Psoriasis and Breastfeeding

CHRISTINE JONES-WOLLERTON AND KATHY GROSSMAN

As a breastfeeding mother Christine Jones-Wollerton has personally experienced the challenges of living with psoriasis and psoriatic arthritis. Today she uses her experiences gained over the last decade to help mothers through her work as a doula, peer counselor and LLL Leader. In this article Christine and Kathy Grossman share information about psoriasis as it relates to breastfeeding and ways Leaders can support mothers.

Various skin irritations and conditions can affect a mother’s comfort while she is breastfeeding. These conditions can include impetigo, bacterial infections, eczema and other types of dermatitis, thrush, poison ivy rashes, and psoriasis (so-RYE-uh-sis). A health professional will make the diagnosis of psoriasis.

TWO FORMS OF PSORIASIS

Psoriasis (Ps) and psoriatic (so-rye-AT-ick) arthritis (PsA) are conditions of the immune system that affect the normal production of healthy skin cells on the body. These often misdiagnosed and misunderstood conditions have lifelong consequences, as there is currently nothing to guarantee a cure or to even stimulate long-term remission. Both conditions can be passed on genetically but cannot be spread from one person to another. Researchers are only now beginning to isolate the genes responsible for their development in the body. Psoriasis is estimated to affect two to three percent of the world’s population and affects males and females equally.^1,2

¹Scientists use DNA from NPF BioBank to identify first gene linked to the disease National Psoriasis Foundation (NFP) (accessed 23 January 2015).

²Statistics, National Psoriasis Foundation (accessed 23 January 2015).

CHRISTINE’S STORY

I was diagnosed with psoriasis in 2002, six months after the birth of my first child. Soon after, large patches of plaque [raised, scaly patches], guttate [small lesions] and erythrodermic [generalized redness] areas, and pustular blisters [raised bumps on the skin filled with pus] covered more than 85% of my body. Twelve months later, I developed psoriatic arthritis. At that time, my arthritis was so severe that I had to retire from my career as a doula. I was accredited as an International Board Certified Lactation Consultant (IBCLC) in 2009. This gave me more flexibility to arrange clients according to how I felt on a particular day. Since that time, I have birthed, and safely breastfed three children while receiving compatible medication and using topical corticosteroids under the supervision of my dermatologist and rheumatologist, my obstetrician, and children’s pediatrician. I am no longer in practice as an IBCLC, but the knowledge I gained is invaluable to help me continue to support mothers as an LLL Leader.

COMPLICATIONS OF PSORIASIS

Psoriasis is associated with numerous other serious, chronic and/or life-threatening comorbidities. [A comorbid condition is when one or more diseases or conditions occur together with the primary condition.] According to the Executive Summary of “Psoriasis and Comorbid Conditions Issue Brief,” January 2012, people with psoriasis:

Can develop potentially disabling psoriatic arthritis.
Are at a 62% increased risk of developing diabetes, independent of factors such as weight, hypertension, and high cholesterol.
Are at an increased risk of cardiovascular disease and associated factors, such as heart attacks and hypertension.
Have a higher prevalence of stroke, atherosclerosis [a common form of arteriosclerosis in which fatty substances form a deposit of plaque on the inner lining of arterial walls], chronic obstructive pulmonary disease (COPD), Crohn’s disease, lymphoma, metabolic syndrome [a collection of heart disease risk factors], cancer, and liver disease.

Psoriasis and psoriatic arthritis can also place people at risk of side effects from the long-term use of medications such as steroids and injectable medications.

WHAT CAUSES PSORIASIS?

Psoriasis is linked to smoking, alcohol use, obesity, and other factors that negatively impact health. But actual triggers for psoriasis, according to the National Psoriasis Foundation psoriasis.org, can be stress, certain medications, skin injury or trauma such as sunburn or scratches, and streptococcus infection (strep throat). ^3,4,5 Psoriasis and psoriatic arthritis can affect people physically, emotionally, financially, and socially. The consequences can range from the minor (mild itching, embarrassment) to the severe (inability to work, physical disability, and public and workplace harassment). When polled about the emotional effects of having a disease, patients with psoriasis rank higher than those with cancer and heart disease.

³Psoriasis Causes and Known Triggers National Psoriasis Foundation (accessed 23 January 2015).

⁴Infection National Psoriasis Foundation (accessed 23 January 2015).

⁵Can Removing Tonsils Improve Guttate Psoriasis? National Psoriasis Foundation (accessed 23 January 2015).

