Psoriasis fertility, conception and pregnancy

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Planning ahead
Having psoriasis does not affect your chances of getting pregnant. The decision to get pregnant rests entirely with you and your partner. This information aims to provide supportive knowledge so that you may find it useful in making that decision.

Before embarking on conception please discuss this thoroughly with your doctor as some of your medications may have an impact on your fertility, sperm or a growing embryo. Therefore this needs to be discussed fully in order to plan an appropriate washout period  (if necessary) before you try to conceive.

What are genes?    
Genes are the body’s identity tags.  Each gene acts in a different way and is responsible for a small part of the workings of the human body.  

All of us carry hereditary genes from our ancestors and parents that are then passed on through our children, these play a part in our eye, hair colouring, skin types, characters, a whole range of things, including carriers for illnesses.

This is where the psoriasis gene comes into play.  As psoriasis is thought to be an hereditary condition, this means that medical researchers believe that the psoriasis genes are carried by a parent(s) and are passed on during conception, at the point of production of the egg and sperm during pregnancy, so being inherited by the child, which leads them on to having a pre-disposition to psoriasis if one or both of their parents have psoriasis. There is also a possibility that during the fertilisation of the egg, genes could have been damaged which causes the gene to become active in triggering psoriasis.

Some people will have this gene which has never been switched on by the body, if you like, remained in a dormant, sleep-like mode, which means the psoriasis will never have been triggered in them. This is why although psoriasis may have been running in the family, a family member may still never have it or will have escaped it because it has just remained asleep.

How are genes important in psoriasis?
As there is a strong familial element to psoriasis - a third of patients will have a family member with the disease.   However, studies in twins show that only 70% of identical twins (who are genetically exactly the same as each other) both have psoriasis. Much research is being done into the genetics of this disease. It is known that the disease is multi genetic and therefore children may not necessarily inherit psoriasis.

Which genes are important in psoriasis?
At present there are several major research groups attempting to identify the psoriasis gene (or genes). So far, seven confirmed areas within the human genome have been linked to psoriasis as a result of genome scanning.  The most significant locus - designated PSORS 1 is on chromosome 6.   In Type 1 psoriasis, were there is disease onset before or at the age of 40 years, there is often a family history of psoriasis together with a strong association with PSORS 1.   In Type 2 psoriasis patients have disease onset after the age of 40, a family history of psoriasis is unusual and there is a much weaker association with PSORS 1. However other chromosomes which have been linked to psoriasis susceptibility include numbers 1, 2, 8, 16 and 20.

Will my children get psoriasis?
Both these factors - the relatively low chance of identical twins both having psoriasis and the large number of chromosomes linked to psoriasis - suggests that it requires more than having the gene to develop the skin lesions.  It is thought therefore that psoriasis is a complex disease where the skin changes only occur in individuals who not only have a genetic predisposition for the condition but who have also encountered an environmental trigger such as infection and stress.

If both parents have psoriasis then the risk of children developing psoriasis is 75% and if one parent has psoriasis, the risk of children developing the disease is 15%.  Therefore, if you have psoriasis, your children will not necessarily also develop psoriasis.   However, if a brother or sister (but neither parent) has psoriasis then the risk of other siblings developing psoriasis is 20%.

It is likely that what is currently called psoriasis may ultimately turn out to be a spectrum of clinically similar, but genetically different diseases. There are three main pieces of evidence which suggest the immune system is involved in psoriasis. Genes and the immune system go together, working alongside each other all playing a part in the master plan of our bodies

What is the immune system?
Your immune system is designed to protect you against disease. It is made up of a number of white blood cells (T cells) that patrol the body in search of cells and proteins that should not be there. All your cells have special identity tags to help your immune system recognise them. Sometimes, however, the immune system over-reacts or even attacks parts of the body to cause problems.

The term tissue type refers to a collection of markers on the surface of the cells in our bodies. These markers contribute to distinguishing one person from another are used by the immune system as identity tags. The directions for the production of these markers are found in the genes of the major histocompatibility complex (MHC) which are passed from one generation to the next and are, therefore shared within families. At present, the search is on for a gene or collection of genes in the MHC which are associated with psoriatic arthritis (PsA). Other rheumatic diseases such as rheumatoid arthritis and ankylosing spondylitis occur more frequently in individuals with particular MHC genes.

