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Narrowband UV-B Phototherapy During Pregnancy and Folic Acid Depletion
Abstract
We read with interest Zeichner ’s¹ case report of acne vulgaris during pregnancy treated successfully with narrowband UV-B (NB-UV-B) therapy. Generally, UV-B is considered a safe form of psoriasis therapy during pregnancy, and this may apply to acne treatment as well. However, it is of utmost importance not to overlook the photodegradation of folic acid associated with light therapy.
Folic acid deficiency is associated with the development of neural tube defects, which complicate 1 in every 1000 pregnancies and can be detected early in the second trimester. There is new evidence in patients with psoriasis that high cumulative NB-UV-B doses cause a proportionate decrease in serum folic acid levels ( ≥118.16 J/cm² in 36 treatments).² Previous studies found insignificant decreases in serum folic acid; however, these studies had smaller numbers of treatments and had lower total cumulative doses (6.9 J/cm² in 9-15 sessions in 19 patients; 2.3 J/cm² in 18-20 treatments in 35 patients).² Furthermore, a more recent pilot study found that patients' folic acid levels decreased after broadband UV-B therapy (110-220 mJ/cm² in 7-22 treatments).³ In addition, there was a case report in Buenos Aires of 3 unrelated patients who had sunbed exposure in early pregnancy; their infants all developed neural tube defects, which may have resulted from folic acid depletion.⁴
... Regarding UVB (ultraviolet B) and folic acid depletion, this effect is only with high cumulative doses and only in mothers not adequately supplementing folic acid. 1 Regarding the case reports of early pregnancy exposure in tanning beds and subsequent neural tube defects, one must keep in mind that there are many anecdotal reports of congenital malformations that may have no association to a particular drug or exposure. ...
... FDG activity detected in blood vessels by PET-CT (Fig 1) is associated with cellular infiltration in active, noncalcified, atherosclerotic plaques. 1 The description of cell populations associated with vascular FDG uptake is evolving. Populations of B cells, T cells, and macrophages have been linked to FDG uptake. 1 Current literature most often associates FDG uptake with concentrations of macrophage-rich areas of lipid-laden plaques and correlates directly with macrophage density. 1 Finally, In the same patient as in Fig 1, this image demonstrates a T1-weighted spin echo MRI with suppressed blood signal fused to PET. ...
... Populations of B cells, T cells, and macrophages have been linked to FDG uptake. 1 Current literature most often associates FDG uptake with concentrations of macrophage-rich areas of lipid-laden plaques and correlates directly with macrophage density. 1 Finally, In the same patient as in Fig 1, this image demonstrates a T1-weighted spin echo MRI with suppressed blood signal fused to PET. This image demonstrates that the FDG tracer uptake at 120 minutes has localized to the arterial wall (white arrows). ...
... Successful and safe use of NBUVB phototherapy to treat acne during pregnancy has been described in a case report [100]. Additional studies have demonstrated reduction of folic acid with high cumulative NBUVB doses, raising concern for risk of neural tube defects [100][101][102]. In pregnant patients and patients attempting pregnancy undergoing NBUVB phototherapy, dermatologists should periodically check folate levels or consult with patients' obstetricians to determine appropriate folic acid supplementation with NBUVB treatments [102]. ...
... Additional studies have demonstrated reduction of folic acid with high cumulative NBUVB doses, raising concern for risk of neural tube defects [100][101][102]. In pregnant patients and patients attempting pregnancy undergoing NBUVB phototherapy, dermatologists should periodically check folate levels or consult with patients' obstetricians to determine appropriate folic acid supplementation with NBUVB treatments [102]. ...
Acne vulgaris frequently affects women during pregnancy and lactation. Hormonal and physiologic changes in pregnancy contribute to the pathogenesis of acne during the various phases of pregnancy. Several effective acne treatments commonly prescribed in the general population are contraindicated during pregnancy or lactation. There is a lack of guidelines and updated resources on acne management in these populations. In this narrative review, we summarize existing evidence on the safety and efficacy of acne treatments during pregnancy and breastfeeding. Acne management in pregnancy and lactation should follow a stepwise approach based on severity to minimize risk. Topical therapies, such as benzoyl peroxide, azelaic acid, or keratolytics, can be used to treat mild-to-moderate disease. Moderate-to-severe acne may require systemic treatments, including penicillin, amoxicillin, cephalexin, and erythromycin, with special consideration for trimester-specific teratogenicity of medications and relevant medical history of the mother and infant. For refractory cases, oral or intralesional corticosteroids as well as laser and light therapies may be considered. This review provides an updated reference to aid patient-physician decision-making on acne management in these special populations.
