Can Vaccines Cause Eczema?
The smallpox (vaccinia) vaccine is absolutely contraindicated in patients with eczema/atopic dermatitis because it can cause eczema vaccinatum—a severe, potentially fatal complication—but modern routine vaccines (MMR, DTaP, influenza, etc.) do not cause eczema and are safe to administer to patients with atopic dermatitis. 1, 2, 3
Smallpox Vaccine: The Critical Exception
Absolute Contraindication
- Never administer vaccinia (smallpox) vaccine to anyone with active eczema, a history of eczema, or household contacts with eczema. 1, 2
- This contraindication applies regardless of whether the eczema is currently active or in remission. 1, 2
- The contraindication extends to other chronic or exfoliative skin conditions including atopic dermatitis, burns, impetigo, or varicella zoster. 1
Eczema Vaccinatum: A Life-Threatening Complication
- Eczema vaccinatum (EV) is a localized or systemic dissemination of vaccinia virus that occurs specifically in persons with eczema or atopic dermatitis. 1
- EV presents with vesicular or pustular lesions following the same progression as the vaccination site, often accompanied by fever, lymphadenopathy, and systemic illness. 1
- Historical mortality rates were 30-40% before vaccinia immune globulin (VIG) became available. 2
- Approximately 30% of EV cases result from contact transmission—when a recently vaccinated person transmits the virus to an unvaccinated person with eczema. 1, 2
Risk Magnitude
- In the 1968 10-state survey, approximately 30% of contact transmissions resulted in eczema vaccinatum, which could be fatal. 1
- EV tends to be most severe among first-time vaccinees, unvaccinated close contacts of vaccinees, and young children. 1
- The most serious cases occur among primary vaccinees and are independent of whether the underlying eczema is currently active. 1
Modern Routine Vaccines: Safe in Eczema
No Contraindication for Standard Vaccines
- Atopic dermatitis is NOT a contraindication to routine childhood or adult vaccines including MMR, DTaP, influenza, hepatitis, HPV, or COVID-19 vaccines. 3
- The CDC explicitly recommends proceeding with routine MMR immunization according to the standard schedule for babies with atopic dermatitis. 3
- Atopic dermatitis is only a contraindication for smallpox (vaccinia) vaccine, not for any other vaccine. 3
Actual Contraindications to Consider
- Anaphylactic reactions to vaccine components (neomycin, gelatin) are true contraindications to specific vaccines like MMR. 3
- Contact dermatitis to neomycin is NOT a contraindication to MMR vaccination. 3
- Egg allergy is NOT a contraindication to MMR vaccination, even with a history of anaphylaxis to eggs. 3
Clinical Pitfalls to Avoid
Screening Failures
- Two-thirds of potential smallpox vaccinees failed to recall an exclusionary dermatologic condition such as atopic dermatitis in themselves or their close contacts. 1
- Poor recall and inconsistent diagnosis of atopic dermatitis contributes to challenging screening programs to exclude persons at risk for EV. 1
- When evaluating vaccinees or close contacts of recent vaccinees with a clinical presentation consistent with EV, consider EV even with a negative self-reported history of atopic dermatitis. 1
Household Contact Risk
- Vaccinia virus can be cultured from the vaccination site from 2-5 days after vaccination until the scab separates (14-21 days after vaccination). 1
- During this period, care must be taken to prevent transmission to household contacts with eczema. 1
- Six cases of contact transmission from a single vaccine recipient have been documented. 1
Treatment When EV Occurs
Immediate Management
- Early diagnosis and administration of VIG is essential to reduce morbidity and mortality. 1
- Second-line therapy includes cidofovir for severe cases. 1
- Intensive monitoring and tertiary-level supportive care are required. 1
- Recent case reports demonstrate successful use of ST-246 (an investigational orthopoxvirus agent) in severe pediatric cases. 4