Biologics, Immunosuppressives, and Pregnancy: What Dermatologists Need to Know in 2026
At the 2026 Masterclasses in Dermatology Annual Meeting, Katherine Economy, MD, MPH, delivered a timely and clinically relevant session on prescribing biologics and immunosuppressants in pregnancy. Her focus was clear: Dermatologists must balance maternal disease control with fetal safety through evidence-informed, patient-centered decision-making.
Dr Economy opened with a reminder of scope. Between 2006 and 2008, “94% of women used at least 1 medication during pregnancy (mean 4.2; range 0–28); 62.5% used at least 1 medication during the first trimester.” For dermatologists treating psoriasis, atopic dermatitis, lupus, and connective tissue disease, medication exposure is not theoretical—it is common.
Pregnancy introduces significant pharmacokinetic changes. Increased plasma volume, cardiac output, renal and hepatic blood flow, and cytochrome P450 activity can alter drug clearance and dosing requirements. Nausea, vomiting, and delayed gastric emptying further complicate absorption.
Shared decision-making is central. “What is the risk of untreated disease?” Dr Economy asked in a complex lupus case discussion. Clear risks of increased adverse pregnancy outcomes accompany active systemic lupus erythematosus and other inflammatory diseases.
Certain medications are considered compatible with pregnancy. Hydroxychloroquine, topical therapies, aspirin, and glucocorticoids fall into the “known and safe” category when appropriately monitored. TNF inhibitors have the most robust safety data among biologics, with no increased risk of major malformations reported. British 2023 guidelines indicate patients on TNF inhibitors do not need to be switched, although discontinuation in the second or third trimester may allow normal infant vaccine scheduling.
By contrast, methotrexate, mycophenolate mofetil, thalidomide, and cyclophosphamide are contraindicated prior to conception due to teratogenic risk. Rituximab, belimumab, anakinra, abatacept, tocilizumab, secukinumab, and ustekinumab should generally be stopped when pregnancy is confirmed, although conditional use of rituximab may be considered for organ- or life-threatening disease.
Understanding placental IgG transfer is critical. IgG is the only antibody class that crosses the placenta via the FcRn receptor, with minimal transfer before 12 weeks and substantial transfer after 36 weeks. Infants exposed in utero to immunosuppressive monoclonal antibodies may require delayed administration of live vaccines.
Dupilumab, an IgG4 monoclonal antibody targeting IL-4 and IL-13 signaling, follows similar gestational transfer patterns—low in early pregnancy and increased in the third trimester.
Dr Economy concluded that “clear risk of increased adverse outcomes with increase disease activity” underscores the importance of maintaining maternal disease control. Many biologics and immunosuppressive agents “may be safely administered during pregnancy with appropriate attention to dosing and fetal monitoring.”
For more meeting coverage, visit the Masterclasses in Dermatology newsroom.
Reference
Economy K. The use of biologics and immunosuppressives in pregnancy. Presented at: Masterclasses in Dermatology; February 19–22, 2026; Sarasota, FL.
