Psoriasis and Pregnancy
New guidelines help doctors and mothers-to-be decide on the best treatment for psoriasis, psoriatic arthritis
Beth Burke-O'Brien relished being pregnant, not only because she and her husband Bill eagerly anticipated having a baby, but because she'd never felt better healthwise. "I loved being pregnant. It was the best time of my life," says the 30-year-old new mom, who has psoriasis and psoriatic arthritis.
Burke-O'Brien, who lives in Boston, gave birth to daughter Cate in October. She says her disease improved during her pregnancy. "It was such a blessing to be pain free."
Lauren Kirkbride, 33, of Arlington, Texas, is expecting her third child this summer. Her psoriasis, which she has had since early childhood, has improved somewhat. She's curious to see whether it will disappear, as it did during her two previous pregnancies.
About 50 percent of women experience improvement in their psoriatic disease during pregnancy, according to Dr. Abby Van Voorhees, associate professor of dermatology at the University of Pennsylvania and National Psoriasis Foundation (NPF) Medical Board member. Twenty-five percent of women see no change in their disease and another 25 percent feel worse.
Doctors aren't sure what exactly triggers disease changes, but believe it may be partly hormone-related, Van Voorhees says. A 2006 study suggests that improvement in psoriasis during pregnancy may be genetic. The study showed that women who carry the main gene that is a risk factor for psoriasis were more likely to improve during pregnancy.
Whether a woman's psoriasis improves, worsens or stays the same, managing psoriasis or psoriatic arthritis while starting a family isn't simple.
"Treating psoriasis in women who are pregnant or breastfeeding presents special challenges due the side effects of certain medications and the ethical concerns of placing them in clinical trials," says Dr. Mark Lebwohl, chairman of the Foundation's medical board. "It's important for women to work with their doctors to determine which treatment is appropriate for them during pregnancy and to consider the precautions for each."
To help pregnant women and their doctors determine the best course of treatment, the NPF Medical Board recently released new guidelines for treating psoriasis in women who are pregnant or breastfeeding. The guidelines Beth Burke-O'Brien, who has psoriasis and psoriatic arthritis, and husband Bill O'Brien welcomed daughter Cate last October. Photo by Gordon Nelson Winter 2012 29 recommend first-, second- and third-line treatments.
Van Voorhees and Dr. Alexa Kimball, vice chair of dermatology at Massachusetts General Hospital and a former member of the NPF Medical Board, helped write the guidelines. Pregnant women with psoriasis need to consider several factors, they say, among them:
- The health and diagnosis of each woman will help determine the best course of treatment. For example, treatment might be different for a woman who has psoriasis and psoriatic arthritis than one who has psoriasis alone.
- Women may not need to go off all medications during their pregnancy. They should consult with both their obstetrician and dermatologist.
- The risks of treatment should be balanced with what the patient wants. Some women aren't comfortable with any kind of medical treatment during pregnancy, while others may base their decisions on the severity of their disease. If a woman has an additional chronic condition, it could shape the treatment she and her doctor choose.
In weighing her treatment options during her pregnancy, Beth Burke-O'Brien stopped taking methotrexate—a potent drug that pregnant women must avoid—about four months before she became pregnant. She continued to take the biologic drug Humira, which she believes contributed to the improvement in her psoriatic arthritis.
She made the tough decision to stop nursing when her daughter was 1 month old because she wanted to resume taking methotrexate to manage her disease.
Lauren Kirkbride spent many years taking methotrexate to manage her psoriasis and stopped taking it about nine months before becoming pregnant with her first child, Hayden, now 8. Since then, she's found more success with Enbrel. Concerned about taking certain medications during her third pregnancy, she has opted to stop taking Enbrel while she's pregnant, although the new guidelines say the biologic drug may be used, with caution, during pregnancy. She does plan to go back on Enbrel following the birth of her baby, but isn't sure when, since she'll be breastfeeding.
Dermatologist Kimball says it's important for pregnant women who have psoriasis and/or psoriatic arthritis to take care of their own health, which, in turn, will help them take care of the baby, during pregnancy and afterward.
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