ACTAS
De mo-Sifiliog áficas
112
(2021)
225---241
CONSENSUS
DOCUMENT
Managemen
o
Pso iasis
Du ing
P econcep ion,
P egnancy,
Pos pa um,
and
B eas eeding:
A
Consensus
S a emen 夽
I.
Belinchón,a,∗,1M.
Velasco,b,1M.
A a-Ma ín,cS.
A mes o
Alonso,d
O.
Baniand és
Rod íguez,eL.
Fe ándiz
Pulido, M.
Ga cía-Bus induy,g
J.A.
Ma ínez-López,hN.
Ma ínez
Sánchez,iA.
Pé ez
Fe iols,jE.
Pé ez
Pascual,k
R.
Ri e a
Díaz,lR.
Ruiz-Villa e de,mR.
Tabe ne
Fe e ,nA.
Vicen e
Villa,o
J.M.
Ca ascosap
aSe icio
de
De ma ología,
Hospi al
Gene al
Uni e si a io
de
Alican e-ISABIAL-UMH,
Alican e,
Spain
bSe icio
de
De ma ología,
Hospi al
Uni e si a io
A nau
de
Vilano a,
Valencia,
Spain
cSe icio
de
De ma ología,
Hospi al
Clínico
Lozano
Blesa,
Za agoza,
Spain
dSe icio
de
De ma ología,
Hospi al
Uni e si a io
Ma qués
de
Valdecilla,
San ande ,
Spain
eSe icio
de
De ma ología,
Hospi al
Uni e si a io
G ego io
Ma a˜
nón,
Mad id,
Spain
Se icio
de
De ma ología,
Hospi al
Uni e si a io
Vi gen
Maca ena,
Se illa,
Spain
gSe icio
de
De ma ología,
Hospi al
Uni e si a io
de
Cana ias,
San a
C uz
de
Tene i e,
Spain
hSe icio
de
Reuma ología,
Hospi al
Uni e si a io
Fundación
Jiménez
Díaz,
Mad id,
Spain
iSe icio
de
Ginecología-Obs e icia,
Hospi al
Uni e si a io
La
Paz,
Mad id,
Spain
jSe icio
de
De ma ología,
Hospi al
Gene al
de
Valencia,
Valencia,
Spain
kSe icio
de
Ginecología-Obs e icia,
Hospi al
Gene al
Uni e si a io
de
Alican e-ISABIAL,
Alican e,
Spain
lSe icio
de
De ma ología,
Hospi al
Uni e si a io
12
de
Oc ub e,
Mad id,
Spain
mSe icio
de
De ma ología,
Hospi al
Uni e si a io
San
Cecilio,
G anada,
Spain
nSe icio
de
De ma ología,
Hospi al
Son
Llà ze ,
Palma
de
Mallo ca,
Spain
oSe icio
de
De ma ología,
Hospi al
San
Joan
de
Déu,
Esplugues
de
Llob ega ,
Ba celona,
Spain
pSe icio
de
De ma ología,
Hospi al
Uni e si a io
Ge mans
T ias
i
Pujol,
Badalona,
Ba celona,
Spain
Recei ed
17
Ap il
2020;
accep ed
2
Oc obe
2020
KEYWORDS
Pso iasis;
Fe ili y;
P egnancy;
Abs ac
Objec i e:
To
de elop
e idence-
and
expe ience-based
ecommenda ions
o
he
managemen
o
pso iasis
du ing
p econcep ion,
p egnancy,
pos pa um,
and
b eas eeding.
Me hods:
The
nominal
g oup
echnique
and
he
Delphi
me hod
we e
used.
Fi een
expe s
(12
de ma ologis s,
2
o
whom
we e
appoin ed
coo dina o s;
1
heuma ologis ;
and
2
夽Please
ci e
his
a icle
as:
Belinchón
I,
Velasco
M,
A a-Ma ín
M,
A mes o
Alonso
S,
Baniand és
Rod íguez
O,
Fe ándiz
Pulido
L
e
al.
Consenso
sob e
las
ac uaciones
a
segui
du an e
la
edad
é il,
el
emba azo,
el
pospa o
y
la
lac ancia
en
pacien es
con
pso iasis.
Ac as
De mosifiliog .
2021;112:225---241.
∗Co esponding
au ho .
E-mail
add ess:
belinchon
[email p o ec ed]
(I.
Belinchón).
1Bo h
au ho s
con ibu ed
equally
o
his
wo k.
1578-2190/©
2020
AEDV.
Published
by
Else ie
Espa˜
na,
S.L.U.
This
is
an
open
access
a icle
unde
he
CC
BY-NC-ND
license
(h p://
c ea i ecommons.o g/licenses/by-nc-nd/4.0/).
I.
Belinchón,
M.
Velasco,
M.
A a-Ma ín
e
al.
Pos pa um;
B eas eeding;
Delphi
p ocess;
Recommenda ions
gynecologis s)
we e
selec ed
o
o m
an
expe
panel.
Following
a
sys ema ic
e iew
o
he
li e a u e
on
e ili y,
p egnancy,
pos pa um,
and
b eas eeding
in
women
wi h
pso iasis,
he
coo dina o s
d ew
up
a
se ies
o
p elimina y
ecommenda ions
o
discussion
by
he
panel
a
a
nominal
g oup
mee ing.
The
expe s
defined
he
scope,
sec ions,
and
in ended
use s
o
he
s a emen
and
p epa ed
a
final
lis
o
ecommenda ions.
Consensus
was
ob ained
using
a
Delphi
p ocess
in
which
an
addi ional
51
de ma ologis s
a ed
hei
le el
o
ag eemen
wi h
each
ecommenda ion
on
a
scale
o
1
( o al
disag eemen )
o
10
( o al
ag eemen ).
Consensus
was
defined
by
a
sco e
o
7
o
highe
assigned
by
a
leas
70%
o
pa icipan s.
Le el
o
e idence
and
s eng h
o
ecommenda ion
we e
epo ed
using
he
Ox o d
Cen e
o
E idence-Based
Medicine
ca ego ies.
The
final
s a emen
was
app o ed
by
he
expe
panel.
Resul s:
The
esul ing
consensus
s a emen
includes
23
ecommenda ions
on
p econcep-
ion
( e ili y
and
con acep ion),
p egnancy
(planning,
pha macological
managemen ,
and
ollow-up),
and
b eas eeding
(managemen
and
ollow-up).
Consensus
was
achie ed
o
all
ecommenda ions
gene a ed
excep
one.
Conclusions:
These
ecommenda ions
o
he
be e
managemen
o
pso iasis
in
women
o
childbea ing
age
could
imp o e
ou comes
and
p ognosis.
