Post partum psoriasis

• prevalence in pregnant women is unknown - probably reflects that of non-pregnant women of child bearing age
• psoriasis in pregnancy
  • chronic plaque psoriasis improves in 40-60% of patients during pregnancy
    • most improvement during the late first and second trimesters
  • psoriasis deteriorates in 10-20% of women during pregnancy
• psoriasis and pregnancy related morbidity:
  • does not affect fertility or rates of miscarriage, birth defects, or premature birth
  • psoriasis is associated with depression - however no evidence that pregnancy exacerbates depression more in patients with psoriasis than in the normal population
  • various treatments for psoriasis are contraindicated in pregnancy
• treatment of psoriasis in pregnancy:
  • topical treatments are first line treatments for psoriasis
    • emollients, topical steroids, and dithranol are considered safe in pregnancy
    • manufacturers of vitamin D analogues such as calcipotriol advise that these agents should be avoided in pregnancy
      • however it unlikely that significant systemic absorption will occur when they are used for localised disease
    • coal tar products - animal studies have suggested teratogenicity, although this has not been reported in humans
      • such products are probably safe for use in the second and third trimesters (1)
    • consider referral to a dermatologist if topical treatments fail to control disease
      • ultraviolet B (UVB) is the safest second line therapy - followed by ciclosporin
• psoriasis in the postpartum
  • more than 50% of women have a flare-up within six weeks of delivery - however this is usually not worse than their prepregnancy state
• psoriasis and breast feeding
  • first line treatment options for breastfeeding women
    • emollients, moderate to low potency topical steroids, and dithranol
    • use of topical treatment should be after breast feeding - must be washed off thoroughly before the next feed.
  • many treatments such as acetretin, methotrexate, ciclosporin, hydroxycarbamide, biological treatments, and PUVA are all contraindicated in breastfeeding women
    • safest second-line agent is ultraviolet B
    • if first line treatment options fail to control disease then breastfeeding may need to be curtailed to increase treatment options

Reference:

1. Psoriasis: The assessment and management of psoriasis. NICE Clinical Guideline (October 2012 - last updated September 2017)