Can vaccines be administered to patients with a current eczema (atopic dermatitis) flare?

Vaccines Should Not Be Administered During an Active Eczema Flare

Vaccines should not be administered to patients with a current eczema (atopic dermatitis) flare due to the significant risk of serious complications, particularly eczema vaccinatum. 1

Risk Assessment and Rationale

Contraindication for Vaccination During Active Eczema

• Patients with active eczema/atopic dermatitis are at increased risk for developing eczema vaccinatum, a potentially life-threatening complication of vaccinia (smallpox) vaccination 1
• The Advisory Committee on Immunization Practices (ACIP) explicitly states that vaccinia vaccine should not be administered to persons with eczema of any degree, those with a past history of eczema, or those whose household contacts have active eczema 1
• This contraindication extends to other acute, chronic, or exfoliative skin conditions (e.g., atopic dermatitis, burns, impetigo, or varicella zoster) which might also increase risk for serious vaccine complications 1

Pathophysiology of Increased Risk

• Atopic dermatitis, regardless of disease severity or activity, creates an immunologic T-cell dysregulation that predisposes affected individuals to disseminated progressive skin lesions 1
• The disrupted skin barrier function, epidermal hyperplasia, and abnormal immune responses in eczema favor the spread of viral infection 2
• Animal studies demonstrate that these immune dysregulations can lead to disseminated lesions even in intact skin areas 1

Complications of Vaccination During Eczema Flare

Eczema Vaccinatum (EV)

• EV is a localized or generalized papular, vesicular, or pustular rash that can occur anywhere on the body, with predilection for areas of previous atopic dermatitis lesions 1
• The rash is often accompanied by fever and lymphadenopathy, and affected persons become systemically ill 1
• EV tends to be more severe among first-time vaccinees or unvaccinated contacts 1
• Historical data showed mortality from EV was 30%-40% before the introduction of vaccinia immune globulin (VIG) 1

Transmission Risk

• Approximately 30% of eczema vaccinatum cases reported in historical studies were a result of contact transmission from recently vaccinated individuals 1
• Eczema vaccinatum may be more severe among contacts than among vaccinated persons, possibly because of simultaneous multiple inoculations at several sites 1

Management Recommendations

When to Postpone Vaccination

• Postpone vaccination until the eczema flare has completely resolved 1
• The skin condition should be in a state of complete remission before considering vaccination 1

Treatment of Current Eczema Flare

• Focus on treating the current eczema flare with appropriate therapies:
  • Liberal use of emollients and daily bathing with soap-free cleansers as maintenance therapy 3
  • Topical corticosteroids as first-line treatment for flare-ups 3
  • Topical calcineurin inhibitors (pimecrolimus and tacrolimus) can be used in conjunction with topical corticosteroids 3

Preventive Measures

• For patients with a history of eczema who require vaccination in the future:
  • Ensure the skin condition is well-controlled and in remission before vaccination 1
  • Consider the risk-benefit ratio of each specific vaccine individually 4
  • In emergency situations (such as smallpox outbreak), different risk-benefit considerations may apply 1

Special Considerations

Household Contacts

• Vaccinia vaccine should not be administered to individuals whose household contacts have active eczema or a history of eczema 1
• This precaution helps prevent secondary transmission of vaccine virus to vulnerable individuals 1

Alternative Protection

• In cases where vaccination is contraindicated but protection is needed, alternative approaches may include:
  • Passive immunization with immunoglobulins when available 5
  • Modified vaccines that have better safety profiles for at-risk individuals 6
  • Prophylactic antiviral medications in specific exposure scenarios 6