... 71 Apesar disso, os níveis séricos maternos de ácido fólico podem sofrer redução com altas doses cumulativas de fototerapia UVB. [72][73][74] Por sua vez, a deficiência de ácido fólico no primeiro trimestre pode predispor ao desenvolvimento de defeitos do tubo neural. 72,74 Assim, as doentes grávidas que recebam tratamentos de fototerapia UVB devem ser submetidas ao doseamento regular dos níveis de ácido fólico, especialmente durante o primeiro trimestre da gravidez. ...
... 72,74 Assim, as doentes grávidas que recebam tratamentos de fototerapia UVB devem ser submetidas ao doseamento regular dos níveis de ácido fólico, especialmente durante o primeiro trimestre da gravidez. 73 É importante saber que o aumento da temperatura corporal central da grávida durante o primeiro mês da gestação pode aumentar o risco de defeitos do tubo neural fetais. Apesar da fototerapia não parecer aumentar a temperatura central corporal, medidas gerais para evitar hipertermia são por isso aconselhadas. ...
O crescente número de fármacos empregues na prática dermatológica e venereológica exige do dermatologista um conhecimento atualizado relativo à sua segurança. No caso particular de mulheres grávidas ou que amamentem, a decisão sobre se se deve ou não tratar com um determinado fármaco deve basear-se numa avaliação ponderada dos benefícios para a saúde materna e dos riscos potenciais para o bem-estar fetal ou do lactente. Quando estas doentes necessitam terapêuticas tópicas ou sistémicas, a maioria pode ser adequadamente tratada com opções consideradas seguras e eficazes. Esta segunda parte deste artigo aborda os dados mais recentes relativos à segurança de alguns dos medicamentos tópicos mais comummente usados em contexto dermatológico, na mulher em idade fértil.
... The controlled use of ultraviolet (UV) phototherapy during pregnancy is thought to be safe. It is important to monitor and supplement folic acid levels in pregnant patients receiving UVB therapy due to possible photodegradation of folic acid (43). ...
Objective. This review examines skin manifestations in women with spondyloarthritis, with a particular focus on psoriatic arthritis (PsA) and associated psoriasis. Methods. A narrative review of the bibliography was conducted using the main databases (PubMed, Scopus, EMBASE). Results. The review showed that the clinical course of PsA and psoriasis in women is influenced by hormonal fluctuations that occur at different stages of life, such as menstruation, pregnancy, postpartum, and menopause. Gender differences in the epidemiology of PsA and psoriasis are discussed and attributed to biological, hormonal, and environmental differences. The role of estrogen in modulating immune responses and its impact on the severity of PsA and psoriasis are reviewed. Special emphasis is placed on the psychosocial impact of visible skin lesions on women’s quality of life and fertility problems associated with psoriasis. Treatment strategies are also taken into account, favoring personalized approaches that consider the safety of treatments during pregnancy and breastfeeding. Conclusions. The review highlights the importance of a holistic and gender-sensitive approach to the management of PsA and psoriasis in women, promoting the integration of physical treatment with support for emotional well-being.
... 75 It has been proven to be a safe treatment option during pregnancy, but its use has been associated with decreased folic acid levels. [76][77][78][79] Therefore, in addition to attaining baseline folic acid serum levels, supplementation with folic acid prior to treatment, as per routine prenatal guidelines, should be sought. 80 AviClear-The AviClear (Cutera) laser is the first device cleared by the FDA for mild to severe acne in March 2022. ...
... 75 It has been proven to be a safe treatment option during pregnancy, but its use has been associated with decreased folic acid levels. [76][77][78][79] Therefore, in addition to attaining baseline folic acid serum levels, supplementation with folic acid prior to treatment, as per routine prenatal guidelines, should be sought. 80 AviClear-The AviClear (Cutera) laser is the first device cleared by the FDA for mild to severe acne in March 2022. ...
Acne vulgaris is a common condition that routinely affects females of childbearing age. Taking into consideration the reproductive journey of women when treating acne is of paramount importance given the safety concerns to both the mother and the fetus associated with certain medications. Therefore, careful consideration of therapeutic choices during pregnancy is crucial. Herein, we summarize the safety of acne treatments during pregnancy and offer practical clinical pearls for routine dermatology practice.
... There are data to suggest that NBUVB also has the potential to reduce folate levels when used long-term in patients with psoriasis. 44 Therefore, patients undergoing UVB will benefit from folic acid level monitoring and supplementation. ...
