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Boards Fodder Vaccines in Dermatology by Caroline A boards fodder Vaccines in dermatology By Caroline A. Nelson, MD LIVE INACTIVATED/KILLED TOXOID SUBUNIT/ CONJUGATE Adenovirus Hepatitis A virus Diphtheria, tetanus, and Anthrax Cholera (oral) Influenza (injection) pertussis Haemophilus influenzae Influenza (intranasal) Japanese encephalitis Hepatitis B virus Measles, mumps, rubella Polio (injection) Human papillomavirus Polio (oral) Rabies Influenza (injection) Rotavirus Meningococcus Smallpox Pneumococcus Tuberculosis Typhoid (injection) Typhoid (oral) Zoster (Shingrix) Varicella zoster virus Yellow fever Zoster (Zostavax) VACCINE ROUTINE INDICATIONS SKIN REACTIONS/ COMPLICATIONS* NOTES† Viral Infections Hepatitis B Infants at 0-, 2-, and 6-months of Anetoderma, granuloma annulare, lichen Patients without evidence of disease or immunity virus (HBV) age and at-risk adults planus, lichen nitidus, lichen striatus, on serologic testing and with risk factors should papular acrodermatitis of childhood be offered vaccination prior to immunosuppression (Gianotti-Crosti syndrome), polyarteritis nodosa, and pseudolymphoma Human papil- Gardasil and Gardasil-9: Patients Localized lipoatrophy Vaccines contain L1 capsid protein of specific HPV lomavirus 9-26 years of age with a second types: Cervarix has 16 and 18; Gardasil has 6, 11, (HPV) dose after 6-12 months (patients 16, and 18; and Gardasil-9 has 6, 11, 16, 18, 31, 33, 15-26 years of age should receive 45, 52, and 58 a second dose after 1-2 months and a third dose after 6 months) Can be administered regardless of history of abnor- mal PAP smear Cervarix is no longer available in the United States (US) Influenza Patients ≥ 6-months of age each flu Lichen planus, linear IgA, papular acro- season (children 6 months-8 years dermatitis of childhood, serum sickness of age may need two doses) like reaction, and Sweet syndrome The intranasal vaccine is contraindi- cated in immunosuppressed patients Measles, Children at 12-15 months and 4-6 Faint morbilliform exanthem, morphea, Patients without evidence of disease or immunity mumps, years of age papular acrodermatitis of childhood, and on serologic testing should be vaccinated prior to rubella (MMR) transient localized hypertrichosis immunosuppression The vaccine is contraindicated in immunosuppressed patients Most common cause of type I hypersen- sitivity Modified measles: reduced severity disease after exposure to natural measles with less confluent exanthem, inconsistent presence of Koplik spots, and shorter course Smallpox Patients at high risk of exposure Auto-inoculation, contact transmis- “High risk” includes military personnel and health (Vaccinia) (not contraindicated in children) sion, eczema vaccinatum, erythema care workers multiforme/Stevens Johnson syndrome, The vaccine is contraindicated in generalized vaccinia, hypersensitivity Formation of a vesiculo-ulcer with 4 cm of ery- immunosuppressed patients reactions (exanthematous > urticarial > thema at the injection site is required to ensure erythema multiforme-like), papular acro- adequate immunity dermatitis of childhood, post-vaccination Bandage the injection site to prevent auto-inocula- follicular eruption, “robust take” (plaque tion and contact transmission of erythema and induration > 10 cm at the injection site), superinfection, and Eczema vaccinatum can also occur in Darier’s disease, vaccinia necrosum/ gangrenosum also Netherton syndrome, and other disorders of cornification known as “progressive vaccinia” Ocular implants, generalized vaccinia in the immuno- deficient patient, eczema vaccinatum, and progressive vaccinia are indications for vaccinia immune globulin Vaccine also decreases severity of Monkeypox Varicella zoster Children at 12-15 months and 4-6 Zoster, pseudolymphoma, and varicella- Even protects individuals who have never had virus (VZV) years of age like eruption seroconversion or whose antibody levels were undetectable from severe VZV disease The vaccine is contraindicated in Modified varicella-like syndrome: immunosuppressed patients reduced severity disease after exposure Patients without evidence of disease or immunity on to natural varicella with more macules serologic testing should be offered vaccination prior and papules than vesicles, shorter to immunosuppression Caroline A. course, and fewer lesions Varicella-like eruption in leukemic children on che- Nelson, MD, PGY-4 motherapy may require acyclovir is a dermatology Zoster Shingrix: Adults ≥ 50 years of age Shingrix is a subunit vaccine (HZ/su) containing resident at the with a second dose after 2-6 months recombinant VZV glycoprotein E and the AS01B University of adjuvant system that decreases risk of disease and Zostavax was recommended for post-herpetic neuralgia by >90% Pennsylvania. adults ≥ 60 years