Does secukinumab (Cosentyx) cause immunosuppression and increase the risk of Ramsay Hunt syndrome or herpes zoster?

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Last updated: October 5, 2026 • View editorial policy

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Does Secukinumab Cause Immune Suppression and Increase Risk of Herpes Zoster or Ramsay Hunt Syndrome?

Secukinumab does cause a degree of immunosuppression by selectively inhibiting IL-17A, but clinical evidence does not demonstrate an increased risk of herpes zoster compared to placebo or other therapies, and there are no reported cases linking it to Ramsay Hunt syndrome. 1

Mechanism and Immunosuppressive Effects

Secukinumab is a fully human monoclonal antibody that selectively targets IL-17A, affecting immune system function 1. The FDA label explicitly states that "COSENTYX is a medicine that affects your immune system" and "may lower the ability of your immune system to fight infections and may increase your risk of infections" 1. This is not theoretical—clinical trials demonstrated higher rates of certain infections compared to placebo:

  • Nasopharyngitis: 11.4% vs 8.6%
  • Upper respiratory tract infections: 2.5% vs 0.7%
  • Mucocutaneous candidiasis: 1.2% vs 0.3% 1

The infection risk appears dose-dependent, with fungal infections (particularly candida) being notably increased 1, 2, 3.

Herpes Zoster Risk: The Evidence

Despite the immunosuppressive mechanism, secukinumab does NOT appear to increase herpes zoster risk. This is a critical distinction:

A systematic review specifically examining IL-17 inhibitors (including secukinumab, ixekizumab, and brodalumab) found that studies did not detect a higher risk of HZ infections in psoriasis patients treated with IL-17 inhibitors when compared to those treated with placebo or other therapies 4. This finding held across multiple indications including psoriatic arthritis, rheumatoid arthritis, and ankylosing spondylitis 4.

Long-term safety data from 28 clinical trials involving 12,637 secukinumab-treated patients with up to 5 years of follow-up showed that opportunistic infections (which would include herpes zoster) occurred at rates <0.2 per 100 patient-years, with no apparent increases over time 5. Active or latent tuberculosis infections were rare, and no new safety signals emerged over the 5-year period 5.

Ramsay Hunt Syndrome: No Established Link

There are no reported cases or evidence linking secukinumab to Ramsay Hunt syndrome in the available literature. The case reports of RHS in the evidence base involve:

  • Local corticosteroid injections 6
  • Older patients with VZV reactivation unrelated to biologics 7

RHS results from varicella-zoster virus reactivation in the geniculate ganglion and typically occurs in immunosuppressed states, but secukinumab's selective IL-17A inhibition does not appear to create the type of broad immunosuppression that triggers VZV reactivation.

Clinical Implications and Vaccination Strategy

Because secukinumab IS considered an immunosuppressive medication, the 2023 ACR guidelines strongly recommend recombinant varicella-zoster virus (VZV) vaccination for patients ≥18 years taking immunosuppressive medication 8. This recommendation is based on:

  • Patients with rheumatic diseases having higher baseline HZ risk
  • The safety and efficacy of recombinant VZV vaccine in immunosuppressed populations
  • ACIP recommendations for immunocompromised individuals ≥18 years 8

Key vaccination timing:

  • Administer recombinant zoster vaccine (Shingrix) BEFORE starting secukinumab when possible
  • Live vaccines are contraindicated during secukinumab therapy 1
  • Children should complete all age-appropriate vaccinations before initiating treatment 1

Common Pitfalls to Avoid

  1. Don't confuse selective IL-17A inhibition with broad immunosuppression: While secukinumab affects immune function, it doesn't carry the same HZ risk as JAK inhibitors (IR 30.5/1000 person-years), rituximab (IR 27.8/1000 person-years), or cyclophosphamide (IR 27.5/1000 person-years) 9

  2. Don't overlook candida risk: The real infectious concern with secukinumab is mucocutaneous candidiasis, not herpes viruses. Monitor for oral thrush, genital candidiasis, and esophageal candidiasis 1, 2, 3

  3. Don't delay vaccination: If a patient needs secukinumab, vaccinate against zoster first—this is preventive medicine, not a response to demonstrated risk 8

  4. Don't ignore active infections: The FDA label is clear—do not initiate secukinumab during active infections, and monitor closely for signs of infection during treatment 1

Practical Algorithm

Before starting secukinumab:

  • Screen for active/latent TB
  • Administer recombinant zoster vaccine if not previously given
  • Ensure no active infections present
  • Document baseline infection history

During treatment:

  • Monitor for candida infections (oral, genital, systemic)
  • Watch for bacterial/viral infections (though HZ risk not elevated)
  • Educate patients to report fever, new skin lesions, or systemic symptoms immediately
  • If serious infection develops, hold secukinumab until resolved 1

References

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.