As with having psoriatic disease, being pregnant with the disease differs depending on the individual. Take Sabrina Skiles, 32, and Joni Kazantzis, 34, for example. Both stopped taking some psoriasis medications in preparation for or during their pregnancies, but from there, their experiences diverged.
Skiles, who lives in Houston and is pregnant with her second child, used only a topical steroid, Clobetasol propionate, during her pregnancies. As a result, in her second trimester her plaque psoriasis flared badly, particularly the itching and flaking on her scalp. Light therapy had been helping her scalp psoriasis, but she stopped her light box sessions while pregnant, mistakenly thinking it was dangerous to continue (see “3 tips for a healthier pregnancy” below).
Kazantzis, who has two daughters and lives in Princeton, New Jersey, stopped taking Humira (adalimumab) about a year and half before her first pregnancy in 2015. During both her pregnancies, her guttate and plaque psoriasis dwindled to near-clearance; a few weeks after delivery, her skin flared, which is something Skiles didn’t experience.
Both scenarios are relatively common, said Alan Menter, M.D., chair of the Division of Dermatology and director of the Dermatology Residency Program at Baylor University Medical Center in Dallas.
Symptoms of psoriatic arthritis (PsA) also tend to ease during pregnancy, but post-birth flares can affect joints according to a 2017 study published in Seminars in Arthritis & Rheumatism.
As it did with Kazantzis, psoriasis often flares after delivery in women whose psoriatic symptoms have cleared during pregnancy, said Menter. “The immune system during pregnancy changes, suppressing cytokines [inflammatory proteins active in psoriatic disease],” he said. “Once the baby is born, it suddenly goes back to normal for that patient, and it overflows. Women can get quite a significant flare-up.”
Dermatologist Alexa B. Kimball, M.D., MPH, has also seen severe postpartum flares. “I ask patients to schedule an appointment soon after they deliver so we can discuss treatment options,” said Kimball, president and CEO of Harvard Medical Faculty Physicians at Beth Israel Deaconess Medical Center, and professor of dermatology at Harvard Medical School in Boston.
Passing the disease to the next generation?
Whether starting a family is a goal in the near or distant future, the earlier women consult their dermatologist, the better. Knowing a woman with psoriatic disease wants to have children at some point can “dramatically impact the therapy she is prescribed from the start,” said Mark G. Lebwohl, M.D., professor and chair of the Department of Dermatology at the Icahn School of Medicine at Mount Sinai in New York City.
Stopping and restarting biologics — as women may want to do before and after pregnancy — can prompt the body to make antibodies to the drug. “Developing antibodies can cause side effects and reduce the drug’s effectiveness, but there are some biologics with which this is less likely to happen,” Lebwohl said.
Many people worry that their children will inherit psoriatic disease, which is a legitimate concern, said Menter. And when both parents have psoriasis, the risk substantially increases. Yet, inheriting genes that carry a susceptibility to developing psoriasis (geneticists have identified about 50) doesn’t tell the whole story. “For psoriatic disease to develop, these genes must be triggered by something in the environment, and we don’t yet understand all those factors,” Menter said. “I tell my patients about 25 percent of their close relatives will develop psoriasis.”
Abby S. Van Voorhees, M.D., professor and chair of dermatology at Eastern Virginia Medical School in Norfolk, Virginia, talks to parents worried about their children inheriting psoriasis about the vast improvement in treatments. “Therapeutic options and our understanding of how to best treat psoriasis have expanded in a really positive way,” she said. “I say to my patients that their experience of psoriasis may be quite different than what their child’s might be — if they do go on to develop it.”
Huy Ngo, a psoriasis vlogger with severe plaque psoriasis, said passing the disease to his son wasn’t a big concern. “My father had psoriasis and taught me all about it,” said Ngo, 35, who lives with his wife and 1-year-old son, Desmond, in Denver. “We can never truly be ready for something before it happens, but my father made sure I was as prepared as I could be. If I need to, I can do the same for Desmond.”
