Psoriasis is a very common chronic inflammatory disease that can affect both fertility and pregnancy, postpartum, and breastfeeding (and vice versa).1–4

Several studies have described a possible association between psoriasis and fertility problems in both men and women.5–7 In the case of pregnancy, an estimated 40% to 88% of women experience a worsening of psoriasis several weeks after giving birth.8 In addition, children born to mothers who have been treated with monoclonal antibodies that cross the placental barrier during the third trimester are at an increased risk of infection and require specific monitoring and management.9 Finally, some of the treatments used in psoriasis, including tazarotene and acitretin, are potentially teratogenic and are therefore contraindicated in pregnancy.10,11

Health care professionals involved in the care of psoriasis patients must have detailed knowledge of the above and have the necessary expertise and skills to prevent or treat problems both early and efficiently.12 These issues are also very relevant to patients.12 In view of the above, the Psoriasis Working Group (GPs in its Spanish acronym) of the Spanish Academy of Dermatology and Venereology (AEDV) published a consensus statement in 2020 containing recommendations aimed at improving the management of patients of reproductive age. The recommendations covered aspects relating to fertility, pregnancy, postpartum, breastfeeding, and perinatal care.13

More than a year after the publication of this consensus statement, the GPs launched a survey to analyze the degree of implementation of its recommendations and examine perceived barriers and facilitators.

This study, initiated by the GPs, involved an online survey that was emailed to members of the GPs. It complied with good clinical practice standards and the ethical principles of the latest version of the Declaration of Helsinki regarding medical research involving human subjects.14

Fifty-three dermatologists answered the survey. Their sociodemographic and professional characteristics are summarized in Table 1. In brief, 53% were women aged 46–55 years, 81% worked in a tertiary care hospital, and 79% worked in a dedicated psoriasis unit.

The vast majority of respondents (96%) were familiar with the GPs recommendations on the management of psoriasis before, during, and after pregnancy, but just over 5% formed part of a multidisciplinary maternity care unit or team. Almost three-quarters reported a lack of specific protocols related to psoriasis and pregnancy in their departments. The use of educational material other than verbal advice and information, such as pamphlets, videos, and web-based tools, was uncommon. The dermatologists, however, were very knowledge about the effects of psoriasis on pregnancy and breastfeeding (and vice versa) and the effects of psoriasis treatments, with mean scores ranging from 7.70 (1.41) to 8.84 (0.71) on a scale of 1 to 10.

This survey was designed to analyze the degree of implementation of the 2020 GPs recommendations on the management of cutaneous psoriasis during preconception, pregnancy, postpartum, breastfeeding, and perinatal care.13 Our findings were mixed. Although the dermatologists surveyed were familiar with and highly knowledgeable about the aspects covered in the GPs consensus statement, implementation of some of the recommendations was low.

At the more general level, few dermatologists (or at least few of those surveyed) form part of multidisciplinary maternity care units or teams, even though 98% of the panel members who drew up the GPs recommendations agreed on the importance of collaborating with other specialists.13 Greater participation in multidisciplinary care has been observed in other disciplines, such as rheumatology.15 The survey also showed that very few dermatology departments have protocols tailored to specific care practices and available resources. Use of educational material other than verbal advice and information (pamphlets, videos, web-based tools, etc) is also uncommon. More work could probably be done in this area.

Almost a third of those surveyed do not routinely inquire about pregnancy plans, and less than 50% ask both men and women, showing that implementation of the GPs recommendation to regularly discuss family planning with all patients is far from optimal.13 Type of preconception advice offered also varies significantly. Very few dermatologists, for example, offer genetic counseling or discuss the potential impacts of psoriasis and psoriasis treatment on fertility. Although the GPs statement recommends routinely assessing pregnancy plans among all patients of reproductive age,13 the survey indicates that dermatologists tend to focus on specific groups of patients, such as women on systemic therapy and women with more severe forms of psoriasis. Another relevant finding to emerge from the survey was that it is often impossible to plan for pregnancy as many patients come to be seen when already pregnant. In view of the above, we consider that there is also room for improvement in preconception management of psoriasis. More widespread implementation of the GPs recommendations for managing psoriasis patients of reproductive age would improve numerous aspects, including, most notably, pregnancy planning.

Implementation of the GPs recommendations was greatest for psoriasis management during pregnancy, especially in relation to disease activity (being in remission or having as little disease activity as possible) and the use of topical, systemic, and biologic treatments. As recommended by the GPs, pregnant women are closely monitored using a tailored approach and appropriate actions in the event of a flare-up.

GPs recommendations relating to postpartum care and breastfeeding are also quite widely implemented according to the survey findings, although dermatologists tend to resume usual follow-up practices quite rapidly. More frequent monitoring during this period would be advisable given the risk of flare-ups.

Of note from our findings on barriers and facilitators for the implementation of the GPs recommendations13 is that nursing support and patient education material were perceived as being the easiest-to-implement interventions for improving the management of psoriasis before, during, and after pregnancy. Although it may currently be difficult to find more time or secure more support from nursing services, improving patient education material and tools is feasible.

Our study has a series of limitations, including some design issues. Because the survey was sent to GPs members, there is a risk of selection bias, as dermatologists who are members of this group may have more interest and experience in the management of psoriasis in relation to pregnancy, and accordingly, may be more familiar with and likely to implement the GPs recommendations. Nevertheless, the low degree of implementation observed for certain recommendations in this same group would suggest that implementation is even lower among dermatologists with less experience or interest in psoriasis. That said, the survey was conducted just a year after the recommendations were published online, and more time may be needed for their dissemination and implementation. Nonetheless, all the recommendations can, in theory, be quickly implemented in clinical practice as they are not affected by resource constraints or other limitations.

In summary, variable degrees of implementation of the GPs recommendations on managing psoriasis in relation to fertility, pregnancy, postpartum, breastfeeding, and perinatal care were observed, with high levels largely seen for treatment-related recommendations and lower levels seen for preconception-related recommendations. Other areas for improvement included greater participation in multidisciplinary maternity care units or teams and development of department-specific protocols and patient education materials. Continued efforts are needed to improve the implementation of the GPs recommendations, particularly in certain areas.

This project was initiated and funded by the AEDV with an unlimited grant from UCB.

The authors declare that they do not have any conflicts of interest in relation to this article.