Psoriasis has a negative effect on patients’ quality of life.1 In Spain, the prevalence of psoriasis is 2.3%, affecting approximately 1 million persons, with little variation between the sexes.2 Onset is between the second and fourth decades of life in 75% of cases, that is, coinciding with a woman's reproductive years, causing concern and uncertainty with respect to childbearing3,4 owing to the lack of information on family planning, pregnancy, and breastfeeding.5,6 According to the BIOBADADERM registry, women with moderate-to-severe psoriasis in Spain are less likely to become pregnant7 and breastfeed than the general population.8

The course of psoriasis during pregnancy is unpredictable. Symptoms improve in around half of pregnant women, remain unchanged in others, and worsen in more than 20%.3 Moreover, symptoms worsen after delivery in 65%.9 Uncontrolled psoriasis during pregnancy is associated with complications for both mother and fetus.3,10–12 While many psoriasis treatments are potentially teratogenic,13–15 current therapeutic options are compatible with pregnancy and breastfeeding.5,16–18The main objectives of the present study were as follows: to determine the impact of psoriasis on the desire to become pregnant and on breastfeeding; to learn more about the concerns and fears of women with the disease before, during, and after pregnancy; and to analyze the information on family planning, pregnancy, and breastfeeding they receive at the clinic with the aim of ensuring that the information provided by their dermatologist is as complete and exhaustive as possible depending on their individual needs. The secondary objectives were to evaluate differences in the impact of the disease, concerns and information depending on whether the woman had been pregnant or had a child, treatment with biologics, and disease activity according to the patient or to the physician.

We performed a multicenter, cross-sectional, descriptive, observational study. Patients were selected during visits to the dermatologist at Spanish clinics and included between March 2020 and October 2021.

We included 153 women from 11 Spanish centers (mean [SD] age, 35.4 [8] years). Table 1 summarizes the sociodemographic and clinical characteristics. Most patients (51.6%) had never been pregnant. Of the 74 patients who had been pregnant, most had had 1 or 2 children (51.4 and 27%, respectively), and 35.1% had had at least 1 spontaneous abortion; 23.9% had received care in high-risk pregnancy units.

The median (IQR) disease duration was 16 years (9-22 years; minimum, 1 year; maximum, 41 years). Most patients had mild disease at the time of the evaluation (BSA<5%, 81.4%). However, severity was perceived as moderate-to-severe (mean VAS, 3-10) by 49% of patients and 38.4% of physicians. Perception of disease activity according to the VAS value was significantly poorer among patients than among physicians (mean VAS, 3.6 vs. 2.7; median 2 vs. 1.5; P<.001). As for quality of life, 41.2% reported this to be moderate or very or extremely affected (Table 1).

The results of the family planning questionnaire are shown in Figures 1, 2, and 3.

Figure 1.

Results of the Family Planning Questionnaire (Questions 1 to 9).

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Figure 2.

Results of the Family Planning Questionnaire (Questions 10-18).

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Figure 3.

Results of the Family Planning Questionnaire (Questions 19 to 27).

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With respect to the impact of psoriasis, more than 30% of the patients somewhat agreed or very much agreed with the statement that the disease can affect their sexual health (item 2). For 35%, psoriasis affected their desire to become pregnant or delayed their becoming pregnant (items 6-7); 20.5% felt that the disease could restrict them from caring for their child appropriately (item 24).

As for concerns, 55%-65% were worried that their psoriasis would worsen if the drug was withdrawn or switched before pregnancy, during pregnancy, or during breastfeeding (items 15, 19, and 23). Around 60% were concerned that treatment could harm the baby (item 21).

More than half of the patients thought that the information received at visits did not address topics such as family planning, desire to become pregnant, or treatment before becoming pregnant (items 11-13). One third considered that they knew which drugs they could and could not take before pregnancy (item 14). Around 60% were aware that psoriasis must be under control before and during pregnancy (items 16-17). A significant proportion of patients had not received information on available options during pregnancy and breastfeeding (items 18 and 22). Almost half of the patients somewhat or very much agreed that if they could receive more information from their doctor, they would reconsider becoming pregnant.

Recent studies indicate that women with moderate-to-severe psoriasis in Spain are less likely to become pregnant7 and less given to breastfeeding than the general population.8 The underlying reasons for this finding include psychological causes, feelings of low self-esteem, stigmatization, and a loss of confidence that leads to sexual problems, social and family-related problems, and concern over the effects of treatment on the fetus.7,8 Our survey showed that more than 40% of patients believed that if they received more information from their physician, they would reconsider the desire to have children. Therefore, in line with a recent consensus statement,13 we think that physicians should be more proactive in providing this information (Table 5).

Psoriasis in women is diagnosed at a mean age of 28 years, with initiation of treatment at 28-45 years, that is, when reproductive activity is highest.5 In our study, the mean age was 35.4 years, and the disease had been progressing for 16.7 years; therefore, our study population is representative of women during their peak reproductive period. Psoriasis has a considerable physical and emotional impact on women, affects their quality of life (to a greater extent than it does that of men), affects their sexual relations, and generates uncertainty over the possible effects of the disease on motherhood.3,5 Little is known about these aspects, which may be undervalued in clinical practice.5,6

Our cohort brings together patients with a significant disease burden. The impact of the disease reduces the desire to become pregnant or delays pregnancy in one third of patients. The survey revealed some of the concerns that could account for these fears, which are associated mainly with the safety of treatment, the course of the disease, and the lack of information. Most women are worried that the treatment could harm the baby, although they are also concerned that the disease could worsen by stopping or changing treatment before pregnancy, during pregnancy, or during breastfeeding.

