, if narrowband ultraviolet B is not available. Lastly, tumor necrosis factor-alpha inhibitors including adalimumab, etanercept, and infliximab may be used with caution as may cyclosporine and systemic steroids (in second and third trimesters). Some specific strategies may be used to minimize risk and exposure. Limitations: There are few evidence-based studies on treating psoriasis in pregnant and lactating women. Conclusions: Because there will always be a question of ethical concerns placing pregnant and lactating women in prospective clinical trials, investigation of both conventional and biologic agents are unlikely to ever be performed. Some of these medications used to treat psoriasis are known abortifacients, mutagens, or teratogens and must be clearly avoided but others can be used with relative confidence in select patients with appropriate counseling of risks and benefits. (J Am Acad Dermatol 2012;67:459-77.)