Treatment of Atopic Dermatitis and Psoriasis in People Who Are Pregnant: It’s Complicated

Women who are pregnant and who have psoriasis or eczema often have limited options. The evidence about the effect that the systemic medications might have on pregnant women and their fetuses is limited.

But women deserve more than just topical treatment and moisturizers, and doctors may be more restrictive than necessary, Elizabeth Kiracofe, M.D., a dermatologist in private practice in Chicago, said during a presentation today at the annual meeting of the American Academy of Dermatology in New Orleans.

Elizabeth Kiracofe, M.D.

“We are more restrictive with both systemics and topical medications in our patients who have atopic dermatitis and psoriasis in a way that is not scientifically backed,” she said. “We may be doing a disservice to patients by being too restrictive in our prescribing patterns. We may have concerns, and there are uncertainties, but these patients deserve to be treated because there's also risk of nontreatment. These patients have a chronic immune-mediated inflammatory disease and they’re pregnant. Having an uncontrolled chronic immune mediated inflammatory disease is also not healthy in pregnancy.”

Inadequate control of disease can lead to flares and infections and even septicemia, Kiracofe said. Additionally, she said, depression is more common in women with psoriasis than in healthy women without psoriasis. And 21% of pregnant women who have psoriasis suffer from depression, compared with 10% of non-psoriasis patients.

In the United States, 4.6% of women have atopic dermatitis, and 3.2% of women have psoriasis. About 75% of women are diagnosed before the age of 40. At the same time, the representation of women in psoriasis studies has decreased. In a recent JAMA study, investigators found that clinical studies with least 45% of women in the enrolled population decreased from 87.2% in the 2010 to 2015 timeframe to 29.5% in the 2015 to 2020 timeframe.

Kiracofe acknowledged the treatment choices for pregnant patients with atopic dermatitis are complicated. There are no large clinical studies on the possible effects and side-effect of biologics on conception, pregnancy and lactation.

When treating pregnant women, it’s important to use the science, Kiracofe said. “We can’t just base decisions on just the label; we need to know the pathophysiology, we need to know how the body works. And we need to have a shared decision-making process and talk with our patients because that is a really important conversation.”

An important piece of the puzzle in the use of biologics in psoriasis and atopic dermatitis during pregnancy is the degree of immune suppression the infant experiences within the few first few months of life.

It’s important to think about the impact of using biologics in the second and third trimester. “That’s a really big frameshift when thinking about medication interacting with our patients. We’re taught from medical school to think about the first trimester fetal malformations. But for these type of systemic medications, we actually want to be thinking in the second and third trimester.”

Kiracofe described how the placental Fc receptor "grabs." The Fc receptor is instrumental in allowing medications to cross the placenta. Cimzia (certolizumab) is the only biologic with a confirmed safety profile during pregnancy and lactation with no increased mortality rate for the fetus, Kiracofe told an audience at the dermatology organization's annual meeting. Cimzia is a TNF-alpha inhibitor that doesn’t bind to the placental Fc receptor.

Cimzia was approved in September 2013 by the FDA as a treatment of active psoriatic arthritis and in May 2018 as a treatment of moderate-to-severe psoriasis in adults. It is also approved for treating rheumatoid arthritis, Crohn's disease, ankylosing spondylitis, and non-radiographic axial spondyloarthritis.