©
2020
AEDV.
Published
by
Else ie
Espa˜
na,
S.L.U.
This
is
an
open
access
a icle
unde
he
CC
BY-NC-ND
license
(h p://c ea i ecommons.o g/licenses/by-nc-nd/4.0/).
PALABRAS
CLAVE
Pso iasis;
Fe ilidad;
Emba azo;
Pospa o;
Lac ancia;
Mé odo
Delphi;
Recomendaciones
Consenso
sob e
las
ac uaciones
a
segui
du an e
la
edad
é il,
el
emba azo,
el
pospa o
y
la
lac ancia
en
pacien es
con
pso iasis
Resumen
Obje i o:
Desa olla
ecomendaciones
basadas
en
la
mejo
e idencia
y
expe iencia
sob e
el
manejo
de
pacien es
con
pso iasis
du an e
la
edad
é il,
el
emba azo,
el
pospa o
y
la
lac ancia.
Mé odos:
Se
siguió
la
me odología
de
g upos
nominales
y
Delphi.
Se
seleccionó
un
g upo
di ec-
o
de
expe os
(12
de ma ólogos
---- d e
los
cuales
2
ue on
los
coo dinado es---- ,
1
euma ólogo,
2
ginecólogos).
Se
ealizó
una
e isión
sis emá ica
de
la
li e a u a
sob e
e ilidad,
emba azo,
pospa o
y
lac ancia
en
pacien es
con
pso iasis.
Con
es a
in o mación
los
coo dinado es
gene -
a on
una
se ie
de
ecomendaciones
p elimina es.
Todo
ello
se
p esen ó
y
discu ió
con
el
es o
de
expe os
en
una
eunión
de
g upo
nominal
donde
se
definió
el
alcance,
los
usua ios,
los
apa ados
del
documen o,
y
donde
se
gene a on
las
ecomendaciones
defini i as.
El
g ado
de
acue do
con
las
ecomendaciones
se
o ó
siguiendo
la
me odología
Delphi,
que
se
ex endió
a
51
de ma ólogos
más,
según
una
escala
de
1
( o al
desacue do)
a
10
( o al
acue do),
definién-
dose
el
acue do
como
una
pun uación
≥
7
po
al
menos
el
70%
de
los
pa icipan es.
El
ni el
de
e idencia
y
el
g ado
de
ecomendación
se
clasifica on
según
el
modelo
del
Cen e
o
E idence
Based
Medicine
de
Ox o d.
El
documen o
comple o
final
ue
ap obado
po
el
panel
de
expe os.
Resul ados:
Se
gene a on
23
ecomendaciones
sob e
el
pe iodo
p e-concepcional
( e ilidad
y
an iconcepción),
el
emba azo
(planificación,
manejo
a macológico
y
seguimien o)
y
la
lac-
ancia
(manejo
y
seguimien o).
Todas
las
ecomendaciones
menos
una
alcanza on
el
ni el
de
acue do
definido.
Conclusiones:
En
los
pacien es
con
pso iasis
en
edad
é il
es as
ecomendaciones
pueden
mejo a
el
manejo,
los
esul ados
y
el
p onós ico.
©
2020
AEDV.
Publicado
po
Else ie
Espa˜
na,
S.L.U.
Es e
es
un
a ´
ıculo
Open
Access
bajo
la
licencia
CC
BY-NC-ND
(h p://c ea i ecommons.o g/licenses/by-nc-nd/4.0/).
In oduc ion
Pso iasis
is
a
e y
common
disease1,2 wi h
2
peaks
in
incidence----one
be ween
age
15
and
30
yea s
and
he
o he
be ween
50
and
60
yea s----al hough
he
disease
fi s
man-
i es s
be o e
age
40
yea s
in
mo e
han
75%
o
cases.3,4
In
clinical
p ac ice,
a
la ge
pe cen age
o
pa ien s
a e
o
ep oduc i e
age,
and
pso iasis
and/o
i s
ea men s
can
a ec
e ili y,
p egnancy,
pos pa um,
and
b eas eed-
ing
and
ice
e sa.5 --- 8 Owing
o
i s
se e i y,
o
o
pain
o
emba assmen
in
he
case
o
geni al
in ol emen ,
pso ia-
sis
may
be
associa ed
wi h
e ili y
p oblems,
bo h
in
men
and
in
women.9---11 Some
ea men s
o
pso iasis,
includ-
ing
aza o ene
and
aci e in,12,13 a e
po en ially
e a ogenic
and
a e
he e o e
con aindica ed
du ing
p egnancy.
I
has
also
been
epo ed
ha
he
disease
wo sens
in
40%
o
80%
o
pa ien s
a
ew
weeks
a e
deli e y14 and
ha
he
child en
o
mo he s
who
ha e
been
in
ea men
wi h
monoclonal
an i-
bodies
ha
c oss
he
placen a
du ing
he
hi d
imes e
a e
a
g ea e
isk
o
in ec ion
and,
he e o e,
equi e
specific
moni o ing
and
managemen .15
Awa eness
o
hese
p oblems
and
a
sui able
app oach
o
p e en ing
hem
o
ea ing
hem
ea ly
and
e ficien ly
should
o m
pa
o
he
knowledge
and
skills
o
heal h
226
ACTAS
De mo-Sifiliog áficas
112
(2021)
225---241
p o essionals
in ol ed
in
he
managemen
o
a ec ed
pa ien s.16 In
addi ion,
hese
p oblems
a e
e y
ele an
o
pso iasis
pa ien s
hemsel es.16
The
objec i e
o
his
consensus
s a emen
is
o
gen-
e a e
a
se ies
o
ecommenda ions
aimed
a
imp o ing
managemen
o
pa ien s
o
ep oduc i e
age
wi h
pso ia-
sis.
The
s a emen
co e s
e ili y,
p egnancy,
pos pa um,
and
b eas eeding.
We
belie e
ha
he
ecommenda ions
a e
o
conside able
in e es
o
heal h
p o essionals
in ol ed
in
ea ing
pa ien s
wi h
pso iasis,
namely,
de ma ologis s,
gynecologis s,
p ima y
ca e
physicians,
and
nu ses.
Me hods
S udy
Design
This
documen
was
p omo ed
by
he
Pso iasis
Wo king
G oup
o
he
Spanish
Academy
o
De ma ology
and
Vene eol-
ogy
(Academia
Espa˜
nola
de
De ma ología
y
Vene eología
[AEDV]).
The
consensus
s a emen
was
d a ed
ollowing
he
nominal
g oup
echnique
and
he
Delphi
me hod,
wi h
he
help
o
a
sys ema ic
e iew
o
he
li e a u e.17 The
p ojec
was
managed
in
ull
ag eemen
wi h
he
p inciples
se
ou
in
he
Decla a ion
o
Helsinki
and
in
line
wi h
cu en
no ms
o
Good
Clinical
P ac ice.
