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Author: Dr Leah Jones, Medical Registrar, Christchurch, New Zealand. DermNet NZ Editor in Chief: Adjunct A/Prof Amanda Oakley, Dermatologist, Hamilton, New Zealand. Copy edited by Gus Mitchell. July 2020.
Drug-induced immune suppression, also known as medication-induced immunosuppression, refers to impaired immune system function as the result of medications used in the treatment of systemic diseases. This typically manifests as recurrent, severe, unusual, or opportunistic infections .
There are several medications used to treat dermatological conditions that affect the immune system to a variable extent.
Chronic drug-induced immune suppression for other reasons (for example, to prevent rejection in organ transplantation patients) is also associated with a number of dermatological complications .
The main medications used in dermatology that cause significant drug-induced immune suppression include :
Other medications that result in a milder impairment of immune function, especially if in conjunction with other agents, include:
Examples of biological agents are:
Immunosuppressive therapy is used in a variety of dermatological conditions, including psoriasis, atopic dermatitis, autoimmune bullous diseases, and cutaneous lupus erythematosus [3,4]. In some patients, drug-induced immune suppression involves multiple agents with synergistic effects on immune suppression [5,6].
Drug-induced immune suppression can occur by one or more mechanisms, including [1,5]:
Drug-induced immune suppression can lead to bacterial, viral, fungal, or parasitic infections, with different medications predisposing to specific types of organisms . Many of these result in cutaneous disease or signs, notably bacterial abscesses, herpes zoster, herpes simplex, cytomegalovirus, and viral warts .
Bacterial infections associated with drug-induced immune suppression include :
Viral infections associated with drug-induced immune suppression include :
Fungal and parasitic infections associated with drug-induced immune suppression include :
High-dose chronic drug-induced immune suppression is associated with non-infectious dermatological problems, such as acne, gingival enlargement, hypertrichosis, and induction of skin cancer, in particular cutaneous squamous cell carcinoma .
Infections associated with drug-induced immune suppression can cause serious morbidity and potentially mortality, particularly in those with a poor functional state at baseline [6,7]. Immunosuppressive therapy can also change the clinical features of an infection, making it more difficult to diagnose .
The development of a serious infection can lead to complex clinical management decisions regarding the immune-suppressive treatment of the underlying condition [5,6].
Drug-induced immune suppression prevents the administration of live vaccines — because they might be hazardous — and limits the efficacy of other vaccines . If practical, it is best to have any recommended vaccinations prior to initiating immunosuppressive drug treatment [5,6].
Drug-induced immune suppression is a clinical diagnosis based on the known effects of the patient’s medications.
To quantify the extent of drug-induced immune suppression, antibody response can be measured before and after vaccination for pneumococcus. However, this predominantly assesses humoral immunity, not cell-mediated immunity, and is rarely performed .
The effects of drug-induced immune suppression can be limited by taking preventative measures such as [5,6]:
If infections are severe or recurrent, the immunosuppressive therapy may need to be reduced or stopped and alterative drug management options considered [1,6].
Drug-induced immune suppression has a variable prognosis. This can be based on the characteristics of the drug, the patient, and the disease being treated [1,5,7].
Drug characteristics include:
Patient characteristics include:
Low-dose, single-agent immunosuppressive therapy for a short duration carries only a minor risk of serious infection and mortality [1,2,9].
If you are not based in New Zealand, we suggest you refer to your national drug approval agency for further information about medicines (eg, the Australian Therapeutic Goods Administration and the US Food and Drug Administration) or a national or state-approved formulary (eg, the New Zealand Formulary and New Zealand Formulary for Children and the British National Formulary and British National Formulary for Children).
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