Treatment of Atopic Dermatitis in Pregnancy

Atopic Dermatitis in Pregnancy

Atopic dermatitis (AD), also known as atopic eczema, is a chronic inflammatory skin condition. Atopic dermatitis may occur de novo in pregnancy or as a recurrence/exacerbation of pre-existing AD. 

Many women with pre-existing AD experience changes in their symptoms during pregnancy, with some noticing improvement and others experiencing exacerbations. 

Clinical Features of Atopic Dermatitis in Pregnancy

Clinical features of AD in pregnancy are the same as those in non-pregnant individuals – scaly, erythematous papules and plaques, often in a flexural or diffuse distribution in adults. See Atopic dermatitis.

Treatment of Atopic Dermatitis in Pregnancy

Managing atopic dermatitis in pregnancy requires a balance between effective symptom relief and both maternal and foetal safety.

Patients tend to reduce the use of topical and systemic therapies during pregnancy to minimise harm, however, undertreated AD can be harmful to the mother and can increase risk of secondary infection.

Recommended treatments for AD in pregnancy include:

Topicals

Emollients and moisturisers:

• Regular application of fragrance-free moisturiser
• This can also be used as a soap substitute.

Topical corticosteroids:

• Weakest effective steroids should be used
• Apply for the shortest effective duration
• Avoid application of potent steroids to the face/neck/skin folds
• Restrict use to 200g/month.

Topical calcineurin inhibitors:

• May be used if topical corticosteroids are inadequate or areas affected are at increased risk of striae/ skin thinning (eg, face, skin folds, abdomen, breasts and thighs)
• Tacrolimus is preferred over pimecrolimus due to the greater available data.

Coal tar

• This should be avoided in the first trimester, and used with caution and in limited amounts in later pregnancy.

Systemic Agents

Antihistamines:

• Loratadine is considered safe in pregnancy; however, unless there is concomitant urticaria, antihistamines are unlikely to relieve pruritus, as AD-associated itch is not due to histamine release.

Narrowband UVB Phototherapy:

• A safe option for moderate-to-severe AD that is inadequately treated with topical therapy.

Systemic immunosuppressants:

• Ciclosporin:
  • First-line oral systemic agent in pregnancy
  • Consider for patients who have failed topicals and phototherapy
  • Maternal renal function and blood pressure should be closely monitored.

Oral corticosteroids:

• Second-line oral systemic agent in pregnancy, however, not generally recommended for patients with AD due to the wide range of associated adverse effects
• If necessary, prednisone should be used for short courses only, at a maximum of 0.5mg/kg/day.

Contraindicated Treatments

• Azathioprine (unless benefits outweigh risks)
• JAK inhibitors
• Methotrexate
• Mycophenolate

Unknown safety

• Crisaborole ointment
• Roflumilast cream
• Tapinarof cream
• Dupilumab - growing evidence suggests minimal risk, however data is still limited.