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How is pregnancy relating to psoriasis?

 

Do hormonal changes have an impact on psoriasis?

What if I am pregnant?

Which treatments are available?

Breastfeeding?

 

 

 

Do hormonal changes have an impact on psoriasis?

 

There have been few studies attempting to establish a link between hormonal fluctuations and psoriasis. However, many women say that their psoriasis improves during pregnancy and gets slightly worse during the menopause. Specialists say that changes in psoriasis at different stages of a woman's reproductive life could be explained by hormonal fluctuations, but they could also be due to other factors which have not yet been identified.

Psoriasis is a chronic skin condition which involves genetic, immunological and environmental factors. Stress, certain drugs and infectious diseases are among the environmental factors which can trigger an eruption. Hormonal changes throughout a woman's life could also influence the condition, either by triggering new flares or conversely by improving lesions.
Most women notice that their psoriasis improves while they are pregnant, and worsens after they have given birth. The condition tends to worsen during the menopause, which is also a period when psoriasis is more likely to appear for the first time.

 

Although some scientific studies have attempted to establish links between hormonal fluctuations and psoriasis, we do not precisely know which hormonal mechanisms trigger the condition and affect its course.


It is thought that factors other than hormonal fluctuations are involved in the onset and subsequent flares of psoriasis. According to some specialists, the fact that psoriasis often appears at the beginning of adolescence does not necessarily mean that hormones are the sole cause. Instead, it has been suggested to be the result of a specific genetic programme.
 
Although some women report that their psoriasis varies according to their menstrual cycle, no study has yet proved the hypothesis that fluctuating levels of hormones during a woman's cycle influence flares of psoriasis. Similarly, no study has clearly demonstrated the positive or negative effect of contraceptive pills.
 

What if I am pregnant?


Psoriasis is not necessarily a barrier to pregnancy. Nor does it affect a woman's ability to raise children.

 

Many people who have psoriasis are afraid of passing it on to their children. As psoriasis is not a contagious disease, there is no risk of passing it on to a child through cuddling or breastfeeding. However, there is a genetic predisposition towards psoriasis. According to research, there is an 8% to 15% risk of transmitting it when one of the parents has psoriasis and a 50% to 60% risk when both partners are affected.

 

Women with psoriasis often worry about becoming pregnant. They ask themselves if the baby will develop normally. Will they be able to breastfeed? Will their psoriasis get worse during pregnancy? Are the treatments they are using safe for the baby?

 

The treatment of pregnant women is problematic, especially if they have severe psoriasis. They need to stop most systemic medication as it may lead to congenital abnormalities.

Women should tell their dermatologist early on if they are planning to become pregnant. The dermatologist will then be able to assess if their psoriasis treatment can be continued during pregnancy and prescribe a new medication if necessary.

 

Women who suffer from psoriatic arthritis sometimes feel greater pain because of pregnancy-related weight gain.
 
Most studies involving pregnant women show that pregnancy affects psoriasis.
An American study* on 248 women with psoriasis aimed at identifying hormonal changes which appear during pregnancy and the menopause and which may have an impact on psoriasis.


The study showed that 30% to 40% of female patients surveyed had experienced an improvement in their psoriasis during their pregnancy, the majority during the first trimester. 20% of them reported that the condition had worsened and the others did not notice any change. This study also showed that the age of patients and the severity of their psoriasis were not related to any improvement or exacerbation of the condition. Other studies report an improvement in up to 63% of women. Some women experience a significant improvement as their lesions whiten during pregnancy.
 
The improvement or exacerbation of psoriasis during a first pregnancy can be used to predict what will happen in subsequent pregnancies. The study quoted above showed that 87% of women who had several children had experienced the same response during each pregnancy.
Although we do not know exactly why psoriasis may improve during pregnancy, several hypotheses have been put forward. Some researchers believe that the greater amounts of oestrogen and progesterone secreted by the body protect it against psoriasis. These hormones exert a temporary immunosuppressive effect which has beneficial effects on the autoimmune processes occurring in psoriasis.
 
Other scientists stress the beneficial role of cortisone. During pregnancy, the body secretes more cortisone, which has an anti-inflammatory action on psoriatic lesions (acting in the same way as a cortisone cream).
 
It is certain that multiple factors lead to psoriatic lesions improving in pregnant women. The improvement is probably primarily due to increased levels of cortisol as this hormone is secreted by both the adrenal glands of both the mother and the foetus. However, it is most certainly also due to other substances which have yet to be identified.
 
In certain cases (in less than one woman in four), psoriasis worsens during pregnancy.
Once again, the reasons for this exacerbation are not known, but it is thought to be due to changes in hormonal metabolism which are probably associated with stress factors.
Some women experience their first flares of psoriasis during pregnancy. 