Selec ion
o
Pa icipan s
The
pa icipan s
selec ed
o med
a
mul idisciplina y
g oup
comp ising
12
de ma ologis s
(2
o
whom
we e
he
coo dina-
o s),
1
heuma ologis ,
and
2
gynecologis s
wi h
expe ience
and
in e es
in
he
subjec
a ea.
Wi h
help
om
me hodolo-
gis s,
he
coo dina o s
defined
he
objec i es,
scope,
use s,
and
sec ions
o
he
documen .
I
was
decided
o
add ess
3
b oad
a eas:
(a)
ep oduc i e
age;
(b)
p egnancy
and
pos -
pa um;
and
(c)
b eas eeding
and
pe ina al
ca e.
Sys ema ic
Re iew
o
he
Li e a u e
and
P elimina y
Recommenda ions
A
sys ema ic
e iew
o
he
li e a u e
was
pe o med
o
assess
e ili y,
deli e y,
and
b eas eeding
in
pa ien s
wi h
pso iasis.
An
expe
documen alis
designed
he
sea ch
s a egies
o
he
PubMed,
EMBASE,
and
Coch ane
lib a y
da abases
( om
baseline
o
No embe
2018)
using
Medi-
cal
Subjec
Headings
and
ee
ex
e ms.
In
o de
o
be
included,
s udies
had
o
ulfil
he
ollowing
c i e ia:
(1)
hey
had
o
include
pa ien s
wi h
pso iasis;
(2)
hey
had
o
p o ide
da a
on
p egnancy,
b eas eeding,
and
pos pa -
um
(e.g.,
p e alence,
in e en ions,
p ognoses);
and
(3)
hey
had
o
be
a
me a-analysis,
sys ema ic
e iew
o
he
li e a u e,
andomized
clinical
ial,
o
obse a ional
s udy.
Two
e iewe s
independen ly
selec ed
a icles
and
collec ed
da a.
Finally,
a
seconda y
sea ch
o
a icles
was
ca ied
ou .
The
quali y
o
he
s udies
was
e alua ed
using
he
2011
classifica ion
o
he
Ox o d
Cen e
o
E idence-Based
Medicine.18 This
in o ma ion
enabled
he
coo dina o s
o
gene a e
a
se ies
o
p elimina y
ecommenda ions.
Mee ing
o
he
Nominal
G oup
The
objec i es,
scope,
use s,
and
sec ions
o
he
docu-
men
we e
confi med
a
he
mee ing
o
he
nominal
g oup.
The
esul s
o
he
sys ema ic
li e a u e
e iew
we e
hen
p esen ed
and
discussed,
as
we e
he
p o isional
ecom-
menda ions.
Finally,
he
defini i e
ecommenda ions
we e
es ablished.
Delphi
P ocess
The
defini i e
ecommenda ions
we e
assessed
using
he
Delphi
p ocess
o
es ablish
he
le el
o
ag eemen
(LA)
wi h
hem.
This
s age
was
ca ied
ou
online.
The
ec-
ommenda ions
we e
sen
o
he
expe
panel
and
o
120
de ma ologis s.
The
o e
was
based
on
a
Like - ype
scale
anging
om
1
(comple ely
disag ee)
o
10
(comple ely
ag ee).
Ag eemen
was
defined
as
a
sco e
o
≥
7
om
a
leas
70%
o
he
pa icipan s.
The
ecommenda ions
wi h
an
LA
<
70%
we e
e alua ed
and,
i
applicable,
e-edi ed
and
o ed
on
in
a
second
Delphi
ound.
I
was
possible
o
include
new
ecommenda ions
in
he
fi s
Delphi
ound.
Edi ion
o
he
Final
Documen
The
defini i e
documen
was
d a ed
based
on
he
sys em-
a ic
e iew
o
he
li e a u e,
he
decisions
o
he
nominal
g oup,
and
he
Delphi
p ocess.
In
addi ion
o
he
LA,
each
o
he
ecommenda ions
was
assigned
a
le el
o
e idence
(LE)
and
a
g ade
o
ecommenda ion
(GR)
acco ding
o
he
ec-
ommenda ions
o
e idence-based
medicine
o
he
Ox o d
Cen e
o
E idence-Based
Medicine.18 The
final
e sion
o
he
documen
was
sen
o
he
expe s
o
a
concluding
e al-
ua ion
and
commen s.
Resul s
Sys ema ic
Re iew
o
he
Li e a u e
and
Delphi
P ocess
A e
elimina ion
o
duplica es,
610
e e ences
we e
eco -
e ed.
O
hese,
49
we e
e en ually
included
(Fig.
1
and
o he
esul s
in
Appendix
A,
Supplemen a y
ma e ial).
A
o al
o
23
ecommenda ions
we e
gene a ed.
The
Del-
phi
esponse
a e
was
50%.
In
he
fi s
Delphi
ound,
he
LA
was
su ficien
o
all
ecommenda ions
bu
one.
The
ecom-
menda ion
o
which
a
su ficien
LA
was
no
eached
was
excluded.
The
esul s
a e
shown
in
Table
1.
P econcep ion
P econcep ion
Counseling
Recommenda ion
1.
P econcep ion
counseling
should
be
o e ed
o
all
pso iasis
pa ien s
o
ep oduc i e
age
(bo h
men
and
women)
(LE
2b;
GR
B;
LA
82%).
P econcep ion
counseling
should
always
be
o e ed
so
ha
pa ien s
wi h
pso iasis
can
make
in o med
decisions
oge he
wi h
he
de ma ologis
and
also
o
a oid,
as
a
as
possible,
unnecessa y
delays
in
concep ion.
227
I.
Belinchón,
M.
Velasco,
M.
A a-Ma ín
e
al.
Table
1
Defini i e
Recommenda ions
and
Resul s
o
he
Delphi
P ocess.