In 2014, the US FDA removed the Pregnancy Category Drug lettering system and enacted the “Pregnancy and Lactation Label Ruling.” This ruling required drug products to contain contact information for drug-specific exposure pregnancy registries, narrative-style sections summarizing the known effect of pregnancy, lactation counseling data, and data describing risks for females and males of reproductive potential. This new ruling has added more dialogue and discussion to the patient-provider decision-making process and equires clinicians to provide more individualized counseling based on the current medical literature. This article summarizes the recent evidence for the safety of the most common dermatological therapies for pregnant and lactating women.
... Ultraviolet phototherapy has been used in pregnancy for other dermatoses 50 , but there are no data available for its use in ICP. If used, care should be taken to provide folic acid supplements as there is a risk of depletion 51 ...
KEY POINTS
Intrahepatic cholestasis of pregnancy (ICP) is a pregnancy liver disease, characterised by pruritus and increased total serum bile acids (TSBA), Australian incidence 0.6–0.7%.
ICP is diagnosed by non‐fasting TSBA ≥ 19 μmol/L in a pregnant woman with pruritus without rash without a known pre‐existing liver disorder.
Peak TSBA ≥ 40 and ≥ 100 μmol/L identify severe and very severe disease respectively, associated with spontaneous preterm birth when severe, and with stillbirth, when very severe.
Benefit‐vs‐risk for iatrogenic preterm birth in ICP remains uncertain.
Ursodeoxycholic acid remains the best pharmacotherapy preterm, improving perinatal outcome and reducing pruritus, although it has not been shown to reduce stillbirth.
... > 30 treatments) folate supplementation should be considered, and the need for supplementation reinforced for those receiving NB-UVB in the first trimester of pregnancy. 98,99 During pregnancy the use of facial shielding during treatment may help to limit the exacerbation of melasma. ...
All BAD guidelines are freely available from the journal website (Wiley). A full list of the published guidelines can be found at
https://onlinelibrary.wiley.com/page/journal/13652133/homepage/bad_guidelines.htm
... Although patients who have been exposed to high levels of UVB radiation do not have an increased risk of abnormal delivery outcomes, it is worth remembering that there is a paucity of studies regarding ultraviolet A (UVA) or UVB light therapy and pregnancy-related complications or long-term effects on the fetus. The use of UVB therapy was linked with low levels of serum folate, and folate supplementation (0.8 mg/ day) should be recommended to reduce the risk of neural tube defects [137][138][139]. Patients are also at risk of developing melasma after UV exposure [140], so facial covering is advised. ...
Pruritus in pregnancy is a common and burdensome symptom that may be a first sign of a pregnancy-specific pruritic disease (atopic eruption of pregnancy, polymorphic eruption of pregnancy, pemphigoid gestationis, and intrahepatic cholestasis in pregnancy) or a dermatosis coinciding with pregnancy by chance. Despite its high prevalence, pruritus is often underrated by physicians, and data regarding the safety profiles of drugs for pruritus are very limited. In this review, we illustrate the epidemiology, possible pathophysiology, clinical characteristics, and diagnostic workup of various pregnancy-related diseases and discuss antipruritic treatments. The prevalence of pruritus in pregnancy demonstrates the importance of symptom recognition and the need for an holistic approach, taking into account both the potential benefits for the patient and the potential risks to the fetus.
... This therapy is considered safe as long as the cumulative dose is not high. When the cumulative dose exceeds the threshold, a decline in folic acid levels has been reported [87][88][89]. Thus, the recommendation is to supplement with folic acid at 4-5 mg/day during UVB therapy to avoid neural tube malformations. ...
Psoriasis is a chronic immunologic disease involving inflammation that can target internal organs, the skin, and joints. The peak incidence occurs between the age of 30 and 40 years, which overlaps with the typical reproductive period of women. Because of comorbidities that can accompany psoriasis, including metabolic syndrome, cardiovascular involvement, and major depressive disorders, the condition is a complex one. The role of hormones during pregnancy in the lesion dynamics of psoriasis is unclear, and it is important to resolve the implications of this pathology during pregnancy are. Furthermore, treating pregnant women who have psoriasis represents a challenge as most drugs generally prescribed for this pathology are contraindicated in pregnancy because of teratogenic effects. This review covers the state of the art in psoriasis associated with pregnancy. Careful pregnancy monitoring in moderate-to-severe psoriasis vulgaris is required given the high risk of related complications in pregnancy, including pregnancy-induced hypertensive disorders, low birth weight for gestational age, and gestational diabetes. Topical corticosteroids are safe during pregnancy but effective only for localised forms of psoriasis. Monoclonal antibodies targeting cytokines specifically upregulated in psoriasis, such as ustekinumab (IL-12/23 inhibitor), secukinumab (IL-17 inhibitor) can be effective for the severe form of psoriasis during pregnancy. A multidisciplinary team must choose optimal treatment, taking into account fetal and maternal risks and benefits.
