What is the evidence-based recommendation for using Hepatitis B Virus (HBV) vaccine, pneumococcal vaccine, and Zoster vaccine in dermatological patients taking biological and Janus Kinase (JAK) inhibitors?

Vaccination in Dermatological Patients on Biologics and JAK Inhibitors

Direct Recommendation

All dermatological patients starting biologics or JAK inhibitors should receive HBV testing (anti-HBs, anti-HBc, HBsAg), pneumococcal vaccination, and the 2-dose recombinant zoster vaccine (Shingrix) series before initiating therapy—this represents high-quality, guideline-level evidence with strong recommendations for infection prevention in immunosuppressed patients. 1

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Evidence Quality and Strength of Recommendations

Hepatitis B Virus (HBV) Screening and Vaccination

HBV testing is mandatory before starting biologics or JAK inhibitors with the highest level of evidence supporting this practice. 1

• Testing requirements: All patients must undergo HBV testing for anti-HBs, anti-HBc, and HBsAg before initiating therapy. 1
• Management algorithm:
  • Chronic HBV infection (HBsAg positive): Avoid biologics/JAK inhibitors if possible; if unavoidable, initiate antiviral prophylaxis (entecavir, tenofovir, or tenofovir alafenamide) with hepatologist consultation. 1
  • Prior HBV exposure (anti-HBc positive, HBsAg negative): Obtain baseline HBV DNA to exclude occult infection; if negative, proceed with therapy but monitor routinely for HBV DNA and HBsAg reappearance (seroreversion). 1
  • HBV DNA or HBsAg turns positive during monitoring: Temporarily stop the biologic/JAK inhibitor, refer to hepatology, and restart therapy only after antiviral treatment is initiated. 1

Evidence level: This represents Grade A evidence from consensus guidelines by the Annals of the Rheumatic Diseases (2021), which provides explicit, algorithmic management for HBV in patients on JAK inhibitors. 1

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Pneumococcal Vaccination

Pneumococcal vaccination should be administered before starting biologics or JAK inhibitors with strong guideline support. 2, 3

• Timing: Administer inactivated pneumococcal vaccine for all patients ≥18 years old before treatment initiation. 2, 3
• Efficacy considerations: Studies demonstrate that monotherapy with TNF antagonists (infliximab, etanercept, adalimumab) does not significantly impair humoral responses to pneumococcal vaccination. 1
• Critical caveat: Methotrexate significantly reduces humoral responses to pneumococcal vaccine when used alone or in combination with TNF antagonists—this is a well-documented pitfall. 1

Evidence level: This represents Grade B evidence from the British Association of Dermatologists (2009) and more recent consensus statements (2021), with consistent recommendations across multiple guidelines. 1, 2, 3

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Herpes Zoster (Shingles) Vaccination

The recombinant zoster vaccine (Shingrix) is the single most important vaccination for patients on JAK inhibitors due to dramatically increased herpes zoster risk. 1, 2, 3

Vaccination Protocol

• Preferred vaccine: Shingrix (recombinant zoster vaccine, RZV) is the only recommended vaccine—never use live-attenuated Zostavax in patients on or about to start immunosuppressive therapy. 1, 2, 3
• Dosing schedule:
  • Standard (immunocompetent): 2-dose series separated by 2-6 months, completed before initiating therapy. 1, 2, 3
  • Immunocompromised patients ≥18 years: Shortened schedule with second dose at 1-2 months after the first dose. 1, 3
• Age indication: All patients ≥18 years old starting JAK inhibitors should receive Shingrix, regardless of age (this differs from the standard ≥50 years recommendation for immunocompetent adults). 1, 2, 3

Clinical Rationale

• Herpes zoster incidence with JAK inhibitors: 3-4 per 100 patient-years in Western populations; up to 9 per 100 patient-years in Asian populations (Japan, Korea). 1, 2, 3
• Mechanism: JAK1/2 inhibition impairs interferon-γ signaling and cellular cytotoxicity against viral pathogens, directly increasing reactivation risk. 2, 3
• Risk factors for zoster reactivation: Age, female gender, concomitant prednisone >7.5 mg daily, and hospitalization. 3