#
Recommenda ion
Mean
SD
Median
P25
P75
Min
Max
%≥7
1
P econcep ion
counseling
should
be
o e ed
o
all
pso iasis
pa ien s
o
ep oduc i e
age
(bo h
men
and
women)
8.23
2.82
9
7.5
10
1
10
82%
2
The
panel
ecommends
egula
assessmen
o
he
desi e
o
become
p egnan
8.66
2.82
9
8
10
1
10
87%
3
The
panel
ad ises
e alua ing
and
ecommending,
i
applicable,
an
e ec i e
con acep i e
me hod
o
as
long
as
a
p egnancy
is
no
desi able
7.89
2.12
9
7
10
1
10
73%
4
The
panel
ecommends
e e ing
he
pa ien
o
a
gynecologis
o
ep oduc i e
heal h
counseling
6.23
1.41
6
5
8.5
1
10
46%
5
Planning
o
p egnancy
should
include
an
assessmen
o
he
gynecologic
and
de ma ologic
his o y,
a
labo a o y
analysis,
assessmen
o
cu en
pso iasis
and
i s
ea men ,
assessmen
o
como bidi ies,
and
possible
con aindica ions
o
p egnancy
8.64
4.24
9
8
10
1
10
93%
6
The
panel
ecommends
ha
pa ien s
be
in o med
on
an
indi idual
basis
abou
ma e nal- e al
isk
ac o s
in
p egnancy
and
abou
all
aspec s
o
ollow-up
o
p egnancy,
including
pos pa um
7.98
1.41
9
7.25
10
1
10
81%
7
The
panel
ecommends
ha
pso iasis
be
as
well
con olled
as
possible
be o e
he
pa ien
ies
o
become
p egnan
7.62
2.83
9
7
9
1
10
78%
8
The
panel
ecommends
es ablishing
he
mos
e ec i e
and
sa es
d ug
p ofile
possible
du ing
p egnancy.
This
should
be
ailo ed
o
he
indi idual
pa ien
9.41
2.12
10
9
10
1
10
98%
9
Po en ially
e a ogenic
opical
agen s
(an h alin,
aza o ene,
opical
pso alen---UV-A)
should
be
discon inued
once
p egnancy
is
confi med.
Topical
d ugs
wi h
a
mo e
a o able
sa e y
p ofile
should
be
conside ed
9.6
1.41
10
9.75
10
5
10
98%
10
Po en ially
e a ogenic
sys emic
agen s
(aci e in,
sys emic
e inoids,
sys emic
pso alen---UV-A,
ap emilas ,
dime hyl
uma a e,
me ho exa e)
should
be
discon inued
be o e
concep ion.
D ugs
wi h
a
be e
sa e y
p ofile
should
be
conside ed
9.56
2.12
10
10
10
5
10
97%
11
In
he
case
o
women
ecei ing
biologic
he apy,
he
panel
ecommends
ha
his
be
main ained
du ing
he
fi s
and
second
imes e s.
Toge he
wi h
he
pa ien ,
he
clinician
should
e alua e
he
isks
and
benefi s
o
con inuing
hese
d ugs
du ing
he
hi d
imes e .
Pa ien s
aking
ce olizumab
pegol
can
con inue
he
d ug
h oughou
p egnancy
only
i
i
is
conside ed
clinically
necessa y
8.48
4.24
9
8
10
1
10
88%
12
Pa ien s
wi h
pso iasis
who
equi e
s anda d
sys emic
ea men
and/o
biologics
o
con ol
hei
disease
mus
be
ollowed
up
closely
by
an
obs e ician
once
he
p egnancy
is
confi med
8.88
0.13
10
8
10
2
10
92%
13
The
panel
ecommends
s ic
ollow-up
and
moni o ing
o
p egnan
women
wi h
pso iasis
8.10
1.41
9
7
10
1
10
83%
14
In
he
case
o
a
fla e-up,
he
panel
ecommends
ea ing
each
case
on
an
indi idual
basis,
aking
in o
accoun
ype
and
se e i y,
week
o
ges a ion,
and
a ailable
he apeu ic
op ions
9.75
0.10
10
10
10
8
10
100%
15
The
panel
ecommends
encou aging
coope a ion
be ween
special ies
(e.g.,
de ma ology,
obs e ics,
pedia ics)
9.50
0.12
10
9
10
5
10
98%
228
ACTAS
De mo-Sifiliog áficas
112
(2021)
225---241
Table
1
(Con inued)
#
Recommenda ion
Mean
SD
Median
P25
P75
Min
Max
%≥7
16
Emollien s
can
be
p esc ibed
du ing
b eas eeding
9.74
0
10
10
10
7
10
100%
17
Wi h
espec
o
opical
ea men s
o
pso iasis
du ing
b eas eeding,
aza o ene
is
con aindica ed.
O he
opical
agen s
can
be
used
p o iding
ha
he
benefi s
ou weigh
he
isks,
a
minimum
doses,
and
o
as
sho
a
pe iod
as
possible.
The
a ea
o
he
nipple
and
a eola
should
be
a oided
9.16
0.71
10
9
10
3
10
97%
18
Topical
PUVA
is
no
ecommended
du ing
b eas eeding.
Na owband
UV-B
pho o he apy
can
be
used
9.18
0.70
10
9
10
2
10
95%
19
Sys emic
co icos e oids
can
be
used
du ing
b eas eeding
as
long
as
he
benefi s
ou weigh
he
isks
They
should
be
adminis e ed
a
minimum
doses
and
o
as
sho
a
ime
as
possible
8.33
0.34
9
7.75
10
2
10
80%
20
O al
e inoids,
ap emilas ,
dime hyl
uma a e,
me ho exa e,
and
ciclospo in
A
a e
no
ecommended
du ing
b eas eeding
9.16
3.54
10
9
10
1
10
95%
21
Ce olizumab
pegol
has
been
app o ed
o
use
du ing
b eas eeding.
Fo
all
o he
biologics,
he
panel
ecommends
assessing
he
isks
and
benefi s
in
each
case
9.38
0.71
10
9
10
5
10
93%
22
Once
he
p egnancy
has
come
o
e m,
s anda d
ollow-up
should
be
esumed
in
he
de ma ology
clinic
as
soon
as
possible
8.91
1.41
10
9
10
2
10
88%
23
The
newbo n
does
no
equi e
special
ca e,
excep
i
he
mo he
has
been
exposed
o
biologics
ha
c oss
he
placen a
and
ha e
been
main ained
beyond
he
second
imes e
8.83
0.71
10
9
10
1
10
87%
Table
2
A eas
o
Be
Co e ed
in
P econcep ion
Counseling.
