For pregnant women with mild psoriasis, over-the-counter topicals such as petroleum jelly or mineral oil are a good choice for treatment. Potential absorption of topical medications through the skin must be considered, particularly when medications are applied under occlusion, over large areas of skin or in large quantities.
Topical steroids, and topical non-streroids, including anthralin, Dovonex (calcipotriene), Taclonex (calcipotriene and betamethasone dipropionate) and Vectical(calcitriol) ointment are classified by the Food and Drug Administration as Category C, meaning that it has not been tested for safety during pregnancy in animal or human studies.
If topical steroids are required, the amount should be limited. Use caution when applying topical steroids on the breasts to avoid passing the medication to the baby while nursing. Superpotent steroids should be used only as a last resort. Occlusion of any steroid medication should only be done under a health care provider's supervision.
Studies of pregnant women treated with systemic steroids have not found an increase in birth defects, despite animal studies suggesting they cause an increased incidence of cleft palate.
No animal or human studies have examined the potential birth defects associated with the use of anthralin, which has been used safely for decades in pregnant women. Studies of Dovonex have shown that high doses administered orally cause birth defects in some animal models but not in others. There are no adequate studies of the topical use of Dovonex, Taclonex, or Vectical ointment in pregnant women. All of these medications should only be used during pregnancy only if the potential benefit outweighs the potential risk to the fetus and only if they are recommended by a health care provider.
Pregnant women and those trying to conceive should avoid Tazorac (a topical retinoid, also known by its generic name tazarotene). Women of childbearing potential should use reliable methods of birth control during treatment with Tazorac. The medication should be stopped immediately if a woman becomes pregnant.
Large doses of Tazorac caused fetal abnormalities in animal studies, although no problems have been observed in human clinical trials. However, retinoids in their oral form cause birth defects. Tazorac used in large quantities or over large areas could be absorbed through the skin and harm the fetus. The drug has no known effects on sperm.
Treatment With Systemics
It is preferable to avoid systemic medications systemic medications during the first trimester of pregnancy.
According to NPF recommendations for psoriasis treatment in pregnant and breastfeeding woman, breastfeeding while taking medications should be avoided due to the lack of long-term and population-based studies.
Biologics may be appropriate for pregnant or breastfeeding women. For some treatments, there is research available to support or discourage their use in pregnant or breastfeeding women.
Women considering pregnancy and pregnant women should work closely with their doctor to weigh the benefit and the risks of using these treatments.
Small studies have been done on pregnant women using biologics that showed no increased risk for low birth weight or birth defect. Researchers and providers are working hard to gain more information on the use of these treatments for women who are pregnant and breastfeeding.
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 health care provider 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.
A pregnancy registry studying multiple drug treatments for psoriatic disease, MotherToBaby Pregnancy Studies, can be found at 877-311-8972. The Organization of Teratology Information Specialists provides up-to-date information about medications taken during pregnancy.
Treatment With Light Therapy
Both components in PUVA treatment — the oral medication psoralen and the UVA light — should be avoided by both sexes around conception and by women during pregnancy as they can cause birth defects. This also applies to bath PUVA, where the entire body is immersed in a tub of water that contains psoralen.
Nursing women should avoid PUVA, because psoralen in breast milk could cause light sensitivity in the infant.
Ultraviolet Light B (UVB)
Treatment with UVB is generally safe during pregnancy, but sunscreens should be applied on the face to prevent melasma (a condition common in pregnant women that causes the appearance of brown spots). UVB is generally acceptable as a psoriasis treatment for women who are nursing.
Combination treatments of UVB with tar or anthralin (called Goeckerman or Ingram regimens, respectively) are considered safe and effective treatment options for pregnant women with widespread psoriasis. These treatments have been used for decades without any evidence of harm to the fetus.