Management of moderate to severe plaque psoriasis in pregnancy and lactation in the era of biologics.

Psoriasis is not uncommon in the reproductive years and therefore in pregnant patients. There are limited data about the impact of psoriasis on the course and prognosis of pregnancy and about the impact of pregnancy on the course of psoriasis. Usually the disease improves during pregnancy and patients experience worsening between 4 and 6 weeks after delivery. A safe option for patients with limited disease is topical therapy, including moisturizers and topical steroids as well as UVB phototherapy. In the case of active psoriasis or even psoriasis worsening during pregnancy, there might be a need for continuation or even introduction of systemic therapy. Methotrexate and acitretin are known teratogens and mutagens, and they must be avoided. Ciclosporin may be regarded as a possible rescue therapy for pregnant psoriasis patients in the case of severe disease. Post-marketing experience regarding the safety of biologics is accumulating, with largely reassuring results. All four biologics approved for the treatment of moderate to severe psoriasis--etanercept, infliximab, adalimumab, and ustekinumab--are not currently recommended in pregnant psoriasis patients. The existing evidence implies that the risk of biologics in pregnancy is relatively low and that the risk of fetal drug exposure may be outweighed by the benefits for the mother.