#
A ea
1
Gene ic
counseling
(he i abili y
o
pso iasis)
2
Impac
o
pso iasis
and
i s
ea men
on
e ili y
3
Use
o
con acep i es
(when
and
ypes)
4
Impac
o
pso iasis
and
i s
ea men
(as
well
as
he
isk
o
no
ea ing)
du ing
p egnancy
( o
mo he
and
e us)
and
pos pa um
5
Impac
o
p egnancy
and
pos pa um
on
pso iasis
6
Planning
o
p egnancy
(e.g.,
jus ifica ion,
al e na i es,
and
modifica ions
o
ea men
be o e
concep ion
and
du ing
p egnancy,
isi
schedule,
es s,
accina ions)
7
Measu es
o
pue pe ium
and
b eas eeding
8
Managemen
o
he
unexpec ed
p egnancy
Pso iasis
is
no
a
con aindica ion
o
ges a ion,
al hough
p egnancy
can
a ec
pso iasis;
in
u n,
pso iasis
(and
i s
ea men )
may
be
a
isk
ac o
o
he
cou se
o
he
p egnancy.4,14,19---25
P econcep ion
counseling
(Table
2)
anges
om
in o ma-
ion
on
he
impac
o
he
disease
on
e ili y
and
p egnancy
o
he
app oach
o
an
unexpec ed
p egnancy
and
gene ic
counseling.26,27 This
in
u n
should
be
adjus ed
o
he
pa ien ’s
cha ac e is ics
and
in ol e
he
pa ne
whe e
possible.
P econcep ion
counseling
should
be
epea ed
pe i-
odically.
While
pso iasis
is
no
a
equen ly
epo ed
p oblem,
i s
se e i y
o
he
consequences
o
geni al
in ol emen
(pain
o
emba assmen )
mean
ha
i
may
be
associa ed
wi h
e -
ili y
p oblems.9,22,25,28---36 Some
o
he
d ugs
used
o
ea
pso iasis
may
also
a ec
e ili y,
al hough
his
has
no
been
demons a ed.10,37---40
Recommenda ion
2.
The
panel
ecommends
egula
assessmen
o
he
desi e
o
become
p egnan
(LE
5;
GR
D;
LA
87%).
This
ecommenda ion
applies
o
all
pa ien s
o
ep oduc-
i e
age
(bo h
sexes),
especially
hose
who
a e
ecei ing
o
who
a e
candida es
o
long- e m
sys emic
ea men .
Recommenda ion
3.
The
panel
ecommends
e alua ing
and
ecommending,
i
applicable,
an
e ec i e
con acep-
i e
me hod
panel
o
as
long
as
p egnancy
is
no
desi able
(LE
2b;
GR
B;
LA
73%).
We
should
ecommend
he
use
o
e ec i e
con acep i e
me hods
o
bo h
men
and
women,
o
as
long
as
a
p eg-
nancy
is
no
en isaged
o
when
i
is
p e e able
o
pos pone
i
(e.g.,
owing
o
he
se e i y
o
he
disease,
ini ia ion
o
a
e a ogenic
ea men ).
Combined
ho monal
con acep ion
is
he
mos
e ficacious
me hod,41 excep
in
he
case
o
a
con aindica ion.42 How-
229

I.
Belinchón,
M.
Velasco,
M.
A a-Ma ín
e
al.
Table
3
Planning
he
P egnancy.
#
Ac ion
1
Comple e
gynecologic
and
obs e ic
his o y
Numbe
o
p e ious
p egnancies
( o
e m
o
no ),
ou e
o
deli e y,
numbe
o
induced
and
spon aneous
abo ions
His o y
o
p eeclampsia,
HELLP
synd ome,
a e ial
hype ension,
o
h ombosis
in
p e ious
p egnancies
His o y
o
delayed
g ow h
o
low
bi h
weigh
P e ious
e ili y
p oblems
2
Iden ifica ion
and
e alua ion
o
como bidi ies
Me abolic
synd ome
(obesi y,
a e ial
hype ension,
diabe es
melli us,
hype choles e olemia)
Smoking
and
d inking
Dep ession
O he ,
depending
on
he
pa ien
3
Cha ac e is ics
and
se e i y
o
pso iasis
(cu en
and
pas )
Du a ion
o
pso iasis
Type
Loca ion
Se e i y
4
Absolu e
and
ela i e
con aindica ions
o
p egnancy
5
Es ima ion
o
he
isk
o
ma e nal- e al
complica ions
du ing
p egnancy
Indi idualized
Age,
ac i i y,
and
damage
caused
by
he
disease
i sel
and
d ugs
Complica ions
du ing
p e ious
p egnancies
6
T ea men s
D ugs
used
in
he
3-36
mon hs
be o e
deciding
o
become
p egnan
Time
since
he
las
dose
o
d ugs
ha
a e
con aindica ed
in
p egnancy
7
Complemen a y
es s
S anda d
labo a o y
wo k-up
(comple e
blood
coun ,
u ine,
biochemis y)
O he ,
depending
on
he
pa ien
8
Re-e alua ion
o
ea men
op ions
In
he
case
o
clinical
emission,
main enance
o
non e a ogenic
d ugs
9
In o ma ion
Complica ions
du ing
p egnancy,
pue pe ium,
and
b eas eeding
Disease
cou se
Plan
o
ac ion
in
he
case
o
complica ions
o
he
unde lying
disease
and/o
p egnancy
Schedule
o
check-ups
Abb e ia ions:
HELLP,
hemolysis,
ele a ed
li e
enzymes,
low
pla ele
coun .
e e ,
he
panel
ecommends
ailo ing
he
me hod
o
he
indi idual
case
and
e e ing
he
pa ien
o
a
gynecologis
o
p ima y
ca e
i
necessa y.
While
assis ed
ep oduc ion
is
conside ed
a
gynecologic
a ea,
de ma ologis s
who
ca e
o
pa ien s
unde going
his
p ocess
should
be
awa e
o
he
gene al
aspec s
o
he
p oce-
du es
in
o de
o
be
able
o
p o ide
app op ia e
in o ma ion.
The
LA
o
he
ecommenda ion
o mula ed
wi h
espec
o
his
a ea
(Recommenda ion
4,
Table
1)
was
insu ficien
(see
Discussion).
Planning
o
P egnancy
Recommenda ion
4.
The
panel
ecommends
e e ing
he
pa ien
o
a
gynecologis
o
ep oduc i e
counseling
(LE
5;
GR
D;
LA
46%).
Recommenda ion
5.
Planning
o
p egnancy
should
include
an
assessmen
o
he
gynecologic
and
de ma ologic
his o y,
a
labo a o y
analysis,
assessmen
o
cu en
pso i-
asis
and
i s
ea men ,
assessmen
o
como bidi ies,
and
possible
con aindica ions
o
p egnancy
(LE
5;
GR
D;
LA
93%).
Recommenda ion
6.
The
panel
ecommends
ha
pa ien s
be
in o med
on
an
indi idual
basis
abou
ma e nal- e al
isk
ac o s
in
p egnancy
and
abou
all
aspec s
o
ollow-up
o
he
p egnancy,
including
pos pa um
(LE
5;
GR
D;
LA
81%).
Recommenda ion
7.
