Psoriasis is an autoimmune disease that causes thick plaques of dry, scaly skin, typically on the elbows, knees, scalp, and back. About 7.5 million people in the United States have psoriasis, and most people first develop symptoms between ages 20 and 40, when most women become mothers. In this article, we will discuss what you can expect to happen with your psoriasis during pregnancy and the best ways to control it.

Will my psoriasis get worse during pregnancy?

The effects of pregnancy on the immune system can be unpredictable. The same goes for immune diseases. For example, in rheumatoid arthritis, pregnancy seems to improve the joint pain, however in lupus, a lot of women report worsening of their symptoms. 

Psoriasis is an immune disease and its course in pregnant women can vary. For example, one study of 91 pregnant women with psoriasis showed improvement in 56% of cases, worsening in 26%, and no change in 18%. Not surprisingly, patients who improved during their first pregnancy usually reported improvement in later pregnancies. Another study of 47 pregnant patients with psoriasis showed similar results: 55% reported improvement, 21% showed no change, and 23% had worsening. In that study, the average amount of body area affected decreased from week 10 to week 20 week of pregnancy. After giving birth, the opposite was true: 65% of patients experienced worsening, whereas only 10% showed improvement. An increase of body area affected was found around six weeks after giving birth. Psoriasis improvement in pregnancy is probably related to high levels of estrogen during pregnancy, which suppresses the immune system. The worsening after birth is associated with the fall of estrogen levels.

Will psoriasis affect my pregnancy? 

There are a few studies that deal with this question but it’s not completely straightforward. For example, one study of more than 3000 women suffering from psoriasis found no effect of psoriasis on pregnancy. For example, the risk of miscarriage among women with psoriasis was similar to women without psoriasis. Another study in Denmark looked at 2553 pregnancies; women with psoriasis had no increased risk of fetal death or prolonged pregnancy. However, some studies have detected an association between psoriasis and pregnancy complications like high blood pressure and preeclampsia, both of which are serious dangers to mom and her baby. Another study showed that a newborn may have lower birth weight from moms with psoriasis, especially if their disease is very severe and uncontrolled. 

How should I control my psoriasis during pregnancy?

For women whose psoriasis improves during pregnancy, stopping previous therapies is the best bet. Many dermatologists recommend discontinuing all drugs during pregnancy. However, stopping treatment is not an option for women with very severe psoriasis. The risk of bad effects on the developing baby has to be balanced with the risk of uncontrolled skin inflammation affecting the pregnancy. 

Moisturizers and low-to-moderate strength topical steroids (creams and ointments) are the first line treatment for pregnant patients. Higher strength topical steroids should be used with caution and only if absolutely necessary during the second and third trimester. The risk of high strength topical steroids applied to a large skin area comes from the potential for absorption into the blood, which can affect the developing baby. Very strong topical steroids have been associated with low birth weight. There’s also possibly an increased risk of cleft lips and palate when used in the first trimester, however this is controversial. Pregnant women should not apply large amounts of steroids on large areas on their body, and should not use topical steroids under tight coverings in order to avoid excessive absorption. Topical steroids also increase the risk of developing stretch marks, which can be difficult to treat.

If topical steroids don’t do the trick, second line treatment for pregnant women is light therapy. To date, there has been no associated increased risk of fetal abnormalities or premature delivery with light therapy. Light therapy can possibly decrease blood folate levels in patients with psoriasis, so to minimize that risk your dermatologist might measure your folate levels and prescribe supplements if needed. Light therapy can make melasma worse, which is also something to consider.

Methotrexate and vitamin A drugs (retinoids) are sometimes used in psoriasis but are an absolute no-no in pregnancy, because they can cause very severe birth defects or miscarriage. Biologic agents like Remicade, Humira, and Enbrel should also be avoided in pregnancy and should be discontinued once a woman knows she’s pregnant. Despite some reports of birth defects in children exposed to these medications during pregnancy, one study of several hundred patients showed that exposure to systemic therapy from the time of conception through the first trimester did not increase risk to either mother or child. However, until we have more safety information, it’s best to stay clear of these medications when you are pregnant.

Putting it all together

Ultimately, many women can expect their psoriasis to improve during pregnancy. However, given the possibility of scary, potentially irreversible effects on the pregnancy, your psoriasis should be managed with frequent communication between your obstetrician and an experienced dermatologist. Because many women flare during the postpartum period, frequent follow-up with your dermatologist after delivery is also recommended.