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.
Final Thoughts
Overall, it is recommended to limit medication use as much as possible in pregnancy. To reduce these exposures, it is imperative to reduce triggers that may lead to symptomatic flares of CLE. Because CLE can be triggered by sun exposure, we advise topical sunscreen to prevent CLE flares that may require additional oral medication.62,63
Various medications are considered safe for the treatment of CLE in pregnant patients (Figure 2). Based on studies in animal and clinical trials, hydroxychloroquine is considered a safe and effective medication for CLE in pregnancy and is a first-line therapy in nonpregnant patients.26,27 If flares occur, IVIG or a short course of oral steroids should be considered to manage symptoms.13,39 For those with severe flares, treatment is difficult, and personalized approaches may be necessary.
Part of the question for the childbearing population is when a patient would like to conceive. For severe cases when hydroxychloroquine is not effective as monotherapy, using a treatment that can encourage remission prior to conception attempts can be a beneficial strategy. Rituximab is an excellent example of such a therapy, as the therapeutic effect outlasts the immunosuppressive effect and therefore is unlikely to affect a future fetus.64 Thalidomide also is a potential option prior to conception, based on its short washout period and its ability to achieve notable remission rates in patients with CLE.57,59 Regardless, patients with CLE should still consult their dermatologist and rheumatologist (if applicable) prior to conception.
Patients of childbearing potential represent a population in which discussion about life goals greatly affects medication options. Having these discussions early and often allows for an open, more successful approach so that treatment regimens are not derailed at the time of conception.