... Park ve ark. (20) açık tenli kişilerde folik asitin foto yıkımının daha belirgin olabileceğini öne sürmüşlerdir. Bizim verilerimiz de bu görüşü destekler niteliktedir. ...
Objectives:Narrow band UVB (NBUVB) treatment is a preferred dermatological treatment modality especially in pregnant women because of high safety profile. Previous studies have shown photodegradation may decrease folate levels in blood. In this study we aim to investigate if phototherapy causes low folic acid levels in our patients.Materials and Methods:Patients applying to dermatology unit and receiving either psoralen plus UVA or NBUVB treatment with regular folic acid level check-ups were analysed retrospectively.Results:In none of the patients folic acid levels lower than reference levels were detected. Mean serum folate values in baseline were 9.30 (±3.22 SD). The mean value after 18 treatment sessions was 7.26 (±4.82 SD), and after 36 sessions was 8.69 (±3.6 SD). In PUVA group baseline mean folate level was 9.16 (±3.76 SD), followed by 6.76 (±4.89 SD) after 18 sessions and 9.41 (±3.79 SD) after 36 sessions. Repeated measure in time were not statistically significant in both groups (p>0.05).Conclusion:NBUVB and PUVA treatments appear to be safe in regards to blood folic acid levels in our population where Fitzpatrick skin type III and IV is more common.
... Ultraviolet B phototherapy may be considered as a management option for the above conditions. However, photodegradation of folic acid is associated with light therapy; thus, to mitigate the risk of folate deficiency during the first trimester, it is important for the mother to supplement with 0.4 mg to 1 mg of folic acid per day (Park and Murase 2012). Currently, there is no consensus on the appropriate folate supplementation during phototherapy (Murase et al. 2010) and patients who are at high risk may require up to 5 mg daily (Wilson et al. 2003). ...
Certain dermatoses that present during pregnancy have a predilection for populations with skin of color (SOC). Additionally, certain systemic diseases such as systemic lupus erythematosus tend to be more aggressive during pregnancy and confer worse prognoses in women with SOC. The purpose of this review is to highlight the unique implications of selected diseases during pregnancy as it relates to SOC. Dermatologists should be vigilant for the unique clinical variations of dermatological conditions in patients of color who are pregnant to ensure correct diagnoses and optimize treatment outcomes.
... Therefore, folic acid supplementation during phototherapy and monitoring its levels are strongly recommended. 80 Patients should also be informed that phototherapy may induce or worsen melasma. Psoralens are a known mutagen and PUVA therapy is markedly associated with low birthweight and possibly premature fetal abnormalities; therefore, it is contraindicated during pregnancy. ...
Psoriasis is a common disease, which has a considerable impact on the healthcare system. Therefore, appropriate use of therapeutic resources is very important. Management of psoriasis in daily clinical practice is highly variable because many issues are still debated and not definitely addressed by the evidence-based medicine. Moreover, the different availability and reimbursability of drugs in each country justifies national guidelines. Expert consensus can provide helpful guidelines for optimizing patient care. A total of 20 dermatologists from different areas of Italy and with large experience in the treatment of psoriasis agreed to participate in the guidelines expert panel who aimed to reach consensus on the factors influencing psoriasis severity, the indications for systemic treatments, the parameters to be considered in the choice of treatment, and the factors to be considered in the choice of biological treatment. The recommendations for the use, screening and monitoring of systemic therapies were based on the 2015 S3 European Dermatology Forum/European Academy of Dermatology and Venereology psoriasis guidelines. Recommendations on the treatment of psoriasis in special patient populations were also agreed. The final document was discussed in a meeting moderated by a facilitator with participation of the entire group and adopting a nominal group technique to reach consensus. A statement was regarded as consented when agreement was achieved by at least 75% of the voting experts according to the Delphi procedure.
... 45 The use of UVB therapy has been associated with low levels of serum folate, and folate supplementation is advocated to decrease the risk of neural tube defect. 46 UVB therapy is also associated with increased risk of recurrent herpes simplex infection. 47 The use of topical immunomodulators, such as pimecrolimus and tacrolimus (Category C), has not been studied in gestational AD; however, most authors consider them to have a positive safety profile if applied on small areas, and they can be considered as a third-line treatment in cases that have not responded to narrowband UVB phototherapy. ...
