Management of psoriasis in pregnancy: time to deliver?

ORIGINAL ARTICLE, p 334 When a woman with psoriasis becomes pregnant are there any risks to mother and baby as a consequence? It has been estimated, using data from 2006, that in the U.S.A. there are approximately 100 000 births to women with psoriasis per annum.1 About 15 000 of those births are to women with severe psoriasis. Despite the numbers of pregnancies our understanding of the risk is limited. In clinical practice, physicians and nurses are concerned about the safety of using topical and systemic therapies during pregnancy, and the likelihood of psoriasis worsening. On balance, 55% of cases of psoriasis improve during pregnancy, compared with 21% where there is no change and 23% where the condition worsens. In some women there is a significant deterioration in psoriasis postpartum. The mechanisms that underlie improvement in psoriasis during pregnancy are currently poorly understood but of themselves may provide clues to future management of psoriasis in general. With the increasing use of systemic therapies for psoriasis there has been a drive to establish registries of women who become pregnant while receiving such treatments, particularly the new biologic therapies. The Organization of Teratology Information Specialists (OTIS) instigated the Autoimmune Diseases in Pregnancy Project. This study is targeted at women being treated with adalimumab for autoimmune disease and includes patients with psoriasis and psoriatic arthritis. In this month’s issue of the Journal Bandoli and colleagues2 have used the OTIS registry to ascertain the risk factors for adverse pregnancy outcomes in women with psoriasis. Over the past several years there has been a growing awareness of the relationship between psoriasis, particularly its severe forms, with comorbidities involving components of the metabolic syndrome. These include cardiovascular disease, diabetes, raised body mass index (BMI), central obesity and hypertension.3 Such patients are more likely to be smokers. Thus, it is probably unsurprising that pregnant women are also at risk of these comorbidities. In the OTIS study, 170 pregnant women with psoriasis and 158 normal, healthy control pregnant women were enrolled. Of significance, 128 of the 170 women with psoriasis had received a biologic therapy at some time during pregnancy; this is indicative of it being a registry designed to assess risk of biologic therapies. Thus, it may not be an accurate reflection of the psoriasis population as a whole, where one would expect that 15% at most would have severe disease and probably less than 10%, i.e. 20 women, to have received a biologic. The findings reveal that pregnant women are more likely to be depressed and overweight with a raised BMI which in turn is associated with race and low socioeconomic status. This approach to assessing risk in pregnancy is commendable and is in line with the current initiative by the International Psoriasis Council (IPC) to increase our knowledge of pregnancy outcomes in psoriasis. Indeed, a recent paper by Horn and colleagues1 from the IPC proposed a minimum dataset for psoriasis pregnancy registries which should be open to all women with psoriasis who become pregnant. The minimum dataset would also include information on disease severity. In the study by Bandoli et al.2 the severity of psoriasis, as assessed by Psoriasis Area and Severity Index (PASI), is not included. A key question is whether severe disease, as assessed by PASI, was more likely to be associated with increased risk of poor outcome. The study itself did not report on the outcomes of the pregnancy, but focused on the potentially modifiable risk factors. Outcomes are the most important data as despite the known risk factors it would be instructive to know whether the fetus is adversely affected. Further, there is a need for research to ascertain whether gestational factors may play a role in the development of childhood psoriasis. Thus, management of pregnant women with psoriasis should not focus narrowly on which topical or systemic therapies to use, but should incorporate a holistic approach to management, including advice on lifestyle modification, prior to pregnancy.