Ten Clinical Considerations to Manage AD in Pregnant Patients

Elizabeth Kiracofe, MD, and Jenny Murase, MD

Treating atopic dermatitis (AD) during pregnancy presents unique challenges that require careful consideration and an individualized approach.

“If you look on the National Eczema Association or the International Eczema Council websites, they don’t have specific resources for patients [with AD] who are considering pregnancy or currently pregnant…so that causes the physician to feel uncertain of what they should recommend. Rightly so, because you’re dealing with 2 patients when you’re prescribing therapy in pregnancy, and one of them is very vulnerable,” said Jenny Murase, MD, a dermatologist at Palo Alto Foundation Medical Group and University of California, San Francisco Medical Center.

In a new Dermatology Times DermView custom video series, “Navigating Pregnancy Safety and Systemic Treatments in Atopic Dermatitis,” Murase and Elizabeth Kiracofe, MD, founder of Airia Comprehensive Dermatology in Chicago, Illinois, highlighted key clinical considerations to optimize care for patients during pregnancy, prepregnancy, postpartum, and breastfeeding.

1) Importance of Conversations

Effective communication between clinicians and patients is crucial for managing AD during pregnancy. Murase said, “The onus is on us as physicians to have that conversation when prescribing therapy for chronic conditions like atopic dermatitis.” Kiracofe agreed, advocating for proactive communication. “We need to have more and better conversations, and we need to have them earlier,” she said. These discussions allow clinicians to address concerns, educate patients on treatment options, and collaboratively navigate the complexities of managing AD across different reproductive stages.

2) Safety Concerns

Clinicians must be acutely aware of safety concerns related to systemic treatments for AD during pregnancy. Kiracofe said, “There’s a lot of uncertainty about data safety, causing hesitation to make recommendations.” Murase added, “Our hands are tied....Our data are limited, but the safety profile looks good so far.” Balancing potential risks and benefits is essential to ensure the well-being of both the mother and the fetus during treatment.

3) Limited Data

Due to limited data on treating AD in pregnant patients, Kiracofe noted that “decisions may need to be based on existing knowledge and patient-specific factors….” Murase added, “A thorough review of existing literature and interim analysis using available safety data is very much appreciated by dermatologists worldwide.” Recognizing these data limitations and pursuing continued research are pivotal for informed clinical decision-making.

4) Allergen Avoidance

Allergen avoidance is a key strategy in managing AD during pregnancy. Murase advocated for a detailed intake process to identify and minimize exposure to potential allergens, thus helping to alleviate symptoms and prevent exacerbations. “If they are kind of petering along and all of a sudden they’re worse than they’ve ever been, think bacteria and think of allergens. If I’m seeing a lot of fissuring, I’m going to culture to see if allergens are playing a role,” Murase said.

5) Topical Treatments

Topical treatments are generally safer options for managing AD during pregnancy. Murase noted, “Topical corticosteroids are the only topical dermatologic medication substantiated by the Cochrane Database for safe use.” She also advised caution with systemic corticosteroids due to associated risks. “Avoid systemic cortisone during certain periods due to a 3-fold increased risk of oral cleft,” she said. Evidence-based decision-making and cautious use of topical treatments are essential to ensure patient safety.

6) Individualized Approach

Tailoring treatment plans to individual patients is critical. “It’s important to individualize therapy for the patient,” Kiracofe said. Murase echoed this sentiment, emphasizing, “Personalized care and careful consideration of treatment options optimize outcomes while minimizing risks.” An individualized approach ensures that treatment plans are tailored to the unique needs of each pregnant patient.

7) Patient Education

Educating patients on the risks and benefits of different treatment options empowers them to make informed decisions. “It’s important to educate patients about the risks and benefits of therapy,” Murase said, stressing the importance of open communication. “Practice having these conversations and acknowledge that they are difficult.” Thorough patient education and communication are vital for ensuring that patients are well-informed and actively engaged in their care decisions.

8) Monitoring and Follow-Up

Regular monitoring and follow-up are crucial to assess treatment effectiveness and make necessary adjustments. “We need a system in place to monitor these patients,” Murase emphasized. Regular follow-up appointments help track progress, assess treatment efficacy, and address any potential adverse effects promptly, ensuring optimal outcomes for both mother and fetus.

9) Multidisciplinary Collaboration

Involving other health care providers in managing AD in pregnant patients ensures comprehensive care. “We have to work together as a team,” Murase said. Multidisciplinary collaboration involving allergists, obstetricians, and other specialists provides holistic management and addresses the complex needs of pregnant patients with AD.

10) Guideline Adherence

Although specific guidelines for treating AD in pregnant patients may be limited, existing resources from organizations like the National Eczema Association and the International Eczema Council can provide general guidance. “We need to follow the guidelines that are out there,” Murase stressed. Currently, guidelines suggest topical steroids in short treatment bursts of up to 2 weeks; for severe cases, evaluate the benefit vs risk with systemics because biologics can cross the placental barrier, according to Murase.