Impetigo herpetiformis is a form of generalised pustular psoriasis which typically appears during pregnancy.

 

This is an extremely severe form of psoriasis, but fortunately it is rare. It most commonly appears during the last trimester or in the period immediately following childbirth.
One third of women who suffer from impetigo herpetiformis have a family or personal history of psoriasis.

 

It is postulated that hormonal factors and/or a disturbance in vitamin D metabolism during pregnancy may cause flares of pustular psoriasis.

 

The eruption often begins in the skin creases. Red plaques, which sometimes cause itching, spread symmetrically across the abdomen and groin. Mucous membranes are sometimes involved. Pustules appear around the edges of lesions.

 

Impetigo herpetiformis is accompanied by deterioration in the patient's general health. Among other symptoms, she may experience nausea, fever and mental disturbance.
Corticosteroids are often ineffective, and so antibiotics are frequently used.


This serious condition also has consequences for the foetus as it leads to miscarriage in one case out of two.


Pregnancy-related pustular psoriasis most often disappears after the child is born. In 82% of cases, it affects women who are pregnant for the first time. However, there is a risk of relapse during subsequent pregnancies.
 

In the first three months following childbirth, the majority of women with psoriasis experience renewed eruptions, including those who had noticed an improvement during pregnancy. Results vary from one study to another.


Some studies note that nearly 88% of women report a relapse in the four months after they have given birth.


The American study quoted above shows that 41% of women surveyed reported that their psoriasis worsened during the period immediately after childbirth, but 55% noticed no change.


 

 

Treatments during pregnancy?


There are not many drugs available to treat pregnant women as most antipsoriatic drugs are toxic for the foetus.


Sometimes psoriasis improves spontaneously during pregnancy which means medication can be reduced.

It is also important to look after the skin during pregnancy so that it does not dry out. 
 

Topical treatments

 

Most systemic treatments have to be stopped during pregnancy, so dermatologists tend to prescribe local, topical medication to treat psoriatic lesions.


However, medications for external use are not free from side effects as they are absorbed by the body. Some should be completely avoided during pregnancy as they are potentially teratogenic. Apart from emollients which do not present any danger for the mother and child, these treatments should only be applied on restricted areas of the skin.
 

Topical treatments to avoid:

 

Vitamin A derivatives for local use: these should be avoided because of their teratogenic effect.
Vitamin D derivatives: these can be used in small quantities in very specific areas.
Possible local treatments:

Emollients: soothing and moisturising creams may be used without incurring any risk.
Corticosteroids (Cortisone): dermatologists sometimes prescribe corticosteroids in small quantities for use on very limited areas. It can increase the risk of stretch marks, so it should not be applied to certain parts of the body such as the breasts, abdomen and hips.
Exfoliants such as urea and salicylic acid: these treatments can be used if their application is limited to small areas of the skin.

 

Systemic treatments

 

Systemic treatments are often teratogenic, meaning that they can lead to serious deformities in the developing foetus. These risks are very high when medication is taken during the first trimester of pregnancy. Consequently, most orally administered medicines are stopped during pregnancy.
 

Systemic treatments to avoid:

 

Acitretine (and other vitamin A derivatives) and methotrexate: these can bring about serious congenital abnormalities and miscarriage in some cases. Women using these treatments must also use effective contraception. Patients should also wait several months after stopping treatment (two years for acitretine and four months for methotrexate) before planning a pregnancy so that no trace of the drug remains in the body.


It should be noted that methotrexate has an effect on male sperm. Couples where the man is taking methotrexate should use effective contraception while he is taking the drug and for three months after treatment has been stopped.


PUVA therapy: this can be dangerous for the foetus because of the psoralens (light-sensitising chemicals) administered prior to the PUVA sessions.


Possible systemic treatments in cases of widespread psoriasis:
 
Cyclosporine: this drug is not dangerous for the foetus, but it does have side effects. A short course can be prescribed in exceptional cases for pregnant women who have severe psoriasis.
UVB treatment: narrow spectrum UVB therapies which treat widespread psoriasis are safe during pregnancy. 

 

 

 

Breastfeeding?

 

Women, including those who have suffered from psoriasis during pregnancy and/or after childbirth, should not hesitate to breastfeed.


Only women who have to use a systemic treatment or local treatment on extensive areas of the skin should avoid breastfeeding as these treatments can be absorbed into the breast milk and may be transmitted to the child.

* Mowad CM., Margolis DJ., Halpern AC., Suri B., Synnestvedt M., Guzzo CA.: Hormonal influences on women with psoriasis, Cutis May 1998; 6, pp. 257-260.

With thanks to Dr Josiane Parier, dermatologist at the Saint-Louis Hospital, and Dr Laurent Misery, dermatologist and researcher at Brest University Hospital

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