Psoriasis in Women of Childbearing Age

On Dr Jenny Murase’s first year of medical school, the chair of the dermatology department told her about a patient whose psoriasis dramatically improved during each of her 3 pregnancies.

That first sparked her interest in taking care of women with skin disease and inspired her to become a lifelong advocate for understanding how psoriasis and other diseases affect women. Since then, she has become a leader in researching how psoriasis impacts women and how to best counsel women in managing their psoriasis.

Initiating Discussions in Women With Psoriasis

Research suggests that although all patients with psoriasis can experience impacts on their quality of life, women with psoriasis may experience greater stress and stigmatization than men.^1,2 In addition, women show a mismatch in subjective and objective measures of their disease. This means that at the same level of disease, psoriasis impacts women more, emphasizing the importance of considering subjective quality of life measures while discussing treatment options to better understand female patients’ experience of their disease.³

Furthermore, women of childbearing age may not always bring up the possibility of pregnancy in discussions with their provider. “Fifty percent of pregnancies are unplanned in the United States,” says Dr Murase, “and 80% of the time [patients] don’t tell the specialist before they are pregnant.” Therefore, it is important to initiate the discussion about family planning and the implications of starting psoriasis treatment in women who are sexually active. “The onus is really on us [the clinicians] to have this discussion with our patients.”

Treatment Considerations

There are many treatment options that are considered safe in patients who are pregnant, and guidelines summarizing the latest evidence about these treatments can help guide discussions in the clinic.^4,5 Although many of these guidelines are not psoriasis specific, due to the amount of overlap in medications for psoriasis and other diseases such as inflammatory bowel disease and rheumatoid arthritis, there are data to guide use of these treatments.

Certain treatments should be avoided, including methotrexate and acitretin, which interfere with normal fetal development.⁴ However, some biologics such as tumor necrosis factor (TNF) inhibitors are considered safe during pregnancy.⁶ Providing recommendations is challenging because clinical trial data in women who are pregnant and breastfeeding are rare. Instead, some of the information we rely on comes from long-term data via inadvertent pregnancies reported in clinical trials, case reports in the literature, and pregnancy registries.

Even though research is improving our knowledge of how to treat women during pregnancy, knowledge gaps still exist in the clinical world. For example, many providers may feel uncomfortable continuing anti-TNF inhibitors during pregnancy or lactation.^7,8 “A significant number of physicians feel that women should discontinue their biologic while breastfeeding even though there are no data to suggest they should,” says Dr Murase. “Overall, there is this fear about making a recommendation just because it is less familiar.”

What may help is including clear guidelines to summarize and raise awareness of the latest evidence. “Dermatologists want guidelines to say it is okay,” says Dr Murase. “That is the bottom line, what is the current understanding of what is okay and what is not.” Although formal treatment guidelines for women of child-bearing age with psoriasis are not currently available, as continued patient and physician advocacy calls for increased research and that research translates into clinical practice guidelines, our understanding of how to best guide women with psoriasis in con- trolling their disease will continue to advance.

Sonia Wang is a year-out medical student at the University of Pennsylvania in Philadelphia, PA, and a volunteer with the National Psoriasis Foundation.

References

1. Gottlieb AB, Ryan C, Murase JE. Clinical considerations for the management of psoriasis in women. Int J Womens Dermatol. 2019;5(3):141-150. doi:10.1016/j. ijwd.2019.04.021
2. Hawro M, Maurer M, Weller K, et al. Lesions on the back of hands and female gender predispose to stigmatization in patients with psoriasis. J Am Acad Dermatol. 2017;76(4):648-654.e2. doi:10.1016/j.jaad.2016.10.040
3. Lesuis N, Befrits R, Nyberg F, van Vollenhoven RF. Gender and the treatment of immune-mediated chronic inflammatory diseases: rheumatoid arthritis, inflammatory bowel disease and psoriasis: an observational study. BMC Med. 2012;10:82. doi:10.1186/1741-7015-10-82
4. Murase JE, Heller MM, Butler DC. Safety of dermatologic medications in pregnancy and lactation: part I. Pregnancy. J Am Acad Dermatol. 2014;70(3):401.e1-415. doi:10.1016/j.jaad.2013.09.010
5. Butler DC, Heller MM, Murase JE. Safety of dermatologic medications in pregnancy and lactation: part II. Lactation. J Am Acad Dermatol. 2014;70(3):417.e1-427. doi:10.1016/j.jaad.2013.09.009
6. Porter ML, Lockwood SJ, Kimball AB. Update on biologic safety for patients with psoriasis during pregnancy. Int J Womens Dermatol. 2017;3(1):21-25. doi:10.1016/j. ijwd.2016.12.003
7. Tincani A, Taylor P, Fischer-Betz R, Ecoffet C, Chakravarty E. FRI0692 Anti- TNF treatments for women with chronic inflammatory diseases: comparing attitudes and perceptions of physicians in Europe and the US. Ann Rheum Dis. 2018;77(Suppl 2):865. doi:10.1136/annrheumdis-2018-eular.1919
8. Tanaka Y, Barrett C, Hirano Y, et al. Management of chronic rheumatic diseases in women 18-45 years of age in Asia Pacific: insights from patient and clinician surveys. Rheumatol Int. 2023;43(4):721-733. doi:10.1007/s00296-022-05206-0