Conference Coverage

Experts in Europe issue guidance on atopic dermatitis in pregnancy

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Task force highlights important topics

I applaud the thoughtful opinion paper developed by the European Task Force on Atopic Dermatitis, which highlights several important topics regarding the management of atopic dermatitis (AD) in pregnant and breastfeeding women. First and foremost, the committee brings to light the safety data available for topical corticosteroid use during the course of pregnancy. As stated in the paper, there is no evidence to support congenital malformation or preterm delivery risk in the use of medium to strong potency topical corticosteroids. The primary counseling points are judicious use around the abdomen and breasts, areas that are expanding as a result of the pregnancy and during lactation, to prevent striae formation. In addition, providers should advise their patients to dilute the cortisones with moisturizer if possible and keep track of the amount of topical cortisone dispensed, given fetal growth restriction has been reported with use of potent topical corticosteroids during the third trimester if over 300 grams have been dispensed throughout the pregnancy.

An important additional counseling point not mentioned in the paper is that, for atopic dermatitis patients of childbearing age receiving phototherapy, daily folic acid supplementation is recommended to prevent a theoretical risk of neural tube defects from vitamin depletion (J Am Acad Dermatol. 2014 Mar;70[3]:401.e1-14).

In addition, two points that I feel are important to mention, which contradict information in the paper are as follows: First, the risk of oral consumption of topical tacrolimus could be significant with long-term application to the nipple, and it is not recommended that topical tacrolimus be applied to a breastfeeding mother’s nipple directly. Second, while there are cases reported of safe infant exposure to maternal cyclosporine use during lactation, the American Academy of Pediatrics and other clinical groups identify cyclosporine as cytotoxic and recommend avoidance of the medication during lactation. If the mother elects to breastfeed, the infant needs to be monitored for symptoms of cyclosporine toxicity, including edema, tremor, hirsutism, hypertension, and seizure, and infant plasma levels should be followed closely (J Am Acad Dermatol. 2014 Mar;70[3]:417.e1-10).

Jenny Murase, MD, is with the department of dermatology, University of California, San Francisco, and is the director of medical consultative dermatology at the Palo Alto Foundation Medical Group, Mountain View, Calif. She has served on advisory boards for Dermira, Sanofi, and UCB; performed dermatologic consulting for UpToDate and Ferndale, and given nonbranded lectures for disease state management awareness for Regeneron and UCB.


 

REPORTING FROM THE EADV CONGRESS

– European atopic dermatitis experts have issued formal guidance on a seriously neglected topic: treatment of the disease during pregnancy, breastfeeding, and in men planning to father children.

Dr. Christian Vestergaard, a dermatologist at the University of Aarhus (Denmark) Bruce Jancin/MDedge News

Dr. Christian Vestergaard

The impetus for the project was clear: “Treatment of atopic dermatitis in pregnancy is often forgotten or even ignored,” Christian Vestergaard, MD, PhD, declared at a meeting of the European Task Force on Atopic Dermatitis held in conjunction with the annual congress of the European Academy of Dermatology and Venereology.

He presented highlights of the task force’s position paper on the topic, for which he served as first author. The group’s recommendations are based on expert opinion, since randomized clinical trial literature in this area is nonexistent because of ethical concerns. But the task force, comprising a who’s who in European dermatology, drew on a wealth of collective clinical experience in this area.

“We have all of Europe involved in doing this position statement. It’s meant as what we think is proper treatment and what we can say about the different drugs,” explained Dr. Vestergaard, a dermatologist at the University of Aarhus (Denmark).

Most nonobstetricians are intimidated by atopic dermatitis (AD) in pregnancy, and are concerned about the potential for treatment-related harm to the fetus. As a consequence, they are reluctant to recommend anything beyond weak class I topical corticosteroids and emollients. That’s clearly insufficient in light of the vast scope of need, he asserted. After all, AD affects 15%-20% of all children and persists or reappears in adulthood in one out of five of them. Half of those adults are women, many of whom will at some point wish to become pregnant. And many men with AD will eventually want to father children.

A key message from the task force is that untreated AD in pregnancy potentially places the mother and fetus at risk of serious complications, including Staphylococcus aureus infection and eczema herpeticum.

“If you take one thing away from our position paper, it’s that you can use class II or III topical corticosteroids in pregnant women as first-line therapy,” Dr. Vestergaard said.

This stance contradicts a longstanding widely held concern that topical steroids in pregnancy might increase the risk of facial cleft in the offspring, a worry that has been convincingly debunked in a Cochrane systematic review of 14 studies including more than 1.6 million pregnancies. The report concluded there was no association between topical corticosteroids of any potency with preterm delivery, birth defects, or low Apgar scores (Cochrane Database Syst Rev. 2015 Oct 26. doi: 10.1002/14651858.CD007346.pub3).

The task force recommends that if class II or III topical corticosteroid use in pregnancy exceeds 200 g/month, it’s worth considering add-on UV therapy, with narrow band UVB-311 nm as the regimen of choice; it can be used liberally. UV therapy with psoralens is not advised because of a theoretical risk of mutagenicity.

Product labeling for the topical calcineurin inhibitors declares that the agents should not be used during pregnancy. However, the European task force position paper takes issue with that and declares that topical tacrolimus (Protopic) can be considered an off-label first-line therapy in pregnant women with an insufficient response to liberal use of emollients. The same holds true for breastfeeding patients with AD. Just as when topical corticosteroids are used in the nipple area, topical tacrolimus should be applied after nursing, and the nipple area should be gently cleaned before nursing.

The rationale behind recommending topical tacrolimus as a first-line treatment is that systemic absorption of the drug is trivial. Plus, observational studies of oral tacrolimus in pregnant women who have received a solid organ transplant have shown no increase in congenital malformations.

The task force recommends against the use of topical pimecrolimus (Elidel) or crisaborole (Eucrisa) in pregnancy or lactation due to lack of clinical experience in these settings, Dr. Vestergaard continued.

The task force position is that chlorhexidine and other topical antiseptics – with the notable exception of triclosan – can be used in pregnancy to prevent recurrent skin infections. Aminoglycosides should be avoided, but topical fusidic acid is a reasonable antibiotic for treatment of small areas of clinically infected atopic dermatitis in pregnancy.

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