It is thought that there is a genetic predisposition to the development of psoriasis and PsA but exactly which genes are involved is unknown at present. Evidence suggests that inflammation in the skin and joints is in part directed and maintained by cells of the immune system called T lymphocytes. Under normal circumstances these cells survey the bloodstream and body tissues for signs of infection and cancer. In the event that a foreign agent, such as a virus, is found, T lymphocytes destroy the infected cells and  send messages into the local area to recruit assistance in clearing the infection. For reasons unknown, T lymphocytes are present in large numbers in the psoriatic skin and inflamed joints of people with PsA. The activity of these T lymphocytes and the messages which they produce contribute to the thickened epidermis in psoriasis and damage in the joint. Many of the stronger drugs prescribed for PsA such as methotrexate, azathioprine and steroids serve to reduce the production and/or activity of the cells of the Immune system, including T lymphocytes. It is through tissue type markers, the products of MHC genes, that T lymphocytes communicate with the rest of the body. These markers are required for a T lymphocyte to receive information as to the identity and state of healthiness of body tissues. If a particular tissue type were found to be linked to the development of PsA it would provide essential information regarding the seemingly inappropriate activity of T lymphocytes. It has been suggested for other diseases linked to certain tissue types that the affected tissue is altered such that the immune system mistakes it for something foreign. Alternatively, an unidentified infection may result in chronic inflammation either because it resides in inflamed tissue or causes confusion in immune cells resulting in healthy tissue being mistaken for infected tissue.

Genetic and immune system
There is a collection of genes which code for the identity tags in the immune system. The way your immune system behaves is controlled by the genes you have inherited. Each gene acts in a different way. Some diseases like psoriasis or rheumatoid arthritis affect certain people with certain identity tags.

The way your immune cells and skin cells act towards each other in psoriasis seems to change:

  • Large numbers of white blood cells (T cells) move into the skin
  • Levels of immune proteins in the skin change - some increase and others decrease

Lesional tissue
Inflamed skin and joints show similar characteristics. The tissue is invaded by T cells (from white blood cells) and other immune cells from the bloodstream. This activity causes cells in the top layer of the skin to divide too quickly. These cells also contribute to the damage which occurs to joints in arthritis. Scientists do not know exactly why this is happening, but controlling the disease seems to depend on controlling these cells.

Therapy
Many of the most potent therapies used to control psoriasis damage the action of immune cells. The drugs attack a wide variety of cells, good and bad. As more is learned about how immune activity contributes to psoriasis, new therapies will be developed which are more specific. If we can manipulate immune responses more selectively, this could be key to the management of psoriasis. These treatments are not widely available at present.

Will my first child be at risk?
Again, nothing is certain, so therefore information can only provide risk statistics, this does not mean any child with a predisposition to the condition with get it. There is to-date no evidence to suggest that first borns are more at risk than following children. It could just be down to circumstances leading to trigger factors.

What if I have another child, would they get it too?
If you already have one child with the condition, it is believed that your following child would have a 20% risk of developing this too, but that does not mean they will get the condition –this is just a risk factor.

Unfortunately there is no sure way to confirm the exact triggers that caused the reaction to happen in your child. They could have experienced a certain situations(s), which could have caused the psoriasis to trigger. Such an experience could have been a traumatic one, or even a recent illness, such as a throat infection, especially one cause by Streptroccal, or ear/chest infections. Researchers further suggest that after such triggers flare-up the psoriasis, it is more likely to appear on skin sites that have been previously injured. This could just be a small patch, or a patches, not necessarily all over the body, which is extremely rare indeed.


Frequently Asked Questions


Q. Will any medications have an adverse effect on conception and the development of a baby?
A.
Yes, some medications are not recommended during or prior to conception therefore you should discuss any planned or unplanned pregnancies with your doctor and appropriate contraception should be in place.
Some medications may have adverse affects on a developing baby in the womb, if you are still taking such medications at the time of conception. This is why a “wash-out” period may be needed to make sure they are cleared from the body to allow every chance of a healthy baby. This is an essential precaution for you to embark on a healthy, happy pregnancy.

However, careful consideration should be made and any precautions taken in good time to ensure healthy conception leading to a healthy pregnancy.  This is because some psoriasis treatments may need to be stopped with a time lapse before conception takes place to avoid any unnecessary fertility or birth problems for example  PUVA which is used in combination with psoralens and ultraviolet light A.
If a certain length of time has lapsed in trying to conceive without success you should always go back with your partner and discuss this as there may be other unconnected issues that may need investigating further on either side.


