Current Recommendations for the Systemic Treatment of Cutaneous Lupus Erythematosus During Pregnancy
Cutaneous lupus erythematosus (CLE) is a heterogeneous autoimmune disease of the skin that commonly affects women of childbearing age. Some of the medications used in the treatment of CLE are safe in pregnancy, whereas others are contraindicated based on their teratogenic effects. We describe the most recent recommendations for the use of commonly prescribed CLE medications for those who are pregnant or plan on becoming pregnant.
Practice Points
- Patients should consult their primary dermatologist when discussing medication options for cutaneous lupus erythematosus (CLE) prior to pregnancy.
- Hydroxychloroquine is a first-line medication for maintenance treatment of CLE, while oral steroids are effective for CLE flares in pregnancy. Second-line medications include dapsone and intravenous immunoglobulin. These classes of medications are considered safe in pregnancy.
- Cutaneous lupus erythematosus medications contraindicated in pregnancy include oral retinoids, mycophenolate mofetil, thalidomide, and methotrexate.
Sulfasalazine—Sulfasalazine is an immunomodulator commonly used for the treatment of inflammatory bowel disease and rheumatoid arthritis. However, studies also have shown that sulfasalazine is an effective treatment of CLE if standard treatments have failed.20,21
During pregnancy, patients exposed to sulfasalazine experienced minimal side effects despite transportation across the placenta.22 In comparison with control, pregnant women taking sulfasalazine experienced no increased risk for low fetal weight,23 congenital abnormalities,24 or spontaneous abortions.25 Of note, sulfasalazine can affect sperm, so male patients also should be counselled.
Category C
Hydroxychloroquine—Hydroxychloroquine is considered a first-line medication for those with CLE based on a symptomatic relief rate of 50% to 70%.26 For those taking hydroxychloroquine during pregnancy, the majority of studies have shown no association between the medication and adverse fetal events, including congenital abnormalities, prematurity, or spontaneous abortions.27-29 Therefore, hydroxychloroquine is considered safe in pregnancy, and those on the medication should continue standard monitoring, including retinopathy screening.30
Of note, hydroxychloroquine can be stored in tissue for weeks to months after discontinuation.5 Therefore, if patients wish to avoid hydroxychloroquine in pregnancy, one should stop taking the medication several months prior to conception.
Dapsone—Dapsone, a medication with both antimicrobial and immunomodulatory properties, is an effective second-line therapy for CLE.31 Although large-scale human trials have not been performed, multiple case reports and observational studies have supported the safe use of dapsone in pregnancy.32-34 However, there are notable side effects, including dose-dependent hemolysis, methemoglobinemia, and hypersensitivity reactions.13 Therefore, once treatment is initiated or continued, folic acid supplementation (5 mg daily) and regular serum analysis, including complete blood cell counts, are recommended in pregnant patients.19
