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- Presentation
Treatment of Atopic Dermatitis in Pregnancy: Safety of Topical, Systemic, and Biologic Therapies
Description
The talk reviews how atopic dermatitis can recur or worsen during pregnancy because of pregnancy-related immune shifts, then compares treatment safety across topical, phototherapy, systemic, and biologic options. Topical corticosteroids are generally safe when used conservatively, with mid-potency agents preferred and very potent steroids reserved for limited areas. Topical calcineurin inhibitors are considered safe due to minimal systemic absorption. Topical PDE4 inhibitors have limited human data: crisaborole appears probably safe but with caution, while newer agents such as roflumilast and difamilast should generally be avoided for now. Topical JAK inhibitors are not recommended in pregnancy because of concerning animal data and minimal human evidence. Tapinarof may be used cautiously, but evidence is sparse. Narrowband UVB phototherapy is considered safe, while PUVA is not recommended; folate levels should be monitored during UVB therapy. Systemic corticosteroids are only for short rescue use, with attention to maternal risks and avoidance of dexamethasone. Diphenhydramine and some other antihistamines are safe if needed for itch or rhinitis. Among immunomodulators, cyclosporine and azathioprine can be used selectively with caution and monitoring, while methotrexate and mycophenolate mofetil are strictly contraindicated and should be stopped well before conception. For biologics, dupilumab has the strongest and most reassuring pregnancy data and appears likely safe, while related IL-13 agents look promising but need more human data; nemolizumab remains too uncertain. Systemic JAK inhibitors are contraindicated because of teratogenic and fetal loss concerns.
View moreConclusions
- In pregnant patients with atopic dermatitis, treatment should prioritize conservative, better-established options such as mid-potency topical corticosteroids, topical calcineurin inhibitors, and narrowband UVB phototherapy.
- Very potent topical steroids should be limited, and PUVA should be avoided in pregnancy because of mutagenic concerns.
- Topical PDE-4 inhibitors, topical JAK inhibitors, and systemic JAK inhibitors have insufficient or concerning pregnancy data and should generally be avoided or used only with extreme caution.
- Tapinarof appears to have minimal systemic absorption and no clear developmental toxicity, but pregnancy experience is too limited to call it clearly safe.
- Systemic corticosteroids should be reserved for short rescue courses, with prednisone or prednisolone preferred and dexamethasone avoided because of placental transfer concerns.
- Common antihistamines may be used for sleep and itch relief when needed, but they are not primary therapy for atopic dermatitis.
- Cyclosporine has the strongest systemic pregnancy experience and can be used when necessary, though monitoring for maternal hypertension, renal effects, and possible preterm or low-birth-weight risk is important.
- Azathioprine may be continued in selected patients during pregnancy, but it is not a first-line choice and may carry some preterm or neonatal hematologic risk.
- Methotrexate and mycophenolate mofetil are clearly contraindicated in pregnancy because they are established teratogens.
- Among biologics, dupilumab currently has the most reassuring human pregnancy data and appears increasingly safe, while tralokinumab and lebrikizumab are promising but still lack enough evidence for routine recommendation.
- Nemolizumab and all systemic JAK inhibitors should not be used in pregnancy at present because available animal and mechanistic data raise concern and human data are inadequate.
- Overall, the presentation concludes that many traditional therapies for atopic dermatitis can be used safely in pregnancy with appropriate limits, but newer targeted agents generally require caution until more pregnancy data accumulate.
- Balakirski G, Novak N. J Allergy Clin Immunol. 2022.