Biologics in the Treatment of Skin Diseases During Pregnancy and Lactation

Dermatologists are frequently faced with questions about the safety of commonly prescribed topical and systemic medications during pregnancy and lactation. Safety data, particularly regarding medications that are unique to dermatology, can be difficult to find as no unified database or reference guides for clinicians are currently available. In the absence of definitive data, it is prudent to recommend to avoid if possible treatment with biologics during pregnancy. The tumor necrosis factor (TNF)-alpha antagonists and ustekinumab have been labeled pregnancy category B, which allows for their use in pregnant patients with severe psoriasis or psoriatic arthritis. In contrast, rituximab is classified as pregnancy category C (although anecdotal data indicate that rituximab has been used safely in pregnancy as well). Regarding lactation, it has been shown that biologics are secreted into breast milk, but whether they are absorbed by the infant’s gastrointestinal system is unlikely. Although no adverse outcomes have been demonstrated in all case reports available, it may be prudent to advise against breastfeeding while on anti-TNF, ustekinumab, or rituximab therapy until further evidence is collected.