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.
Rituximab—Recent studies have demonstrated that rituximab can be an effective treatment of subacute and chronic CLE.35,36 Through inhibition of CD20, rituximab causes a decrease in circulating B cells and a reduced immune response. Therefore, experts recommend discontinuation of rituximab for 12 months prior to conception to reduce potential side effects to the fetus, which may include a transient reduction of circulating fetal B cells.37
If continued during pregnancy, most studies suggest discontinuation of rituximab during the third trimester, as it has been associated with neonatal infections and congenital abnormalities.19,37 However, these results are based on limited case reports, and thus robust research is needed to better understand the effect of rituximab in utero.
Intravenous Immunoglobulin Infusion—Intravenous immunoglobulin (IVIG) infusion is a well-tolerated treatment for many autoimmune disorders.38 Although not first line, limited case studies have demonstrated remission of refractory CLE following IVIG.39,40 Although no studies have directly investigated the effect of IVIG on fetal development, it has been frequently administered and well tolerated during pregnancy, especially in those with multiple sclerosis or antiphospholipid syndrome.41 Commonly reported side effects include headache and fatigue, and a rare associated side effect to be aware of is embolic events.42,43
Cyclosporine—Cyclosporine rarely is used in the treatment of localized CLE due to its extensive side-effect profile, most notably nephrotoxicity.44 However, studies have shown that cyclosporine may be efficacious if symptoms extend beyond the skin, involve multiple organs, and/or other treatments have failed.39 For those who are pregnant and wish to continue cyclosporine use, studies have associated low birth weight and premature delivery with its exposure in utero.44
Category D
Mycophenolate Mofetil—In conjunction with standard therapy, mycophenolate mofetil (MMF) is an adequate treatment of refractory CLE.45 Unfortunately, case reports have demonstrated an increased risk for fetal congenital abnormalities and first-trimester spontaneous abortion with use of MMF during pregnancy.46,47 Therefore, it is recommended that patients on MMF discontinue the medication at least 6 weeks prior to conception.46