PSORIASIS AND THE MISFIRING IMMUNE SYSTEM

In a non-psoriatic person, skin cells typically cycle (grow and shed) every three weeks. In a person with psoriasis, the skin cycles every three to four days, causing scaly skin to build up in excess, forming plaques and inflammation of the skin and joints. Plaque psoriasis (silvery, scaly patches which may be red beneath) can cause itchiness, bleeding, and excessive shedding of skin flakes. Inflamed areas may bleed, secrete a pus-filled liquid, and be tender to the touch. In severe cases, the constant cycle of skin shedding may also cause nerve damage underneath the affected areas.

The National Psoriasis Foundation website further explains:

“A normal immune system protects the body against ‘invaders’ by destroying bacteria, viruses, and other foreign proteins. In the person who has psoriasis, the immune system ‘misfires’ and inappropriately causes inflammation and an accelerated growth of skin cells. The skin cells reproduce too quickly, and the skin (and the joints in some people) becomes inflamed. Many steps in this misfired immune response are targeted by specific treatments such as systemic and biologic drugs. One goal of treatment is to block or modify the response by focusing on very specific immune cells, thus avoiding widespread effects on the rest of the body.”

CLASSIFICATIONS OF PSORIASIS AND PSORIATIC ARTHRITIS

There are five classifications of psoriasis and five types of psoriatic arthritis. A person may be diagnosed with one or more of these. While 30% Body Surface Affected (BSA) is considered moderate to severe, the full impact of psoriasis is not determined by the BSA number but by how the disease impacts the individual physically and emotionally. A person may have 5% BSA, but, if the areas affected include the palms of the hands and soles of the feet, this is likely to drastically impact the ability to perform simple functions. Psoriatic arthritis is diagnosed when a person with psoriasis also develops arthritis. This arthritis is directly related to the person’s psoriasis, and, while it is similar in nature to rheumatoid arthritis, it is a separate disease.

PSORIASIS AND MOTHERHOOD

As Leaders, we may encounter mothers who have questions about the safety of breastfeeding while being treated for these conditions. We may also encounter mothers whose babies or older children have been diagnosed with one of these conditions.

THE PREGNANT MOTHER WITH PSORIASIS

During pregnancy, the same functions of the body’s immune system that are boosted in order to protect the development of a new life may also decrease the mother’s inflammation. Some mothers find that their condition improves during pregnancy, while others may see no change or even an increase in symptoms.

Some mothers may choose to delay attempts to conceive until they are no longer taking pharmaceutical medications and therefore may also believe it is best to avoid breastfeeding once medications are resumed. See below for online resources to check the safety of individual medications while breastfeeding.

Quote from Durocher, H.J. Psoriasis and Psoriatic Arthritis: What You See and What You Don’t 2014

“Dr Mandelin⁶ says that while some medications are known to be too dangerous to use during pregnancy (Trexall® [methotrexate], for example, is often prescribed for psoriasis but can potentially cause birth defects), other treatments are safe and can provide symptom relief both when a woman is expecting and during breastfeeding.”

A mother with moderate to severe psoriasis or PsA may find labor physically uncomfortable as she tries to position her body to minimize pain and discomfort to her skin surfaces and joints. A labor assistant such as a doula may help her with suggestions; however, some mothers plan a cesarean delivery, hoping to avoid any physical trauma they perceive as a risk related to a vaginal birth.

A Leader can help a mother with psoriasis by reassuring her that her baby will not contract psoriasis from her milk. You can suggest comfortable positioning tools such as nursing pillows, or you can demonstrate how she can nurse in the side-lying position. She may also need more time to attend to wound care on other parts of her body other than her breasts or nipples. She may need suggestions regarding how to make expressing breast milk less painful.

⁶Arthur Mandelin II, MD, PhD, is the assistant professor of medicine in the Department of Medicine, Division of Rheumatology, at Northwestern University Feinberg School of Medicine in Chicago, Illinois, USA.

THE BABY WITH PSORIASIS

Psoriasis is not transmitted through breast milk, though it is possible that a child may later develop a form of psoriasis because of shared genes. The benefits of colostrum and breast milk’s nutrients will help a baby develop a healthy immune system in general and may help delay the onset of symptoms. The physical appearance of a baby with psoriasis may be upsetting to parents. They may feel guilt and need time to grieve, process, and accept this information. Leaders can provide information and resources about the advantages of breastfeeding for the entire family. Mothers may also need practical tips about how to nurse to minimize physical discomfort to the baby.

