Immunisation in immunosuppressed dermatology patients

Author: Dr Diana Purvis, Paediatric Dermatologist, Starship Hospital, Auckland, New Zealand. Reviewed by Gary Reynolds PhD (Immunology) FRNZCGP, GP Medical Advisor to IMAC, April 2012.

Background: Immunodeficiency

Immunodeficiency can be caused by inherited syndromes, infections, drugs, medical conditions, pregnancy, ageing and many other factors. Immunodeficiency is defined as inadequate functioning of the immune system. It can occur at multiple points across the immune response. It can then lead to:

Immunodeficient people that become unwell should be carefully evaluated and infection should be treated aggressively.

Immunosuppression due to drugs

Immunosuppression is general dampening of the immune response, usually in response to immunosuppressive drugs. The immune response is still mounted but it is not as efficient or efficacious.

Immunosuppressive drugs include:

Lower doses or shorter courses of systemic steroids are not considered significantly immunosuppressive. Low-dose methotrexate used for skin diseases mainly acts as an anti-inflammatory drug and is only weakly immunosuppressive.

Immunisation prior to immunosuppression in dermatology patients

In dermatology we are frequently responsible for patients commencing immunosuppressive treatment for inflammatory skin disorders. Whenever possible, immunosuppressive treatments should be delayed until immune status has been optimised.

Step 1: Take an immunisation history

Prior to starting immunosuppressive therapy, determine the following:

The government funded New Zealand National Immunisation Schedule (2011) includes:

Changes to the schedule for 1 July 2014 add rotavirus vaccine, varicella vaccine (for high-risk immunosuppressed patients), hepatitis A vaccine (for eligible patients) and a monovalent meningococcal C vaccine. The HPV vaccine is changed to 'up to 18 years'. Revaccination of children following significant immunosuppression will also be funded. The pneumococcal vaccine will be replaced by a 13-valent product and the current polysaccharide meningococcal A, C, Y and W-145 vaccine will be replaced by a conjugate product.

Other non-funded vaccines are available against varicella, various meningococcus strains, tuberculosis (BCG), rotavirus and seasonal influenza. Vaccines recommended for travel may include hepatitis A, cholera and yellow fever.

Live injected vaccines are MMR, oral polio (not IPV), varicella, zoster (shingles), yellow fever and BCG. There are live oral vaccines for rotavrus and typhoid. These are best avoided while on immunosuppressive medication because they may result in severe vaccine reactions.

Step 2: Perform appropriate tests

If starting a cytotoxic drug such as cyclophosphamide or biologic therapy, or if considered at high-risk of TB from the history, screen for tuberculosis. Methods include:

Check varicella, measles, hepatitis A/B/C and HIV serology. (There are no vaccines for hepatitis C or HIV).

Step 3: Vaccinate prior to starting immunosuppressive therapies

To avoid the risks of preventable infections:

*New Zealand Immunisation Schedule 6 June 2014

Step 4: Vaccinations after starting immunosuppression

All patients on immunosuppressants should be warned that they are at risk of more severe infections than usual. They should be told to alert their care team if they are exposed to chickenpox (varicella) or measles.

Exposure of immunosuppressed patients to varicella and measles

Patients who are significantly immunosuppressed and are exposed to varicella or measles need to be given passive antibody protection, whether or not they have detectable antiviral IgG antibodies.

Passive antibody protection is not considered necessary for those who have evidence of immunity with detectable IgG antibodies and are taking methotrexate as their only immunosuppressive drug.


There is a significant risk of varicella if a non-immune person is exposed to the virus during the infectious period. This occurs from 2 days before the rash appears until the blisters have crusted over. The incubation period after exposure is 7-21 days. ‘Significant’ exposure is considered to be 15 minutes of close contact/play with a contagious individual.

Chickenpox may also occur after direct contact with shingles/herpes zoster blisters.

If an immune suppressed patient is in contact with varicella, passive protection should be provided with varicella zoster immune globulin (VZIG) within 96 hours (ideally 72 hours) of contact.


There is a significant risk of measles if a non-immune person is exposed to the virus during the infectious period. This occurs from 5 days before the rash appears until 4 days after the onset of rash. The inclubation period for measles is 10-14 days after exposure. ‘Significant’ exposure is considered to be 15 minutes of close contact/play with a contagious individual. Measles in the contact should be confirmed by viral serology, as measles rash may appear similar to other viral exanthems or morbilliform drug eruptions.

If an immune suppressed patient is in contact with measles, the following treatment is recommended regardless of antibody status.

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