Prurigo (PP) and pruritic folliculitis of pregnancy (PFP) are poorly characterized entities. Traditionally, classified under specific dermatoses of pregnancy, they were reclassified under a new umbrella entity, the Atopic Eruption of Pregnancy (AEP), which also includes atopic dermatitis (AD) that can worsen or present for the first time in pregnancy. Still, several aspects of AEP have not been adequately elucidated. It needs to be clarified whether it is the intrinsic (“nonallergic” or “atopiform dermatitis”) and/or extrinsic (IgE-associated) AD that is affected by pregnancy. Future studies need to examine the postpartum prognosis of AD that develops for the first time during gestation. A revision of diagnostic criteria of AEP will allow a more accurate estimate of its prevalence, as well as clarification of the relationship between AD and specific dermatoses, such as PP and PFP. In this context, this review discusses the history, epidemiologic data, clinicopathologic features, and management of the above entities.
... Phototherapy does degrade and lower levels of folic acid which in prepregancy and the first trimester could contribute to neural tube defects. Therefore supplementation during phototherapy and or monitoring folic acid levels has been recommended 369 . Phototherapy may also worsen melasma and patients should be warned of this possibility 364 . ...
... Psoriasis often clears as a result of the pregnancy itself. We published a study prospectively observing the change of body surface area of psoriasis in pregnant patients, revealing that the majority of patients (55%) experience dramatic improvement, with an average lesion resolution of 84%. 10 Is it in the best interest of the patient to stop her biologic during the first trimester, undergo topical therapy and narrowband ultraviolet B therapy with adequate folic acid supplementation, and see if the psoriasis slowly ameliorates, or is it best for her to continue her tumor necrosis factor inhibitor? 11 This decision involves a discussion between patient and dermatologist on a case-by-case basis. ...
... Measure folic acid levels in phototherapy patients considering pregnancy, and initiate appropriate folic acid supplementation during phototherapy. 36,37 Psoralen plus ultraviolet A light phototherapy Psoralen plus ultraviolet A light phototherapy has not been shown to increase risk of congenital malformations or infant mortality, but there was a marked increase in low birth weight babies. 38,39 Because psoralen is a known mutagen and teratogen, it is recommended to avoid psoralen plus ultraviolet A light phototherapy treatment during pregnancy. ...
Dermatologists are frequently faced with questions about the safety of commonly prescribed topical and systemic medications during pregnancy and lactation from women of childbearing age who are pregnant, considering pregnancy, or breastfeeding. Safety data, particularly regarding medications that are unique to dermatology, can be difficult to locate and are not consolidated in a single reference guide for clinicians. Parts I and II of this continuing medical education article provide a capsule summary of key points for the most commonly prescribed dermatologic medications to facilitate patient medication risk counseling in pregnancy. A summary table details safety classification data for 3 primary international classification systems: the US Food and Drug Administration, the Swedish Catalogue of Approved Drugs, and the Australian Drug Evaluation Committee. In addition, this table includes an alternative pregnancy classification system developed by a consortium of active members of teratology societies in the US and Europe detailed in Drugs during Pregnancy and Lactation: Treatment Options and Risk Assessment and a safety classification system developed for breastfeeding mothers detailed in Medications and Mother's Milk.
Considerable progress has been made to explain the aetiology of intrahepatic cholestasis of pregnancy (ICP) and of the adverse pregnancy outcomes associated with high maternal total serum bile acids (TSBAs). The reported thresholds for non-fasting TSBA associated with the risk of stillbirth and spontaneous preterm birth can be used to identify pregnancies at risk of these adverse outcomes to decide on appropriate interventions and to give reassurance to women with lower concentrations of TSBA. Data also support the use of ursodeoxycholic acid to protect against the risk of spontaneous preterm birth. A previous history of ICP may be associated with higher rates of subsequent hepatobiliary disease: if there is a suspicion of underlying susceptibility, clinicians caring for women with ICP should screen for associated disorders or for genetic susceptibility and, where appropriate, refer for ongoing hepatology review.
Chronic skin disease is common in women of reproductive age. Although skin can improve or remain stable during pregnancy, it is also common for existing conditions to flare and for new conditions to develop. A small number of medications used to control chronic skin disease can potentially have adverse effects on the outcome of the pregnancy. This article forms part of a series on prescribing for pregnancy and highlights the importance of achieving good control of the skin disease prior to conception and during pregnancy. It emphasises the need for patient-centred, open and informed discussions around medication options to achieve good control. During pregnancy and breastfeeding each patient should be treated as an individual in accordance with the medications that are appropriate for them, their preferences, and the severity of their skin disease. This should be done through collaborative working across primary care, dermatology and obstetric services.
Introduction:
While topical medications are the first line of treatment for mild to moderate atopic dermatitis, they are ineffective in individuals with diffuse disease and moderate-to-severe atopic itch. For these individuals, as well as those who do not respond to topical treatments, systemic medicines are typically essential and helpful.
