Elsevier

Clinics in Dermatology

Volume 34, Issue 3, May–June 2016, Pages 344-352
Clinics in Dermatology

Management of rheumatic and autoimmune blistering disease in pregnancy and postpartum

https://doi.org/10.1016/j.clindermatol.2016.02.006Get rights and content

Abstract

The treatment of rheumatic and autoimmune skin disease in women who are pregnant or of childbearing potential can present challenges to the dermatologist. We discuss the current approaches to treating lupus erythematosus, antiphospholipid antibody syndrome, dermatomyositis, morphea and systemic sclerosis, mixed connective tissue disease, rheumatoid arthritis, and autoimmune blistering disease in such patients. In the appropriate setting, topical and systemic corticosteroids, hydroxychloroquine, dapsone, azathioprine, and ultraviolet B phototherapy may be safely and cautiously used during pregnancy. Considerations about contraception, planned conception, therapeutic options, and disease control are paramount in optimizing pregnancy outcomes and minimizing risks to both mother and fetus.

Section snippets

Overview

Rheumatic and autoimmune blistering skin disease can present management challenges to clinicians when they occur in pregnant women or in those with a desire to become pregnant. Considerations about contraception, planned conception, therapeutic options, and disease control are paramount in optimizing pregnancy outcomes and minimizing the risk to the patient.1

Medication choices include consideration of severity of disease activity, medication safety in pregnancy, efficacy, and tolerability.

Pregnancy safety classifications

Until 2015, the FDA classified pregnancy safety of prescription medications into 5 classes (A, B, C, D, and X) (discussed in “Drug Safety: Pregnancy Rating Classifications and Controversies” in this issue).2 Due to the limited clinical utility of this classification system,3 new medication labeling has been recently instituted to include a summary of risks and a discussion of the supporting data. We refer to the former FDA pregnancy safety classes in this review for their historical relevance.

Safety of medications in pregnancy and lactation

Prepartum considerations

Preconception planning and counseling is critical for optimizing maternal and fetal outcomes during and after pregnancy.[70], [71] First, disease stability should ideally be achieved before conception. It is best to plan for pregnancy after at least 3–6 months of disease quiescence. Second, if patients are contemplating pregnancy but are taking medications that would be contraindicated in pregnancy, then medications must be stopped or changed to safer alternatives as soon as feasible. For

Systemic lupus erythematosus

There are contradictory findings in the literature regarding whether systemic lupus erythematosus (SLE) flares are more common in pregnancy compared with the nonpregnant state. This controversy may be explained in part by discrepancies in the definition of an SLE flare, assessment of disease activity, and the challenge of differentiating normal pregnancy-related complications from increased lupus activity.[20], [72] It has been found that women who meet the criteria for SLE with mucocutaneous

Pemphigus vulgaris

Some patients see improvement in pemphigus vulgaris (PV) during pregnancy, whereas other women may present with PV for the first time during pregnancy.[63], [106] Pregnancy should be timed to a period of disease quiescence when maternal antibody titers are ideally low.107 Adverse outcomes such as neonatal pemphigus and perinatal death have been correlated more with poor maternal disease control and higher maternal antibody titers than with adverse effects of medications used to treat the

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    Wan and Imadojemu are co–first authors.

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