Can a patient with a leg laceration from a metal box receive a Tdap (tetanus, diphtheria, and pertussis) injection while taking Skyrizi (risankizumab), an immunosuppressive medication?

Tdap Administration in Elderly Patient on Skyrizi with Leg Laceration

Yes, this elderly male patient should receive Tdap vaccination for his contaminated leg laceration from a metal box, as Skyrizi (risankizumab) is not a contraindication to tetanus prophylaxis and does not require TIG administration unless he has severe immunodeficiency or an incomplete vaccination history. 1

Wound Classification and Vaccination Requirements

• A leg laceration from a metal box is classified as a contaminated/tetanus-prone wound because injuries from metal objects may be contaminated with dirt, soil, and debris that harbor Clostridium tetani spores 1

• This classification is critical because it determines a 5-year interval (not 10-year) for booster administration rather than the routine 10-year interval used for clean, minor wounds 1

Vaccination Algorithm Based on Immunization History

If the patient has ≥3 previous doses:

• Last dose <5 years ago: No tetanus vaccine needed 1, 2
• Last dose ≥5 years ago: Administer Tdap immediately WITHOUT TIG 1
• Tdap is strongly preferred over Td if the patient has not previously received Tdap or Tdap history is unknown, as this provides additional protection against pertussis 1

If the patient has <3 previous doses or unknown history:

• Administer BOTH Tdap AND TIG (250 units IM) at separate anatomic sites using separate syringes 1, 3
• The patient must complete a 3-dose primary vaccination series for long-term protection 1

Skyrizi (Risankizumab) Considerations

• Skyrizi is an IL-23 inhibitor used for psoriasis and does not constitute "severe immunodeficiency" as defined by CDC guidelines 1

• TIG is only required for severely immunocompromised patients (HIV infection with severe immunodeficiency, not routine immunosuppressive medications) with contaminated wounds, regardless of vaccination history 1, 2

• Patients on biologic immunosuppressants like Skyrizi can receive Tdap safely and should follow standard wound management protocols based on their tetanus vaccination history 1

Special Considerations for Elderly Patients

• Elderly patients (≥60 years) are at higher risk for tetanus because 49-66% lack protective antibody levels, making vaccination particularly important in this population 1

• Complete primary vaccination provides nearly 100% protection, and persons who have received at least 2 doses rapidly develop antitoxin antibodies after a booster dose 1, 2

Critical Clinical Pearls

• Do not confuse the 10-year routine booster interval with the 5-year interval for contaminated wounds - this is the most common error in tetanus prophylaxis 1

• Proper wound cleaning and debridement are crucial components of tetanus prevention in addition to vaccination 1

• If the patient has a history of Arthus reaction following a previous tetanus toxoid dose, do not administer tetanus vaccine until >10 years after the most recent dose, even with contaminated wounds 1, 2

• Verify vaccination history carefully - patients with unknown or uncertain histories should be treated as having zero previous doses and receive both Tdap and TIG 1, 3