The
panel
ecommends
ha
pso ia-
sis
is
con olled
as
well
as
possible
be o e
he
pa ien
ies
o
become
p egnan
(LE
2b;
GR
B;
LA
78%).
P egnancy
can
a ec
pso iasis,
and
his
(and
i s
ea -
men )
may
be
a
isk
ac o
o
he
cou se
o
he
p egnancy.4,14,19---25 Con ol
o
pso iasis
and
p econcep ion
use
o
d ugs
wi h
a
low
isk
o
he
e us
make
i
possible
o
educe
he
isk
o
ma e nal- e al
complica ions.
The e o e,
i
is
essen ial
o
plan
he
p egnancy
and
ensu e
collabo a ion
wi h
a
gynecologis
and
p ima y
ca e
physician.
Planning
(Tables
3
and
4)
should
in ol e
a
pe son-
alized
p econcep ion
assessmen
co e ing
he
pa ien ’s
comple e
gynecologic
and
obs e ic
his o y,
con aindica-
ions
o
p egnancy,
and
isk
ac o s
o
ma e nal- e al
complica ions,22,25 including
he
d ugs
used
be o e
and
du -
ing
p egnancy
(Table
5).
230
ACTAS
De mo-Sifiliog áficas
112
(2021)
225---241
Table
4
Risk
Fac o s
o
Ma e nal-Fe al
Complica ions
in
Pa ien s
Wi h
Pso iasis.
P e ious
Bad
Obs e ic
His o y
Se e e
p eeclampsia
HELLP
synd ome
P e ious
ecu en
misca iage
.
.
.
Dependen
on
he
Pa ien
o
on
Pso iasis
Age
>
40
y
Family
his o y
o
p eeclampsia
Pe sonal
his o y
o
p eeclampsia,
mul iple
p egnancies,
nullipa i y,
o
diabe es
Obesi y
o
a e ial
hype ension
a
he
beginning
o
p egnancy
Mode a e
o
se e e
pso iasis
Como bidi y
Exposu e
o
Te a ogenic
D ugs
Be ween
6
and
36
mo
be o e
concep ion
Abb e ia ion:
HELLP,
hemolysis,
ele a ed
li e
enzymes,
low
pla ele
coun .
Pso iasis
imp o es
in
33%-60%
o
women
du ing
p egnancy,4,14,19 emains
unchanged
in
25%,
and
wo s-
ens
in
25%.14 Howe e ,
40%-88%
expe ience
a
fla e-up
a e
deli e y.4,6,14,19,24,43---45
Da a
on
he
e ec
o
pso iasis
in
p egnancy,
childbi h,
and
he
newbo n
a e
somewha
con o e sial.5,25,34,46---48
Some
s udies
associa e
poo
esul s
specifically
wi h
pa ien s
who
ha e
mode a e
o
se e e
pso iasis.7,48 A
p esen ,
he e
a e
no
da a
sugges ing
an
associa ion
be ween
pso iasis
and
he
de elopmen
o
congeni al
mal o ma ions,7,49 and
while
findings
a e
he e ogeneous,
he e
does
seem
o
be
an
asso-
cia ion
be ween
pso iasis
and
he
de elopmen
o
diabe es
and
ges a ional
a e ial
hype ension.7,48
Finally,
i
is
also
essen ial
o
ensu e
ha
pso iasis
is
inac-
i e
o
3-4
mon hs,
using
non e a ogenic
d ugs.
I
his
is
no
possible,
hen
he
lowes
deg ee
o
ac i i y
possible
should
be
sough
on
an
indi idual
basis.
P egnancy
and
Follow-up
P egnancy
Recommenda ion
8.
The
panel
ecommends
es ablishing
he
mos
e ec i e
and
sa es
pha macological
p ofile
possible
du ing
p egnancy.
This
should
be
ailo ed
o
he
indi idual
pa ien
(LE
5;
GR
D;
LA
98%).
Knowledge
o
sa e y
o
medica ions
is
one
o
he
pilla s
o
e ec i e
and
sa e
medical
and
obs e ic
ca e
(Table
5).
Howe e ,
we
lack
su ficien
e idence
o
p o ide
obus ,
explici
ecommenda ions
o
all
d ugs.9,50,51 The e o e,
du -
ing
p egnancy,
d ugs
should
be
p esc ibed
wi h
cau ion,
a e
pe o ming
a
me iculous
e alua ion
o
he
isks
and
benefi s
o
each
pa ien
and
aking
in o med
decisions,
which
should
be
ag eed
wi h
he
pa ien .40
Topical
D ugs
Recommenda ion
9.
Po en ially
e a ogenic
opical
agen s
(an h alin,
aza o ene,
opical
pso alen---UV-A
[PUVA])
should
be
discon inued
once
p egnancy
is
confi med.
Top-
ical
d ugs
wi h
a
mo e
a o able
sa e y
p ofile
should
be
conside ed
(LE
3a;
GR
C;
LA
98%).
The
panel
also
conside s
i
impo an
o
assess
he
isk-
benefi
a io
on
an
indi idual
basis.
In
he
case
o
opical
d ugs
wi h
a
mo e
a o able
sa e y
p ofile,
hese
should
be
p esc ibed
a
he
lowes
dose
possible
o e
as
small
an
a ea
as
possible
o
as
sho
a
ime
as
possible.
Occlusi e
d essings
should
be
a oided
(Table
5).
The
only
associa ion
epo ed
o
opical
co icos e oids
is
be ween
low
bi h
weigh
and
he
use
o
high-
and
e y-
high-po ency
co icos e oids,
especially
when
he
du a ion
o
exposu e
and
cumula i e
dose
a e
conside able.15,52 Topi-
cal
calcineu in
inhibi o s15 and
calcipo iol
ha e
been
shown
o
be
sa e.
Howe e ,
ma e nal
i amin
D
deficiency
can
be
associa ed
wi h
a
e a ogenic
isk.
As
o
coal
a ,
he e
a e
no
da a
o
sugges
e a ogenici y
o
poo
p egnancy
ou come
in
humans,
al hough
cases
o
mal o ma ion
ha e
been
epo ed
in
animals.15,53,54 A
mode a e
amoun
o
op-
ical
salicylic
acid
(9%-25%)
can
be
abso bed
sys emically,
and
i
has
been
epo ed
ha
use
o
his
agen
du ing
he
fi s
imes e
could
be
associa ed
wi h
an
inc eased
isk
o
gas oschisis.15,55 I
is
impo an
o
no e
ha
pho o he apy
wi h
na owband
UV-B
adia ion
is
sa e
du ing
p egnancy.56
While
e a ogenici y
and
poo
p egnancy
ou come
ha e
no
been
epo ed
wi h
an h alin,
his
agen
should
be
suspended
4
weeks
be o e
concep ion.15 As
o
op-
ical
aza o ene,
i
is
es ima ed
ha
6%
is
abso bed
sys emically57,58;
in
addi ion,
sys emic
abso p ion
may
inc ease
owing
o
indi idual
ac o s,
such
as
damage
o
he
skin
ba ie .
