Treatment with systemics
Generally, women and men should avoid the use of systemic medications for psoriasis when trying to conceive. Systemic medications for psoriasis should also be avoided when nursing as the drugs can be secreted in breast milk.
It is unknown what effect biologics may have on a developing fetus or on a nursing infant. Long-term animal studies conducted with Enbrel (etanercept), Humira (adalimumab) and Remicade (infliximab) revealed no evidence of harm to the fetus.
Because of the limited information, biologic drugs should be used during pregnancy only if there is a clear medical need. Women considering pregnancy and pregnant women should work closely with their doctor to weigh the benefit and the risks of using these drugs and consider enrolling in a pregnancy registry.
Cyclosporine is generally used to treat moderate to severe psoriasis. A worldwide registry of transplant patients (cyclosporine is used in organ transplant patients) treated with the drug during pregnancy did not show an increased rate of birth defects, although low birth weight and premature birth were traced to cyclosporine use. Cyclosporine should only be used during pregnancy if the benefits outweigh the potential risks.
Methotrexate is capable of causing miscarriages or fetal malformations. Both men and women should discontinue using methotrexate at least 12 weeks before trying to conceive. Methotrexate poses little or no risk to pregnancies that occur after it is discontinued. There are studies on hundreds of women who were treated with high doses of methotrexate for uterine cancer and gave birth to healthy babies after having discontinued methotrexate within the recommended minimum time period prior to conception.
Methotrexate does not harm a man's or a woman's long-term potential of conceiving a healthy child. Methotrexate also may lower sperm count while a man is on the drug.
All retinoids, including oral, carry a very high risk of causing birth defects if taken by a woman who is pregnant or trying to conceive. Oral retinoid treatment does not appear to have any effect on male fertility.
Soriatane (acitretin) should never be taken for psoriasis during pregnancy. Women of childbearing age who take Soriatane must use reliable methods of birth control during treatment and wait three years after discontinuing the medication to become pregnant.
During treatment and for two months after, women taking Soriatane must avoid consuming any alcohol (including cough syrups, etc.) because it can cause acitretin to convert into a substance called etretinate in the bloodstream that can stay in the body indefinitely. Etretinate is known to cause birth defects. It's not certain how much alcohol will trigger this reaction or how much acitretin is converted. Given these uncertainties, many doctors avoid prescribing Soriatane for women of childbearing age.
Isotretinoin is a member of the retinoid family that is sometimes used to treat psoriasis. Isotretinoin can cause birth defects if a woman takes it at the time of conception, so reliable birth control must be used for one month before treatment, during treatment and for at least one month after. Isotretinoin leaves the body more quickly than acitretin, so a woman may safely get pregnant two months after she stops taking this drug.
The iPLEDGE program is a risk-management program designed to eliminate fetal exposure to isotretinoin. The doctor prescribing isotretinoin must enter patient information in the iPLEDGE system before a pharmacist can dispense medication.
Women considering pregnancy and pregnant women, who are on medication(s), should talk to their doctor about enrolling in a pregnancy registry. A pregnancy registry is maintained to track women that are on a drug during pregnancy to better understand the effects of a particular drug on the mother and fetus. Pregnancy registries that are drug specific include Acitretin at (855) 850-2138, Cyclosporine at (888) 522-5581, and Enbrel at (800) 772-6436. A pregnancy registry studying multiple drug treatments for psoriatic disease can be found at (877) 311-8972.
Another resource is the Organization of Teratology Information Specialists (OTIS), which provides up-to-date information about medications taken during pregnancy.