Q. Do contraceptive pills have any effects on psoriasis/psoriatic arthritis?
A. Contraceptive pills work by controlling a women’s hormones and can have both good and bad effects on a person’s body depending on the individual and because everyone is different there is no way of predicting such outcomes.


Q. Will having genital psoriasis affect conception?
A. No, having genital psoriasis will not cause any problems, only if you are very sore and uncomfortable and this prevents you having intercourse.


Q. If my partner has psoriasis/psoriatic arthritis will the medications affect  conception ?
A. You should discuss the medications with your doctor before attempting conception in case there needs to be a wash-out period of certain drugs that may affect sperm quality or have any consequences to sperm abnormalities. A doctor should be able to advise on these questions.


Q. Is it important that my midwife, medical team are aware that I have psoriasis/psoriatic arthritis?
A. Yes because they can help in the planning of your medical care and be prepared for any additional help that you made need if you should experience a flare-up, or indeed, to try and make the necessary steps to help you prevent one by not getting too stressed. They can also make sure any others who care for you will know your medical background too.


Q. Will psoriasis affect my pregnancy?
A. There is no reason why psoriasis should interfere with you having a normal pregnancy and delivery. However, It is important to plan ahead. Some psoriasis treatments should not be used during pregnancy and you may need to wait a while after stopping them before trying to conceive. Ask your doctor for advice.


Q. If I become pregnant, will my skin get worse or better?
A. Most women with psoriasis find their skin improves during pregnancy or there is no change. A minority, between 10 and 20%, find their skin gets worse. Unfortunately, there is no way of predicting how each individual will react.Any improvement is usually fairly short-lived. The signs and symptoms usually recur 6-12 weeks after delivery but are generally no worse than before.
Occasionally, the rash of psoriasis may appear for the first time after childbirth, and in some women with psoriasis, symptoms of psoriatic arthritis may develop for the first time after pregnancy.


Q. If needed, what drugs may be used to control my psoriasis during pregnancy?
A. Understandably, the main concern regarding psoriasis and pregnancy revolves around the treatments needed to control the disease. If you are pregnant or considering getting pregnant it is important to consult your doctor and find out if the treatments you are currently using are safe for you and your baby. If possible, it is best to try and avoid all drugs during pregnancy, including over the counter remedies, but sometimes some form of treatment is necessary.  Always read if a treatment or product is suitable during pregnancy if in doubt consult your doctor or pharmacist.


Q. Are complementary therapies safe to use during pregnancy?
A. All treatments should be viewed in the same way as standard therapy during pregnancy with suitable and expert advice If in doubt consult your doctor or pharmacist.


Q. Will having a C-Section affect my psoriasis?
A. Yes, it is a possibility, as this will be an operational surgical site where the skin has been damaged and needs to heal, and could cause the Koebner phenomenon.


Q. What is the Koebner phenomenon.
A. In some people with psoriasis, trauma to the skin including cuts, bruises, burns, bumps, vaccinations, tattoos and other skin conditions can cause a flare-up of psoriasis symptoms either at the site of the injury or elsewhere. Also it may be that the effects of anaesthesia, antibiotics or other medications used may cause some worsening of psoriasis. If you are concerned  talk to your anaesthetist or hospital staff members caring for you so that they can take this into account when making a health plan for you whilst in hospital.


Q. Can i breatfeed if I have psoriasis?
A.If your nipples become sore which they can do normally during the initial onset of breastfeeding, but you have psoriasis on or around them, don’t worry, psoriasis will not harm your baby, but may be painful for you and you may feel like giving up. Moisturising in generous amounts on the nipples and surrounding areas is essential to help the skin and discomfort. Talk to your midwife, she may be able to suggest other positions to breastfeed that can alleviate some of the discomfort. You may have to try a few products to find the one that your baby is happy with and will let you use.


Q. Are biologic medications safe to take whilst breastfeeding?
A.Unfortunately, there are no data at the present time to answer this question.


Q. Should my health visitor be aware that I have psoriasis/psoriatic arthritis?
A. Yes, the more information they have about your circumstances the more they can help you or signpost you to others that can support you further.


Q. What drugs may be used to control my psoriasis during breast feeding?
A. Should you decide to breast feed some precautions need to be taken. Topical medications should not be used on the nipples and there is a possibility that if you are having to treat large areas of skin some of the drug may be absorbed into your blood stream and then appear in your milk.Systemic medications, taken by mouth or injection should be avoided during breast feeding if possible because they might be absorbed into the milk and passed to the baby. If you are thinking of breast feeding, It is best to discuss all this with your doctor before you start.


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