of age (contra- indicated in immunosuppressed 24 hours before until 14 days after you administer patients); however, Shingrix is now Zotstavax, antivirals should be stopped. recommended including for those who previously received Zostavax p. 4 • Spring 2018 www.aad.org/DIR boards fodder Vaccines in dermatology (continued) By Caroline A. Nelson, MD VACCINE ROUTINE INDICATIONS SKIN REACTIONS/ COMPLICATIONS* NOTES† Boards Bacterial Infections Fodders Diphtheria, DTaP: Children at 2-, 4-, 6-, 15–18 Localized lipoatrophy, morphea, pan- Vaccination against diphtheria does not necessarily tetanus, and months and 4-6 years of age niculitis, and papular acrodermatitis of prevent cutaneous disease pertussis childhood online! Tdap: Patients 11-64 years of age (once) Td vaccination should be offered prior to immuno- suppression Td: Patients every 10 years and after a severe and dirty burn or wound (cat bite, dog bite, human bite, frostbite, myiasis, centipede bite, or brown recluse spider bite) Meningococcus Monovalent (MenB): Patients ≥ 10 “Increased risk” includes asplenia, persistent years of age at increased risk of complement component deficiency, and eculi- exposure and patients at 16-23 zumab therapy, and, for the quadrivalent vaccine, In addition to this years of age to provide short-term college freshmen living in dormitories and military issue’s Boards Fodder, protection with a second dose ≥ 1 recruits month after you can download the new online Quadrivalent (MenACWY and MPSV4): Children at 11-12 and Boards Fodder at 16 years of age and patients at www.aad.org/ increased risk of exposure Directions. Pneumococcus PCV13 (“Prevnar”): Children 2-, Patients should be vaccinated with PPSV23 prior to 4-, 6-, and 12-15 months of age, immunosuppression Go online for a very patients 2-64 years of age with Immunosuppressed patients should be vaccinated special Boards certain health conditions, and with PCV13 followed by PPSV23 if not given previ- adults ≥ 65 years of age Fodder exclusive, ously PPSV23 (“Pneumovax”): Patients Melanoma and 2-64 years of age with certain Mycosis Fungoides health conditions, adults 19-64 by Parin Pearl years of age who smoke cigarettes or have asthma, and adults ≥ 65 Rimtepathip, MD, years of age and Janna Mieko Vassantachart, MD. Tuberculosis BCG is not routinely administered “BCGitis” (enlarging granulomatous May result in false positive tuberculin skin test (Bacillus of in the US but is recommended for plaque at the injection site), dermatomyo- (TST) To view, download, Calmette and infants and children at high risk of sitis, disseminated disease, granuloma Chronic granulomatous disease patients are at Guérin [BCG] exposure and exposed health care annulare, lichen striatus, lupus vulgaris, or print every Boards particularly high risk of disseminated disease strain of workers in high-risk settings pityriasis rosea-like eruption, regional Fodder ever Mycobacterium lymphadenitis, scrofuloderma, Sweet BCG can also be used as post-exposure prophy- The vaccine is contraindicated in published, check out bovis) syndrome, transient localized hypertri- laxis for household contacts of leprosy patients immunosuppressed patients chosis, and the tuberculids: erythema <12 years of age the archives at induratum, lichen scrofulosorum, and www.aad.org/ papular and papulonecrotic tuberculid boardsfodder. Melanoma Traditional Clinical trials Trial data showing improved survival of Vaccines stimulate the antitumor response, which tumor-associ- melanoma patients consists of a priming phase (tumor antigens ated antigen- released by dying tumor cells captured by dendritic based vaccines cells and presented to T lymphocytes) followed by (e.g. gp100 an effector phase (immune response) peptide) and personalized neoantigen- based vaccines *All vaccines may cause injection site reactions and type I hypersensitivity (urticaria, angioedema, and anaphylaxis). Nicolau syndrome may occur after intramuscular vaccinations. Aluminum-containing vaccines may cause nodules and foreign body reactions. Thimerosal-containing vaccines (a mercury- based preservative) may cause allergic contact dermatitis or eosinophilic cellulitis (Wells syndrome). †Live vaccines are contraindicated in immunosuppressed patients including those on high dose prednisone (equivalent to ≥20 mg/day of prednisone or ≥2 mg/kg/day in children weighing <10 kg), biologic agents such as tumor necrosis factor (TNF) inhibitors, interleukin (IL)-12, -23 inhibitors, IL-17 inhibitors, dupilumab, IL-1 inhibitors, rituximab, omalizumab, and Janus kinase (JAK) inhibitors. REFERENCES 1. Bolognia JL, Schaffer JV, Cerroni L, eds. Dermatology. 4th ed. Philadelphia, PA: Elsevier; 2018. 2. James WD, Berger TG, Elston DM. Andrews’ diseases of the skin: clinical dermatology. 11th ed. Philadelphia, PA: Elsevier;
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