Optimal Timing Algorithm

For elective JAK inhibitor initiation:

1. Administer first Shingrix dose immediately
2. Wait 2-6 months and give second dose
3. Start JAK inhibitor after completing vaccination series 2, 3

For urgent JAK inhibitor initiation:

1. Administer first Shingrix dose
2. Start JAK inhibitor 2-3 weeks after first vaccine dose
3. Complete second Shingrix dose 1-2 months later 2, 3

If recombinant vaccine unavailable (rare scenario):

• Live zoster vaccine (Zostavax) must be administered at least 3-4 weeks before starting JAK inhibitors, though its efficacy is questionable. 2, 3

Management of Breakthrough Herpes Zoster

• Temporarily interrupt JAK inhibitor treatment until the herpes zoster episode completely resolves. 3
• Recurrent zoster: Consider antiviral prophylaxis for patients who develop recurrent episodes. 3
• Important note: Even with vaccination, breakthrough cases can occur (vaccine efficacy ~92%), but vaccinated individuals experience less severe disease and lower rates of post-herpetic neuralgia. 4

Evidence level: This represents Grade A evidence from multiple high-quality guidelines including the Journal of the American Academy of Dermatology (2024), Annals of the Rheumatic Diseases (2021), and consistent recommendations across all recent consensus statements. 1, 2, 3

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Additional Critical Vaccinations

Influenza Vaccination

• Annual inactivated influenza vaccine is recommended for all patients on biologics or JAK inhibitors. 2, 3
• Timing consideration: Consider a 1-week pause of JAK inhibitor treatment after COVID-19 vaccination to prevent insufficient vaccination response (though this should be balanced against disease control needs). 2, 3

Live Vaccine Contraindications

• All live vaccines are absolutely contraindicated once biologic or JAK inhibitor therapy has begun. 1, 2, 3
• Live vaccines include: BCG, measles, mumps, rubella, yellow fever, oral polio, oral typhoid, and live-attenuated Zostavax. 1
• If live vaccines are needed: They must be administered at least 3-4 weeks (preferably 6 months per UK Department of Health guidance) before starting immunosuppressive therapy. 1, 2, 3

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Summary of Evidence Quality

Vaccine	Evidence Level	Strength of Recommendation	Key Guideline Source
HBV Testing	Grade A	Mandatory	Annals of the Rheumatic Diseases 2021 [1]
Pneumococcal	Grade B	Strongly Recommended	British Journal of Dermatology 2009, Consensus 2021 [1,2,3]
Herpes Zoster (Shingrix)	Grade A	Mandatory for JAK inhibitors	JAAD 2024, Annals of the Rheumatic Diseases 2021 [1,2,3]
Influenza	Grade B	Strongly Recommended	Multiple guidelines [2,3]

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Common Pitfalls to Avoid

1. Never delay vaccination series unnecessarily, but recognize that urgent clinical scenarios may require starting therapy before completing the full Shingrix series—in such cases, give at least the first dose before initiating JAK inhibitors. 2, 3

2. Never use live-attenuated Zostavax in patients on or about to start biologics/JAK inhibitors—only Shingrix (RZV) is appropriate. 1, 2, 3

3. Do not assume methotrexate is safe to combine with pneumococcal vaccination—it significantly impairs vaccine response and should be considered when timing vaccinations. 1

4. Do not forget that HBV testing is not just about vaccination—it's about identifying patients who need antiviral prophylaxis to prevent life-threatening hepatitis flares. 1

5. Do not initiate biologics/JAK inhibitors in patients with any active serious infection, including localized infections, until completely resolved. 3

6. Do not combine JAK inhibitors with other biologic DMARDs or potent immunosuppressive agents (cyclosporine, tacrolimus) due to increased immunosuppression risk. 3