Areas covered:
We conducted a review of the literature to identify established systemic therapies, novel biologic agents, and recent advances in the pathophysiology of atopic dermatitis. The review discusses these data, which show that the majority of atopic itch medications now in development target the type 2 immune axis and brain sensitization, two main etiologies of atopic itch. We emphasize the evidence, efficacy, and side effect profiles of currently available systemic medications for atopic itch, as well as future potential for tailored therapy.
Expert opinion:
We give our professional opinion on the current state of knowledge about atopic eczema pathogenesis and the innovative targets and therapies for atopic itch that include MRGPRX2, Periostin, gabaergic medicines, and JAK/STAT inhibitors. Additionally, we discuss patient populations that stand to benefit the most from targeting these molecules or utilizing these drugs, as well as those who may face a disproportionate weight of adverse effects.
The integumentary system undergoes significant changes during pregnancy. This may lead to new or worsening of dermatological conditions for which the pregnant or postpartum woman may seek over-the-counter remedies or the advice of the health care provider to resolve. Deciding upon an appropriate pharmacological approach is complex and often hazed by the dearth of evidence to guide clinical management. As a result, health care providers are seemingly perplexed concerning the safest course of action for this population. While there are a number of dermatological conditions, clinical guidance regarding common conditions, such as acne, psoriasis, dermatoses, bacterial infections, viral infections, fungal infection, and parasitic infections, can help to provide the much needed direction health care providers often seek.
Atopic dermatitis (AD) is the most common skin disorder in pregnancy. Its pathogenesis is complex and likely multifactorial, including changes in the maternal immune system and de-escalation of medical interventions in pregnant patients. Management of this condition is possible through the cautious use of topical and systemic medications. While treatment of atopic dermatitis in pregnancy is of clear benefit to the pregnant patient, it was previously thought that the benefit of treatment did not extend to the unborn fetus. However, there is new evidence to suggest that failure to treat atopic dermatitis in pregnancy may have significant implications for the fetus, making an understanding of appropriate treatment options imperative.
Pregnancy Dermatoses are a group of inflammatory, pruritic skin diseases which occur only during pregnancy or directly postpartum. These pregnancy dermatoses include polymorphic eruption of pregnancy, atopic eruption of pregnancy, intrahepatic cholestasis of pregnancy and pemphigoid gestationis. Together, these dermatoses encompass a wide range of clinical presentations, and distinguishing amongst the diagnoses enables the dermatologist to guide each patient through appropriate risk stratification, maternal and fetal prognosis, and a targeted therapeutic approach.
A 26-year-old woman presents with worsening diffuse-body psoriasis while on a regimen of topical steroids and ultraviolet B phototherapy. She qualifies for treatment with biologics, but she is also planning pregnancy. Certolizumab pegol, a novel tumor necrosis factor inhibitor that does not undergo transplacental transport, is considered the safest biologic with regards to fetal outcomes. After counseling on the risks and benefits of biologic therapy, the patient chose to switch her regimen to certolizumab pegol prior to becoming pregnant.
Atopic dermatitis (AD) and allergic contact dermatitis (ACD) involve cell-mediated immune mechanisms with overlapping pathophysiology and manifestations. Atopic dermatitis is a chronic, inflammatory, and pruritic skin disease due to a complex interplay of immunopathology, environmental factors, and inherent skin barrier defects. Allergic contact dermatitis encompasses an inflammatory skin reaction which develops through external allergenic skin exposures, subsequently leading to immunologic inflammatory pathways. Both dermatoses may occur in the pregnant patient, either as a new diagnosis or an exacerbation of pre-existing disease, resulting in significant emotional distress and adversely impacting a patient’s quality of life. Appropriate diagnosis of new-onset pruritus with or without skin rash in the pregnant patient is important since there are pregnancy-specific dermatoses (i.e., polymorphic eruption of pregnancy, intrahepatic cholestasis of pregnancy) which may require prompt treatment in order to prevent adverse maternal and/or fetal outcomes. Fetal prognosis is generally not affected by maternal AD or ACD. However, treatment options for AD and ACD are relatively limited in the pregnant patient, given the potential fetal adverse effects of several therapeutic options, especially for moderate-to-severe cases.
Background:
Ultraviolet (UV) degradation of folate has been studied in vitro and in vivo, but comprehensive reviews of the subject and recommendations for supplementing folate are lacking, especially for women of childbearing age, in whom decreases in folate predisposes newborns to neural tube defects.
Objective:
We reviewed the effects of phototherapy on folate and provide a recommendation for women of childbearing age on phototherapy.
Methods:
PubMed was searched for in vivo studies comparing folate levels before and after phototherapy.
