For clinicians

Psoriatic arthritis (PsA)

PsA, psoriatic arthritis, psoriasis with arthritis

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Bottom lineBottom line: in the largest prospective cohort (RevNatus, 108 pregnancies, peripheral PsA), joint disease was low and stable overall, eased modestly in pregnancy, and rose significantly by 6 months postpartum before returning to baseline by 12 months; a clinically meaningful postpartum flare (DAS28-CRP rise >=1.2) occurred in about 1 in 5. That cohort did not find postpartum psoriasis worsening, though PASI data were incomplete. Continue pregnancy-compatible therapy (TNF inhibitors are the guideline mainstay for active disease); stop methotrexate and leflunomide pre-conception. Obstetric outcomes were not this cohort's endpoint and remain drawn from guideline sources.

By domain

Will pregnancy affect my PsA? ●●○○low evidenceconditional

In the RevNatus prospective cohort (108 pregnancies, 103 women, all peripheral PsA), about 75% were in remission or had low DAS28-CRP activity from preconception to 12 months postpartum. Activity decreased in pregnancy and rose significantly by 6 months postpartum (mean DAS28-CRP 2.71 vs 2.45 at 6 weeks, P=0.016), returning to baseline by 12 months. The mean change was small (largest difference 0.36, below the >=1.2 meaningful threshold), but about 1 in 5 women with paired data had a meaningful postpartum flare, and EULAR remission fell from 68% in the third trimester to 52% at 6 months postpartum. BASDAI followed the same low, stable pattern with a significant 6-month postpartum rise (3.69 vs 2.95, P=0.013). Psoriasis activity was low (PASI 0 in 54% of assessments), and this cohort did not find the postpartum skin deterioration reported elsewhere, though PASI was missing in half of visits. DAS28-CRP underestimates PsA activity (misses DIP joints, ankles, enthesitis, dactylitis, skin, axial disease) and the population was homogeneous, so absolute activity may be understated.^[4]

Will PsA affect the pregnancy? ●●○○low evidenceconditional

Generally favourable; active disease and associated metabolic comorbidity may modestly increase preterm birth and caesarean rates.^[1]

Planning ahead ●●●○moderate evidencestrong

Discontinue methotrexate/leflunomide pre-conception; transition to compatible therapy; aim for low disease activity at conception.^{[1, 2]}

Medicines ●●●○moderate evidenceconditional

TNF inhibitors are the principal option for active PsA; sulfasalazine for peripheral disease; NSAIDs short-term earlier in pregnancy. Avoid methotrexate, leflunomide, and JAK inhibitors. Some IL-17/IL-23 agents have growing but limited pregnancy data.^{[1, 2]}

After birth ●●○○low evidenceconditional

Anticipate a postpartum rise in joint activity peaking around 6 months (a meaningful flare in about 1 in 5); this cohort did not find postpartum skin worsening. Pre-plan a breastfeeding-compatible regimen and a postpartum review.^[4]

About psoriatic arthritis ●●●○moderate evidenceconditional

2018 ACR/NPF guideline (verified, general, non-pregnancy): incidence ~6 per 100,000/year, prevalence ~1-2 per 1,000; among people with psoriasis, PsA prevalence ranges 6-41%. Skin disease usually precedes arthritis; the arthritis presents first in 10-15%. Nail involvement occurs in ~80-90%. General PsA management (including treat-to-target and drug selection) follows this guideline; drug choices in pregnancy instead follow the reproductive guidelines below.^[3]

Key points

Point	Evidence
TNF inhibitors are the guideline mainstay for active PsA through pregnancy. In the RevNatus cohort, the few women who continued a TNFi in pregnancy (n=7) had significantly lower disease activity (mean DAS28-CRP 2.22 vs 2.72 at 6 months postpartum, P=0.043). This is observational, with small numbers and possible confounding by indication, and no trial has tested a disease-modifying effect of TNFi in pregnancy.^{[2, 4]}	●●●○moderate evidenceconditional

Point

Evidence

TNF inhibitors are the guideline mainstay for active PsA through pregnancy. In the RevNatus cohort, the few women who continued a TNFi in pregnancy (n=7) had significantly lower disease activity (mean DAS28-CRP 2.22 vs 2.72 at 6 months postpartum, P=0.043). This is observational, with small numbers and possible confounding by indication, and no trial has tested a disease-modifying effect of TNFi in pregnancy.^{[2, 4]}

●●●○moderate evidenceconditional

References

Sammaritano LR, et al. 2020 ACR Guideline for the Management of Reproductive Health in RMD. Arthritis Rheumatol. 2020;72(3):529-556. https://acrjournals.onlinelibrary.wiley.com/doi/10.1002/art.41191
Ruegg L, et al. EULAR recommendations for antirheumatic drugs in reproduction, pregnancy, and lactation: 2024 update. Ann Rheum Dis. 2025;84(6):910-926. https://ard.eular.org/article/S0003-4967(25)00818-0/fulltext
Singh JA, Guyatt G, Ogdie A, et al. 2018 American College of Rheumatology/National Psoriasis Foundation Guideline for the Treatment of Psoriatic Arthritis. Arthritis Care Res (Hoboken). 2019;71(1):2-29. https://doi.org/10.1002/acr.23789
Ursin K, Lydersen S, Skomsvoll JF, Wallenius M. Psoriatic Arthritis Disease Activity During and After Pregnancy: A Prospective Multicenter Study. Arthritis Care Res (Hoboken). 2019;71(8):1092-1100. https://doi.org/10.1002/acr.23747