Navigating Skin Disease Treatment During Pregnancy

In a series of 3 presentations at the 2024 Elevate-Derm West Conference, Jennifer Murase, MD, covered topics and pearls related to women’s health. Her first session, titled, “Fulfilling Great Expectations: Safe Medical Management of Skin Disease in Pregnancy,” considered guidelines for treatment, medication safety and counseling, and the implications of untreated skin conditions in pregnant women.

TRANSCRIPT

Murase: My name is Dr Jenny Murase, and I am the director of medical consultative dermatology at the Palo Alto Foundation Medical Group, and I'm associate clinical professor at UCSF. I just presented at NP Elevate in Arizona over the past few days on 3 presentations related to women's health and dermatology.

Dermatology Times: What topics did you cover in "Fulfilling Great Expectations: Safe Medical Management of Skin Disease in Pregnancy"?

Murase: There are a lot of therapeutics on the market now. It'svery exciting, 10 years prior within the Journal of American Academy of Dermatology I did a continuing medical education Article, part 1: Pregnancy and part 2: Lactation, describing the counseling points when prescribing medications in women of childbearing age. So they asked us for a 10 year update because of all the new therapeutics. That was just published last month, in October, and I summarize the contents, particularly focusing on those newer therapeutics. In general, there is increasing safety data to show that the biologics are, for the most part, safe in pregnancy. They really do not cross the first trimester, and really they just start to cross kind of mid second trimester and right before delivery. It's designed so that the baby gets an antibody boost. The antibodies they build, they bind to something called an FC portion, they bring it across the placenta, so the baby is getting a lot more antibody right before delivery, whereas the time of embryo genesis, when the baby is developing, there really is no antibody transfer. Now that's in contrast with small molecule medications like TYK2 for example, or the JAK inhibitors, like Otezla. You know these types of treatments, because they are small molecules, we don't recommend those in pregnancy. I think when you're having discussions with women of childbearing age, it's really important to consider that whether you're prescribing in a chronic dermatologic condition like acne or psoriasis or atopic dermatitis. The reality is that women become pregnant 50% of the time without talking to any healthcare professional. If you look at specialists, it's only 20% of the time they'll have a conversation. That means 80% of the time they're going to get pregnant without having the conversation with you. So the onus is on you as a provider to have that discussion and make sure they're on appropriate contraceptive therapy if you are prescribing small molecules in conditions like atopic dermatitis and psoriasis.

DT: How can clinicians work with patients to create a treatment plan and set expectations?

Murase: I think it's a very compelling question, because what it gets the heart of that question is: What does the pregnancy itself do to the medical condition? If you take something like psoriasis, for example, there's a tendency for psoriasis to improve in pregnancy, so the hormones that are going to change in pregnancy will actually result in improvement. The estrogen is a nuclear receptor, like cortisone, for example. We actually showed in the article that I published years ago, was Archives of Dermatology and now it's JAMA Derm, that most people will improve in pregnancy,.There's an 80% improvement in terms of body surface area coverage. It's almost like the pregnancy itself is a therapeutic and so if you have a patient that may improve just from the pregnancy itself, then maybe you don't need to be putting them on medication. The other question is: Does the underlying condition have implications if you don't treat? For example, cutaneous lupus patients. There's implications to the fetus if it's not well controlled. It's very important to have a patient on hydroxychloroquine, because that medication will keep the lupus under control, so that there isn't complications resulting from the lupus not being under control. The same applies in my mind for atopic dermatitis, if the patient's getting infected, if they're itchy, miserable, they can't sleep, there's implications to the health of that pregnancy. You want to make sure that a woman is able to have the underlying disease under control, so that it'snot impacting the outcome of the pregnancy.

[Transcript has been edited for clarity.]