Results:
There is no evidence of decreased folate levels after UVA exposure. Decreased folate levels after sun exposure were limited to subjects taking folate supplements. Studies using narrowband UVB showed mixed results, potentially explained by dose-dependent degradation of folate; exposure >40 J/cm(2) cumulatively and >2 J/cm(2) per treatment were associated with 19%-27% decreases in serum folate levels, while lower doses did not affect folate levels.
Limitations:
Extensive variability in results from studies and lack of considering confounders.
Conclusions:
We recommend all women of childbearing age on phototherapy take 0.8 mg/day of folate supplements, as suggested by current guidelines for women of childbearing age, to reduce the risk of neural tube defects in unplanned pregnancy.
Systemic and localized scleroderma are difficult to manage diseases with no accepted gold standard of therapy to date. Phototherapeutic modalities for scleroderma show promise. A PubMed search of information on phototherapy for scleroderma was conducted. The information was classified into effects on pathogenesis and clinical outcomes. Studies on photopheresis were excluded. There were no randomized, double-blind, placebo-controlled studies, and only three controlled studies. The vast majority of identified studies evaluated ultraviolet A1 (UVA1) phototherapy. More rigorous studies are needed to evaluate phototherapy in the treatment of scleroderma. Based on the limited studies available, 20–50 J/cm2 of UVA1 therapy 3–4 times a week for 30 treatments is recommended.
A switch from cell-mediated to humoral immunity (Th1 to Th2 shift) during gestation plays a key role in placental immune tolerance. As a result, skin diseases that are Th2-mediated often worsen while skin diseases that are Th1-mediated often improve during gestation. Also, due to fluctuations in glandular activity, skin diseases involving sebaceous and eccrine glands may flare, while those involving apocrine glands may improve during pregnancy. Despite these trends, inflammatory and glandular skin diseases do not always follow the predicted pattern, and courses are often diverse. We review the gestational course of inflammatory skin diseases, such as atopic dermatitis (atopic eruption of pregnancy), psoriasis, impetigo herpetiformis, urticaria, erythema annulare centrifugum, pityriasis rosea, sarcoidosis, Sweet syndrome, and erythema nodosum, as well as glandular skin diseases, including acne vulgaris, acne rosacea, perioral dermatitis, hidradenitis suppurativa, Fox-Fordyce disease, hyperhidrosis, and miliaria. For each of the above diseases, we discuss the pathogenesis, clinical presentation, and management with special consideration for maternal and fetal safety.
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.
Psoriasis is a chronic inflammatory disease with a well-documented negative effect on the quality of life of affected patients. Psoriasis often occurs in the reproductive years, during which the issue of pregnancy needs to be addressed. The course of psoriasis during pregnancy is unpredictable, and many patients face the challenge of needing treatment during pregnancy. In this review we provide an overview of the key considerations for managing psoriasis in pregnant women, covering the potential effects of active psoriasis and co-morbid conditions on the health of the mother and fetus, as well as the effects of psoriasis treatment options on the developing fetus. Although there are no robust data on the safety of systemic treatment of pregnant women, increasing evidence regarding the safety of cyclosporine (ciclosporin) treatment as well as anti-tumor necrosis factor-α is available and should be considered in pregnant women with moderate to severe psoriasis unresponsive to local corticosteroids and UVB light treatment.
Psoriasis is an inflammatory skin disorder not uncommonly seen in pregnant patients. Several drugs have been approved for its treatment in non-pregnant patients, but special precautions are necessary when selecting a treatment plan during pregnancy to prevent harm to the fetus and child. This article reviews the treatment options for the treatment of psoriasis in the pregnant and lactating patient.
Autoimmune skin disease occurs in pregnancy, and treatment is often required to control both maternal disease and fetal outcomes. Here we present the available safety data in pregnancy and lactation for medications used to treat autoimmune skin diseases, including cutaneous lupus erythematosus, dermatomyositis, morphea and systemic sclerosis, pemphigus vulgaris, pemphigus foliaceus, and pemphigoid gestationis. A PubMed search of the English-language literature using keywords, "pregnancy" "rheumatic disease," and "connective tissue disease" was performed. Relevant articles found in the search and references were included. Reasonable evidence supports the careful and cautious use of topical steroids, topical calcineurin inhibitors, systemic corticosteroids, hydroxychloroquine, and azathioprine in pregnancy. Case reports or clinical experience suggest intravenous immunoglobulin, dapsone, phototherapy, rituximab, and plasmapheresis may be safe. Several treatment options exist for autoimmune skin disease in pregnancy and lactation, and should be considered when treating these patients.