Al hough
he e
a e
no
da a
poin ing
o
emb yopa hy,
his
d ug
is
con aindica ed
du ing
p egnancy.
Simila ly,
opical
PUVA
d ugs
a e
no
ecommended
du ing
p egnancy.15
Sys emic
D ugs
Recommenda ion
10.
Po en ially
e a ogenic
sys emic
agen s
(aci e in,
sys emic
e inoids,
sys emic
PUVA,
ap emilas ,
dime hyl
uma a e,
me ho exa e)
should
be
discon inued
be o e
concep ion.
P esc ip ion
o
opical
and/o
sys emic
and/o
pho o he apy
wi h
a
be e
sa e y
p ofile
should
be
conside ed
(LE
3a;
GR
C;
LA
97%).
No
cases
o
congeni al
mal o ma ions
o
o he
ele an
p oblems
ha e
been
epo ed
o
sys emic
co icos e oids.59---61
Aci e in
is
a
po en
e a ogen
in
humans.62,63 I
can
be
de ec ed
in
blood
2
mon hs
a e
he
las
dose,
al hough
in
some
ci cums ances,
such
as
he
p esence
o
alcohol,
i
can
be
con e ed
o
e e ina e
and
be
de ec ed
o
120
days.
The e o e,
i
is
usually
ecommended
o
suspend
his
d ug
o
up
o
2
yea s
be o e
concep ion.
Cases
should
be
man-
aged
on
an
indi idual
basis.15,64,65 O he
o al
e inoids,
such
as
ali e inoin
and
iso e inoin
a e
also
con aindica ed
du -
ing
p egnancy.39,40
Po en ial
associa ions
be ween
sys emic
PUVA
agen s
and
e a ogenic
complica ions
emain
unclea 15,66,67;
he e o e,
hese
agen s
a e
con aindica ed
du ing
p egnancy.
Na ow-
band
UV-B
pho o he apy,
on
he
o he
hand,
has
p o en
o
be
sa e
du ing
p egnancy.56
No
da a
a e
cu en ly
a ailable
on
he
e a ogenic
po en-
ial
o
ap emilas
in
humans,
al hough
abo ion
and
low
bi h
weigh
ha e
been
epo ed
in
animals;
consequen ly,
i s
use
231
I.
Belinchón,
M.
Velasco,
M.
A a-Ma ín
e
al.
Table
5
Sa e y
o
Commonly
Used
De ma ologic
D ugs
Wi h
Respec
o
Fe ili y
and
P egnancy.
D ug
MR
FR
FDA
AEMPS
and
O he
Da a
Re
[0,1-6]Topical
Co icos e oids
U
U
B-C
-No
da a
on
e ec
on
he
e us
o
on
o he
p egnancy
ou comes
in
humans
-I
co icos e oids
a e
necessa y,
opical
agen s
should
no
be
used
ex ensi ely
du ing
p egnancy,
ha
is,
in
la ge
amoun s,
o
o e
long
pe iods,
o
o e
wide
a eas.
Occlusi e
d essings
should
be
a oided
98---100,116
Calcineu in
inhibi o s
-Pimec olimus
-Tac olimus
U
U
C
-No
da a
on
he
e ec
on
he
e us
o
on
o he
p egnancy
ou comes
-Do
no
use
du ing
p egnancy,
excep
when
he
po en ial
benefi
ou weighs
he
po en ial
isk
o
he
e us
117---120
Calcipo iol
U
U
C
-Animal
s udies
ha e
e ealed
cases
o
cle
pala e
and
lack
o
lung
ma u a ion
-
No
da a
on
he
e ec
on
he
e us
o
on
o he
ou comes
o
p egnancy
in
humans
-
Do
no
use
du ing
p egnancy,
excep
when
he
po en ial
benefi
ou weighs
he
po en ial
isk
o
he
e us
104
An h alin
U
U
C
-No
animal
o
human
da a
-Expe s
ecommend
suspending
ea men
o
4
wk
be o e
concep ion
and
a oiding
i
du ing
p egnancy
-AEMPS:
no
men ioned
Coal
a
U
U
C
-
Animal
s udies
ha e
e ealed
cases
o
cle
pala e
and
lack
o
lung
ma u a ion
-Du ing
p egnancy,
he
p oduc
should
be
used
in e mi en ly,
a
low
concen a ions
and
o e
a
educed
body
su ace
a ea.
Coal
a
should
be
a oided
du ing
he
fi s
imes e
53,54,101
Salicylic
acid
U
U
C
-Expe s
ecommend
a oiding
his
agen
a
high
doses
(>
3%)
and
in
la ge
amoun s
(e.g.,
>
20
g/d).
Occlusi e
d essings
should
also
be
a oided
-AEMPS:
no
men ioned
Re inoids
( aza o ene)
U
U
X
-No
da a
o
humans
-Con aindica ed
du ing
p egnancy
-AEMPS:
no
men ioned
13
Topical
PUVA
U
U
C
-
No
da a
o
humans
-Expe s
ecommend
a oiding
he
d ug
du ing
p egnancy
-AEMPS:
no
men ioned
67
NBUVB
U
U
---
-Few
da a
in
humans
(occasional
case
epo s)
-Expe s
conside
ha
i
can
be
used
du ing
p egnancy
-AEMPS:
no
men ioned
56
[0,1-6]Sys emic
Co icos e oids
B-C
-AEMPS:
No
need
o
in e up
i
adminis e ed
a
s anda d
doses
59,60
Aci e in
U
U
X
-Te a ogenic
in
humans
-AEMPS:
Con aindica ed
du ing
p egnancy
12
O he
e inoids
U
U
X
-Te a ogenic
in
humans
-AEMPS:
Con aindica ed
du ing
p egnancy
39,40
PUVA
U
U
C
-Possible
e a ogenic
e ec
-Expe s
ecommend
a oiding
he
d ug
du ing
p egnancy
-AEMPS:
no
men ioned
15,66,67
232
ACTAS
De mo-Sifiliog áficas
112
(2021)
225---241
Table
5
(Con inued)
D ug
MR
FR
FDA
AEMPS
and
O he
Da a
Re
NBUVB
U
U
---
-No
associa ed
wi h
e a ogenici y
-AEMPS:
no
men ioned
56
Ap emilas
U
U
C
-No
da a
o
humans
-Cases
o
misca iage
epo ed
in
animals
-AEMPS:
Con aindica ed
du ing
p egnancy
15
Dime hyl
uma a e
U
U
C
-No
da a
o
humans
-Expe s
ecommend
no
using
he
d ug
du ing
p egnancy
-AEMPS:
Con aindica ed
du ing
p egnancy
9
Me ho exa e
D
U
X
-Cases
o
misca iage
and
congeni al
mal o ma ions
epo ed
in
animals.