Postpartum hormones coupled with the emotions of severe arthritis can affect a mother’s confidence. You can help her achieve her breastfeeding goals by offering her, her family, or other helpers information and emotional support while she dialogues with doctors, specialists, and postpartum staff. Encourage the mother to describe how her condition impacts her daily life, and help her create a realistic postpartum care plan so that she feels she has tools and resources. Perhaps encourage her to join an in-person or online support group. Leaders may want to be aware that some mothers might be very self-conscious about nursing at meetings, even among other supportive mothers. A mother may worry about exposing her body when breastfeeding, in case she reveals lesions, scaly, or blistered skin.

Ask what comfort measures the mother uses in her daily routine. She could apply ointment and wrap her skin with gauze or bandages to cushion any active lesions on her arms or torso. Pillows may help to support her wrists or a rolled-up washcloth or cloth diaper may support her breast as the baby nurses. A mother with plaque psoriasis on her body might try a breastfeeding pillow that wraps fully around the torso. She could also place a soft towel or baby blanket between the pillow and her body to provide extra cushioning against her skin. If she has arthritis in her hands, she could try side-lying, laid-back nursing, or the football hold position with her legs bent at the knees or propped up to raise the baby’s head to breast level. Another idea is to use a flat nursing pillow on a low table, or even stand against a high counter supporting the baby’s body.

Certain biologic (injectable) medications that are commonly used to treat the mother’s psoriasis and PsA place her at an increased risk of developing infections such as the common cold. As Leaders, we know that an advantage of nursing is that breastfed babies and children in the home are quite often the only ones who do not catch a cold that has affected other family members.

MEDICATIONS AND BREASTFEEDING

A mother might receive her initial diagnosis of psoriasis within a year of a child’s birth, or she may find that her psoriasis “flares” within a few weeks or months after the birth of a child. These flares are often severe and may cause the mother significant distress, leading to or heightening a postpartum mood disorder. Leaders may find that these mothers also have concerns about antidepressant medications (especially selective serotonin reuptake inhibitors, SSRIs) that were taken during pregnancy as well as after giving birth and whether they are compatible with breastfeeding. The most common medications for psoriasis are steroids (oral and applied locally to skin area), systemics (prescription drugs), and biologic (injectable). Leaders can encourage mothers to consult with their and their baby’s physicians about their concerns and refer to the most recent edition of Thomas W. Hale and Hilary E. Rowe’s Medications and Mother’s Milk, or online at Medsmilk (needs a subscription), LactMed or e-lactancia for information on the safety of drugs during breastfeeding.

Topical medication can be gently wiped off nipples before breastfeeding. In general, mothers may wish to take care using topical prescriptions on nipples because some products may thin out the skin and thus create more sensitivity for the mother. Mothers may be surprised to learn many medications do not enter breast milk or may only appear in negligible amounts. They may be relieved that they do not have to choose between their own health and the desire to breastfeed.

SUPPORT IS IMPORTANT

As Leaders we have an opportunity to help mothers find current information about psoriatic disease to share with their healthcare providers. This can help them make truly informed decisions with confidence when others may be judgmental or pressuring them about their desire to breastfeed in this situation. We can validate the mother’s concerns and provide positive words when she faces challenges. With a good support system, including Leaders and Group members, mothers do not have to feel isolated.

RESOURCES

Buescher, E. S., and Hatcher, S. W. Breastfeeding and Diseases: A Reference Guide, Hale Publishing, 2008.

Hale, T. W. and Berens, P. Clinical Therapy in Breastfeeding Patients, Third Edition. Hale Publishing, 2011.

Hale, T. W. and Hilary E. Rowe. Medications and Mothers’ Milk, 16^th Edition. Hale Publishing, 2014.

International Lactation Consultant Association (ILCA) at 1-888-ILCA-IS-U or www.ilca.org

La Leche League International (LLLI)

Infant Risk Center at Texas Tech University

National Psoriasis Foundation (NFP)

Organization of Teratology Information Specialists (OTIS). A nonprofit organization providing information to patients and health care professionals about exposures during pregnancy and lactation. Call toll free at 866-626-6847.

Durocher, H.J. Psoriasis and Psoriatic Arthritis: What You See and What You Don’t 2014 (accessed 14 January 2015).

The Womanly Art of Breastfeeding, 8^th Revised Edition. Schaumburg, IL: La Leche League International, 2010.

Accredited in 2004, Christine Jones-Wollerton is a Leader with the LLL of Toms River AM Group, New Jersey, USA. She and her husband Christopher live in Toms River and are the parents of Aisling (12), Damien (6), and Coraline (4).

Kathy Grossman lives in Moab, Utah, USA. Her grown up sons Sam, Ed, and Monty visit when they can and Kathy has a new granddaughter Lucy. Kathy was Managing Editor of Leaven from 2011 through 2014.