The management of acne vulgaris in the setting of pregnancy raises important clinical considerations regarding the efficacy and safety of acne treatments in this special patient population. Particular challenges include the absence of safety data, discrepancy in safety data between different safety rating systems, and lack of evidence-based recommendations for the treatment of acne during pregnancy. Nonetheless, many therapeutic options exist, and the treatment of acne in pregnant women can be safely and often effectively accomplished. For mild or moderate disease, patients can be treated with topical antimicrobial agents, anti-inflammatory agents, as well as glycolic and salicylic acid. Several topical agents, notably benzoyl peroxide, previously viewed as potentially dangerous are cited by many sources as being considered safe. When necessary, systemic therapies that can be safely added include penicillins, amoxicillin, cephalosporins, erythromycin, clindamycin, and tetracyclines or sulfonamides, depending on the stage of fetal development. Adjunct therapy may include phototherapy or laser treatments. Physicians should work with this often highly motivated, safety-conscious patient population to tailor an individualized treatment regimen. This treatment regimen will likely shift throughout the different stages of fetal development, as distinct safety considerations are raised prior to conception as well as during each of the trimesters of pregnancy. Important considerations regarding acne management in breast-feeding mothers is also discussed.
Atopic dermatitis (AD), also referred to as eczema, is one of the most frequently observed skin diseases in pregnant patients. The presentation and histopathology of this condition during pregnancy is identical to that of the non-pregnant individual. AD is a T-helper 2 dominant disease and may worsen during pregnancy, which favors this population of T-lymphocytes. AD management during pregnancy requires special precautions to avoid harming the fetus. Herein is an exploration of the different options available for the treatment of the pregnant patient with AD. The management of concomitant bacterial and viral infections is also discussed.
Narrowband ultraviolet B phototherapy (NB-UVB) is a widely used modality in the treatment of psoriasis and is generally accepted as safe in pregnancy. Previous studies have described photodegradation of serum folate after exposure to UVA radiation but the effect of UVB is not known. We studied the effect of NB-UVB phototherapy on serum folic acid levels in patients with psoriasis and the relationship between changes in serum folate levels and the total cumulative dose of NB-UVB. Included in the study were 30 psoriatic patients between 13 and 55 years of age. Serum folate levels were measured at baseline, and after exposure to 18 and 36 sessions of NB-UVB irradiation. There were significant decreases in mean serum folate levels after NB-UVB exposure. After exposure to 18 and 36 sessions the decreases were 19% and 27%, respectively. After 18 sessions, the mean serum folate level had decreased in 18 patients (60%) from 8.64 ng/ml at baseline to 7.02 ng/ml (mean NB-UVB cumulative dose 40.02 J/cm(2); P = 0.019). After 36 sessions, the mean serum folate levels had decreased in 22 patients (73%) to 6.32 ng/ml (mean NB-UVB cumulative dose 118.16 J/cm(2); P = 0.002). The present study showed that high cumulative NB-UVB doses can induce folate photodegradation and decrease serum folate levels in patients with psoriasis and that this effect is directly related to the total cumulative dose of NB-UVB.
The treatment of acne during pregnancy is a challenge because of the potential teratogenic effects. Medications currently deemed safe during pregnancy are largely unsatisfactory in treating acne. Narrowband (NB) UV-B phototherapy is a safe option for treatment of psoriasis during pregnancy. We report the successful use of NB UV-B for the treatment of acne in a pregnant patient.REFERENCES1 +Sannerstedt
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Ultraviolet radiation, UV, is widely used for treatment of psoriasis. UV radiation may destroy blood folates in test tubes, but clinical data are scarce. Folate deficiency may increase the risk of cardiovascular diseases, colorectal carcinoma, megaloblastic anemia, pregnancy and birth complications, depression and dementia. The aim of the present study was to investigate the influence of solar radiation, sunbeds and/or broadband UVB phototherapy on the levels of serum and erythrocyte folate in patients with psoriasis or healthy volunteers. Serum and erythrocyte folate status in patients with psoriasis and healthy volunteers was measured before and after exposure to solar radiation, broadband UVB or use of sunbeds. In some cases plasma homocysteine and serum 25-hydroxyvitamin D (25(OH)D) were also measured. Serum and erythrocyte folate levels in healthy volunteers and in psoriasis patients were not influenced to any statistically significant extent after exposure to solar radiation, to single or to multiple UV treatments. However, a slight decay of blood folates and an increase of plasma homocysteine levels were observed in psoriasis patients after exposure to UV radiation. Exposure to sun or sunbeds does not have any significant effect on the levels of blood folate of healthy humans. High doses of broadband UVB phototherapy may slightly decrease blood folates in psoriasis patients. Further studies, using proper, adequate 5-methyltetrahydrofolate methodology, are needed to clarify the influence of broadband phototherapy on folate degradation and the consequences of these on the health of psoriasis patients.
