Motherhood and Dermatoses: Exploring the Connection Between Pregnancy, Breastfeeding, and the Skin

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Considerations for Eczema and Psoriasis

Pregnant women with dermatologic conditions such as psoriasis or atopic dermatitis may need different treatment approaches due to the unique changes pregnancy can cause in the skin and the differing impact of these conditions on men and women.

Elizabeth Kiracofe, MD, a dermatologist in Chicago, highlighted the importance of considering health care decisions in various life stages, including pregnancy, menopause, and estrogen decreases, which can affect women's skin similarly, in an article from the American Academy of Dermatology.¹

Common treatments during pregnancy include milder corticosteroids, moisturizers, and phototherapy, although many medications are not approved for use during pregnancy and may require discontinuation. Kiracofe emphasized the importance of consulting a dermatologist early on for pregnant or planning-to-be-pregnant patients to explore safe and effective treatment options.

Candidal Mastitis

At the 2023 American Academy of Dermatology Meeting, Jenny Murase, MD, discussed common skin conditions affecting pregnant and lactating women's breasts, emphasizing the importance of proper breastfeeding techniques for preventing issues like pain and inflammation.

She highlighted the significance of a good latch and referred to lactation consultants for support. Murase explained various causes of breast pain, including dermatologic conditions, plugged ducts, and infections such as Candida and Staph aureus. Murase discussed home remedies and treatment options, along with considerations for medication safety during breastfeeding.

Acne and Family Planning

At the 2023 Society of Dermatology Physician Assistants Annual Fall Dermatology Conference, Allison Arthur, MD, addressed acne in adult women, highlighting its prevalence and complexity.²

Arthur emphasized the importance of understanding acne's underlying causes for effective treatment decisions. She discussed various aspects including the pathogenesis of acne, differential diagnosis considerations, comprehensive patient evaluation, and the association of acne with conditions like Polycystic Ovary Syndrome and hormonal disorders. Treatment options may range from hormonal therapies to integrative approaches like dietary modifications and light/laser therapies. Arthur also provided insights into managing acne during pregnancy, emphasizing safety considerations for both topical and oral treatments.

Managing Melanoma in Pregnancy

While pregnancies have occurred during immune checkpoint inhibitor (ICI) treatment for melanoma, commencing such treatment during pregnancy is generally not recommended.

According to authors of a clinical study exploring clinical practice guidelines for immunotherapy, it is crucial to engage in clear discussions regarding the risks and benefits, adhere to effective pregnancy prevention measures, and implement post-treatment precautions.³ Specifically in cases of melanoma, there is a lack of clinical trial data on the efficacy or safety of ICIs during pregnancy. Therefore, the decision to initiate or continue ICI treatment in pregnant patients should involve thorough risk-benefit discussions with the patient and relevant stakeholders, alongside multidisciplinary evaluation including high-risk obstetrics.

Patient-Centered Decision Making

When pregnant patients seek dermatologic care, clinicians must consider the implications of treatment on both the patient and the developing fetus, said Katherine Economy, MD, in an interview with Dermatology Times.

While some dermatologic conditions may necessitate treatment, the lack of information on drug safety during pregnancy can pose challenges. However, untreated conditions can lead to adverse outcomes for both the mother and baby. Clinicians must conduct a comprehensive review of the patient's medications, considering their potential effects on pregnancy and ensuring patient safety. Patient-centered decision-making is crucial, weighing the risks and benefits of treatment options. Pregnant individuals may require adjusted medication doses due to physiological changes during pregnancy.

Biologic Use

In a recent publication in Clinical Pharmacology and Therapeutics, experts introduced a novel benefit-risk conceptual framework aimed at guiding the utilization of biologics in pregnant patients.⁴

Their proposed framework, outlined in a mini-review, draws upon existing literature and expert opinions to establish a comprehensive approach to assessing biologic therapy in pregnancy and breastfeeding. The conceptual model developed by the researchers comprises 4 scenarios spanning from preconception to postpartum, with particular focus on Scenario 2, which addresses the continuation of biologic therapy during pregnancy.

The authors advocated for the establishment of a consortium to validate and refine the proposed framework, emphasizing its adaptability to specific biologic indications and mechanisms of action. Bozzi et al. underscored the necessity of a structured B-R framework in facilitating informed decision-making in obstetrics, gynecology, perinatology, neonatology, and pediatrics concerning biologic use during pregnancy.

References

1. Treatment options for pregnant women living with eczema and psoriasis. American Academy of Dermatology Association. March 17, 2023. Accessed May 10, 2024. https://www.aad.org/news/treatment-pregnant-women-eczema-psoriasis
2. Arthur A. Acne in Adult Women. Presented at: 2023 SDPA Annual Fall Dermatology Conference: October 26-29, 2023; Nashville, TN.
3. Pavlick AC, Ariyan CE, Buchbinder EI, et al. Society for Immunotherapy of Cancer (SITC) clinical practice guideline on immunotherapy for the treatment of melanoma, version 3.0. J Immunother Cancer. 2023;11(10):e006947. doi:10.1136/jitc-2023-006947
4. Bozzi LM, Jacobson MH, Yost E, et al. A benefit-risk conceptual framework for biologic use during pregnancy: A mini-review. Clin Pharmacol Ther. March 20, 2024. Accessed May 10, 2024. doi:10.1002/cpt.3239