Clinical considerations for the management of psoriasis in women

Abstract

The burden of psoriasis is particularly high for women, who report lower levels of happiness (women: 18.5%; men: 11.3% lower vs. general population) and are more likely to experience stress (women: > 60%; men: 42%), loneliness (women: 25-28%; men: 19-24%), stigmatization (Feelings of Stigmatization Questionnaire score; women: 93.2; men: 78.0), and reduced sexual activity (women: 33%; men: 19%) compared with men. The onset of psoriasis is bimodal, with one incidence peak (15-30 years) that coincides with the prime reproductive age for women, which poses specific challenges for their treatment. However, well-established guidelines for the treatment of women of childbearing age are lacking. Many women experience stabilization (21%) or improvement (55%) of their skin during pregnancy, but up to a quarter can experience disease worsening, and postpartum flares are common (> 50%). Therefore, balancing the risk of treatment with the risk of uncontrolled disease is important. Because half of pregnancies are unplanned, the implications of therapeutic options must be considered for all women with psoriasis who are sexually active, irrespective of intentions to start a family. Timely initiation of these discussions by health care professionals is paramount to prevent unintentional toxicity to the developing fetus. For example, acitretin, methotrexate, and oral psoralen/ultraviolet A are all contraindicated in pregnancy. Reassuringly, safety data for other psoriasis treatments during pregnancy are increasingly available, particularly for anti-tumor necrosis factor therapies. Despite encouraging data from pregnancy exposure registries and clinical studies now being included in anti-tumor necrosis factor drug labels, comfort with prescribing these therapies to pregnant women remains low (U.S. dermatologists: 21%; EU-5 dermatologists: 10%). In this article, we review issues specific to treating women of childbearing age with psoriasis and highlight the need for treatment guidelines to ensure consistent care and optimal outcomes for these patients.

Interaction of psoriasis and pregnancy: Maternal and fetal outcomes

“…Although it is not thought to affect fertility, pregnancy rates have been observed to be approximately 22% lower in women with psoriasis. Among the reasons for this, it has been suggested that many factors such as women's unwillingness to voluntarily, concerns about pregnancy and/or postpartum disease activity, fear of the effect of psoriasis treatments on pregnancy and baby, as well decreased closeness due to embarrassment and/or physical inability play a role [8,11].…”

“…In a cohort study using prospective data There are still some diffi culties in treatment due to the lack of well-established guidelines in pregnant women with psoriasis. However, United States and European drug labeling now summarize safety data on pregnancy and lactation to inform treatment choice in this patient population [8,48].…”

“…Exceptionally, the only agent that can overcome this rule is certolizumab, which does not have a placental transfer from mother to baby. Nevertheless, United States and European certolizumab labels indicate that the theoretical risk of administering live or live-attenuated vaccines to infants exposed to this biological agent inutero should be weighed against the benefi ts of these vaccines [8,63]. On the other hand, inactive vaccines that are routinely administered can be applied to babies whose mothers used anti-TNF- agents during pregnancy [57][58][59].…”

“…About half of all patients with psoriasis are women, and in more than 75% of those cases the onset age of psoriasis is observed before the age of 40 years. In other words, the diagnosis of psoriasis (mean age: 28 years) and the onset of treatment coincide with the peak reproductive age (18-45 years) [1,8]. Additionally, accompanying diseases (obesity, hypertension, diabetes mellitus, depression, and other chronic infl ammatory diseases such as infl ammatory bowel disease and rheumatoid arthritis) were found to be associated with adverse pregnancy and birth outcomes in most patients with psoriasis [5].…”

Use of biologic therapies for psoriasis during pregnancy and long‐term outcomes of exposed children: A 14‐year real‐life experience at a tertiary center in Turkey and review of the literature

“…6 However, 65% of patients reported worsening during the postpartum period. 6 Although well-designed guidelines on the treatment of psoriasis during pregnancy are lacking, 7 there are expert opinions and consensus recommendations. [8][9][10] Emollients and low-to-moderate-potency topical steroids are recommended as first-line therapy in limited disease, while narrowband ultraviolet B phototherapy as second-line therapy.…”