This
e ec
seems
o
be
dose-dependen
in
humans
and
is
associa ed
mainly
wi h
high
d ug
doses
-AEMPS:
Con aindica ed
du ing
p egnancy
109
Ciclospo in
A
U
U
C
-Case
epo s
o
low
bi h
weigh
and
p e e m
bi h
-AEMPS:
Use
i
benefi s
ou weigh
isks
73---75
Infliximab
U
U
B
-No
da a
showing
an
associa ion
wi h
e a ogenici y
o
poo
p egnancy
ou comes
-AEMPS:
Use
i
benefi s
ou weigh
isks
83,121
Adalimumab
U
U
B
-No
da a
showing
an
associa ion
wi h
e a ogenici y
o
poo
p egnancy
ou comes
-AEMPS:
Use
i
benefi s
ou weigh
isks
15,83
E ane cep
U
U
B
-
No
da a
showing
an
associa ion
wi h
e a ogenici y
o
poo
p egnancy
ou comes
-AEMPS:
No
ecommended
84
Ce olizumab
pegol
U
U
B
-Da a
simila
o
hose
o
he
gene al
public
-App o ed
by
he
EMA
o
use
du ing
p egnancy
81,82,122,123
B odalumab
U
U
B
-Few
da a
o
humans
-AEMPS:
P e e ably
a oid
113
Secukinumab
U
U
B
-No
da a
showing
an
associa ion
wi h
e a ogenici y
o
poo
p egnancy
ou comes
-AEMPS:
P e e ably
a oid
89
Us ekinumab
U
U
B
-Lack
o
da a
o
humans
-AEMPS:
P e e ably
a oid
78,87,88,124
Ixekizumab
U
U
B
-Few
da a
in
humans
-AEMPS:
P e e ably
a oid
15
Guselkumab
U
U
B
-Few
da a
in
humans
-AEMPS:
P e e ably
a oid
125
Abb e ia ions:
AEMPS,
Agencia
Espa˜
nola
del
Medicamen o
y
P oduc os
Sani a ios
(Spanish
Agency
o
Medicines
and
Medical
De ices);
D,
doub ul;
FDA,
Food
and
D ug
Adminis a ion;
FR,
e al
isk;
MR,
ma e nal
isk;
NBUVB,
na owband
UV-B
pho o he apy;
PUVA,
pso alen---UV-A;
U,
unknown.
is
con aindica ed
in
p egnancy.15 Simila ly,
he
lack
o
da a
in
humans
o
dime hyl
uma a e
means
ha
his
agen
is
no
ecommended.9
Animal
da a
show
ha ,
in
addi ion
o
causing
abo ion,
me ho exa e
is
a
e a ogenic
d ug.
Howe e ,
a ious
obse -
a ional
s udies
sugges
ha
de ec s
a e
induced
wi h
doses
o
me ho exa e
g ea e
han
10
mg/wk
and
ha
he
c i -
ical
pe iod
would
be
6-8
weeks
a e
concep ion.68---72 This
d ug
is
cu en ly
con aindica ed
in
p egnancy
and
should
be
suspended
3
mon hs
be o e
concep ion.
Finally,
ciclospo in
A
has
been
associa ed
wi h
a
g ea e
isk
o
low
bi h
weigh
and
p e e m
bi h
in
p egnan
women
who
ha e
ecei ed
solid
o gan
ansplan s,
bu
no
wi h
a
g ea e
isk
o
congeni al
abno mali ies.73---75
Biologic
The apy
Recommenda ion
11.
In
he
case
o
women
ecei ing
biologic
he apy,
he
panel
ecommends
ha
his
be
main-
ained
du ing
he
fi s
and
second
imes e s.
Toge he
wi h
he
pa ien ,
he
clinician
should
e alua e
he
isks
and
ben-
efi s
o
con inuing
hese
d ugs
du ing
he
hi d
imes e .
Pa ien s
aking
ce olizumab
pegol
can
con inue
he
d ug
h oughou
p egnancy
only
i
i
is
conside ed
clinically
nec-
essa y
(LE
3a;
GR
C;
LA
88%).
In
he
case
o
monoclonal
an ibodies,
ans e
o
immunoglobulin
(Ig)
G
an ibodies
begins
in
he
second
imes e
by
means
o
binding
o
placen al
Fc
ecep o s.9
Ne e heless,
no
all
monoclonal
an ibodies
ha e
he
same
a fini y
o
binding
o
hese
ecep o s.
IgG1
(adalimumab,
233
I.
Belinchón,
M.
Velasco,
M.
A a-Ma ín
e
al.
52.
Chi
CC,
Wang
SH,
Ki schig
G,
Wojna owska
F.
Sys ema ic
e iew
o
he
sa e y
o
opical
co icos e oids
in
p egnancy.
J
Am
Acad
De ma ol.
2010;62:694---705.
53.
F anssen
ME,
an
de
Wil
GJ,
de
Jong
PC,
Bos
RP,
A nold
WP.
A
e ospec i e
s udy
o
he
e a ogenici y
o
de ma ological
coal
a
p oduc s.
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De m
Vene eol.
1999;79:390---1.
54.
Zanga
RC,
Sp inge
DL,
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RL,
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DD.
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son
o
e o oxic
e ec s
o
a
de mally
applied
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55.
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E,
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o
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J,
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o
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o
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in
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60.
Os ensen
M,
Mo a
M.
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he
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o
an i heuma ic
d ugs
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nu sing.
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Clin
P ac
Rheuma ol.
2007;3:400---6.
61.
Reinisch
JM,
Simon
NG,
Gandelman
R.
P ena al
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o
p ednisone
pe manen ly
al e s
figh ing
beha io
o
emale
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62.
de
Die-Smulde s
CE,
S u kenboom
MC,
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J,
an
Ka wijk
C,
Sas owijo o
P,
an
de
Linden
E.
Se e e
limb
de ec s
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c anio acial
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in
a
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concei ed
du ing
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63.
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B onbe g
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M,
Alba
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H,
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H.
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o
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66.
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Lange
R.
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o
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among
women
and
pa ne s
o
men
wi h
a
his o y
o
exposu e
o
me hoxsalen
pho-
ochemo he apy
(PUVA)
o
he
ea men
o
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