Keeping your disease under control during pregnancy
Limited use of low to moderately potent topical steroids is the preferred first-line treatment during pregnancy, followed by ultraviolet B light therapy. Both are generally safe for pregnant and breastfeeding women, according to guidelines issued in 2012 by the NPF, co-authored by Kimball, Lebwohl and Van Voorhees and published in the Journal of the American Academy of Dermatology. (Always ask your dermatologist how much of your medication you can safely use.)
However, two medications for psoriatic disease, methotrexate and acitretin, can cause miscarriage and birth defects, respectively. Methotrexate should ideally be stopped at least three months before conception and should not be taken while breastfeeding.
In addition, there is no safe way to mix pregnancy and the oral retinoid acitretin, and it should never be prescribed for women who may one day have children, said Menter, lead author of the American Academy of Dermatology’s guidelines on pregnancy and psoriatic disease.
However, Menter said many biologics are considered relatively safe for use during pregnancy and breastfeeding, in the sense that benefits outweigh potential risks. Some women choose to stop biologics during pregnancy and instead use topicals or light therapy, or simply choose to go without treatment. Everyone is different, and women will make different choices depending on their disease and beliefs. It’s critical for women to have a discussion with their doctor as early as possible about individual risks and benefits.
“There are several key phases during pregnancy, and medication risk is different during each of them,” said Kimball. “Understanding the particular risks and benefits of each medication at each stage is important.”
Individuals with PsA may find they need to continue biologics or other medications during pregnancy to keep pain and joint symptoms at bay. “I’ve had patients with psoriatic arthritis who have not been able to stop their medications during their pregnancy, though that was their initial hope,” said Kimball. “It is important for mothers to understand that keeping their disease under control, both during pregnancy and after, is important for both their own well-being and their baby’s.”
Moisturizing is still the message
Psoriasis can affect the genitals, but that does not present a problem during childbirth, said Van Voorhees. “Psoriasis can be on the lips of the vagina, but not in the vaginal vault [upper portion of the vagina] itself, so it usually does not cause any unique problems for women giving birth,” she said. “Moisturize affected skin so it’s as comfortable and flexible as possible before delivery.”
Psoriasis around the nipples is also common and should be treated before birth, especially if you’re planning to breastfeed, said Menter. “This is not because it’s dangerous for the baby to come in contact with or ingest flaking skin — it’s not — but because the friction of swollen breasts, tight bras and breastfeeding can cause more irritation and therefore skin flares, making things very uncomfortable for the mother,” he said.
Katzantzis said she faced this issue when she started pumping breast milk and treated her lesions with a medication-free mild emollient. A diluted topical steroid can also be used up to four hours before breastfeeding, said Menter.
Steps can also be taken to help prevent psoriasis on the nipples, said Van Voorhees. “Moisturize nipples well during pregnancy and be sure you’re wearing a well-fitting bra as your breasts change size to minimize rubbing. In doing so, hopefully we keep [irritation] from occurring at all,” she said.
3 tips for a healthier pregnancy
Boost your overall health. “Women with psoriasis are at higher risk for diabetes, high blood pressure and obesity, all of which can contribute to poor pregnancy outcomes. Getting these diseases under control prior to and during pregnancy is likely to be helpful and improve the health of the mother and the baby,” said Alexa B. Kimball, M.D., MPH, president and CEO of Harvard Medical Faculty Physicians at Beth Israel Deaconess Medical Center, and professor of dermatology at Harvard Medical School in Boston.
Communicate closely with your dermatologist. Doing so allows you to treat flares before they worsen and prevent miscommunication like the one that left Sabrina Skiles with uncomfortable, unnecessarily untreated scalp psoriasis. Skiles stopped UVB light therapy — the only treatment that helps her scalp psoriasis — because she was mistakenly told by a nurse that it wasn’t safe during pregnancy.
Don’t fret about an unplanned pregnancy. “The first thing to do is have a conversation with your physician and potentially a genetic counselor,” said Kimball. “Even with some of the medications that we try to avoid and that aren't recommended for women who are pregnant, some women have had successful and unaffected pregnancies. So don’t panic, but get more information immediately.”
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