The data suggest that the information provided in the dermatology clinic on family planning, desire to become pregnant, and safety of treatment is insufficient, both before conception and during pregnancy and breastfeeding, especially in women who have not previously been pregnant. We think that all women of reproductive age should receive appropriate information at the clinic. Moreover, up to 50% of pregnancies are not planned; therefore, in line with other authors,5 we believe that women of reproductive age should be provided with a treatment plan that is compatible with pregnancy, irrespective of their intentions with respect to family planning. Furthermore, it is important to train and improve the role of dermatologists as providers of information on family planning.

Our results suggest that women taking biologics are followed up more appropriately and have a better quality of life, with less impact of the disease on sexual health, than patients not taking biologics. Treatment of psoriasis during pregnancy and breastfeeding is challenging for the clinician.3,13,14 While numerous therapies with potential teratogenic effects must be withdrawn before conception,13 some treatments can be used safely during pregnancy and breastfeeding, and we should inform patients in this regard. Certolizumab pegol is the safest biologic in both pregnancy and breastfeeding, given that its passage across the placenta to the mother's milk is minimal or nonexistent.16,17,20 Pregnant women treated with biologics can continue treatment during the first and second trimesters. The risks and benefits of continuing treatment during the third trimester can be discussed with the patient. However, patients taking certolizumab pegol can continue to do so throughout their pregnancy, if considered clinically necessary, as well as during breastfeeding.13

It has been shown that in both healthy women20 and in women with other chronic diseases,21 attitude toward pregnancy is influenced by perception of risk.22 Chronic diseases are associated with various risks during pregnancy, and the perception of risk is unique to each individual and not based only on objective information with respect to the risk.20 Therefore, further research is necessary to understand women's perception of risk in specific chronic diseases. In addition, efforts must be made to improve the information provided to patients on objective risks.20 In the specific case of psoriasis, recent guidelines address patient management.13

Our study is limited by its cross-sectional, descriptive, and observational design and the fact that it lacks a control group comprising women without psoriasis or male patients with psoriasis. However, we believe that our sample is representative of women of reproductive age seen at dermatology clinics in Spain, and who provide some indication of their needs and concerns with respect to family planning. Our findings lead us to believe that it is essential to provide more information to patients at the clinic.

The results of our study suggest that psoriasis has an impact on family planning and desire to become pregnant. Various concerns may affect a woman's desire to become pregnant or delay pregnancy. The information provided on these aspects during follow-up is not complete.

This study was funded by a nonrestricted grant from the Universidad Francisco de Vitoria-UCB Chair in Bone Health and Inflammation.

Natalia Jiménez Gómez has acted as a consultant and/or investigator and/or speaker for AbbVie, Almirall, BMS, Celgene, Janssen, LEO Pharma, Lilly, MSD, Novartis, and UCB.

Ricardo Ruiz-Villaverde has received fees for consultancy from AbbVie, Novartis, UCB, Celgene, and Janssen.

María Luisa Alonso Pacheco has received research/consultancy fees from AbbVie, Novartis, Lilly, LEO Pharma, UCB, Celgene, and Janssen.

Rosa María Izu has been a consultant, adviser, speaker, or clinical trial participant for Almirall, Novartis, AbbVie, Lilly, LEO Pharma, UCB, Sanofi, Celgene, Pfizer, Janssen, and Kyowa-Kirin.

Raquel Rivera-Díaz has received research/consultancy fees from AbbVie, Boehringer Ingelheim, Celgene, Janssen, LEO Pharma, Lilly, Pfizer, Novartis, and UCB.

Jordi Mollet Sanchez has received research/consultancy fees from AbbVie, Amgen, Boehringer Ingelheim, Celgene, Janssen, LEO Pharma, Lilly, Novartis, Pfizer, Sanofi, and UCB.

Mar Llamas-Velasco has received research/consultancy fees from AbbVie, Boehringer Ingelheim, Celgene, Janssen, LEO Pharma, Lilly, Kyowa Kirin, Novartis, Pfizer, and UCB.

Álvaro González-Cantero has received research/consultancy fees from AbbVie, Amgen, Celgene, Janssen, LEO Pharma, Lilly, Novartis, Novartis, and UCB.

Pablo de la Cueva has acted as a consultant and/or investigator and/or speaker for AbbVie, Almirall, BMS, Boehringer, Celgene, Janssen, LEO Pharma, Lilly, MSD, Novartis, Pfizer, Roche, Sanofi, and UCB.

Elena Martínez Lorenzo has received fees for consultancy from AbbVie, Almirall, Janssen, LEO Pharma, Novartis, and UCB and has given talks or participated in training programs for AbbVie, Almirall, Celgene, Janssen, LEO Pharma, Lilly, Novartis, Roche, and UCB.

Ofelia Baniandrés Rodríguez has received research/consultancy fees from AbbVie, Amgen, Celgene, Janssen, LEO Pharma, Lilly, Novartis, Pfizer, and UCB.

Gerard Pitarch Bort has participated in clinical trials and studies for AbbVie, Janssen, Novartis, and UCB and has received speaker fees from AbbVie, Janssen, LEO Pharma, and Novartis and training grants from AbbVie, Almirall, Janssen, Novartis, and UCB.