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Q&A: High Herpes Zoster Risk in Inflammatory Skin Diseases

Q&A: High Herpes Zoster Risk in Inflammatory Skin Diseases

Wed, 01/22/2020 - 18:29

Dr. Silverberg

A recent study showed patients with chronic inflammatory skin diseases had an increased risk for hospitalization from herpes zoster (HZ).

“Previous studies found that patients with chronic inflammatory and autoimmune diseases, such as rheumatoid arthritis and inflammatory bowel disease, had higher risk of HZ, especially if they were using systemic immunosuppressants and biologics,” said corresponding author Dr Silverberg, associate professor of dermatology and director of clinical research and contact dermatitis at George Washington University School of Medicine and Health Sciences.

He and Raj Chovatiya, MD, PHD, from Northwestern University Feinberg School of Medicine, initially hypothesized that patients with chronic inflammatory skin diseases have a similarly increased risk of HZ. They analyzed data of 68,088,221 children and adults enrolled in the Nationwide Inpatient Sample from 2002 through 2012.

The Results

After adjusting for age, sex, race/ethnicity, insurance, household income, and long-term systemic corticosteroid use, the researchers found hospitalization for HZ was associated with atopic dermatitis (adjust odds ratio [OR] 1.38; 95% CI 1.14-1.68), psoriasis (adjusted OR 4.78; 95% CI, 2.83-8.08), pemphigus (adjusted OR 1.77; 95% CI, 1.01-3.12), bullous pemphigoid (adjusted OR 1.77; 95% CI, 1.01-3.12), mycosis fungoides (adjusted OR 3.79; 95% CI, 2.55-5.65), dermatomyositis (adjusted OR 7.31; 95% CI, 5.27-10.12), systemic sclerosis (adjusted OR 1.92; 95% CI, 1.47-2.53), cutaneous lupus erythematosus (adjusted OR 1.94; 95% CI, 1.10-3.44), vitiligo (adjusted OR 2.00; 1.04-3.85), and sarcoidosis (adjusted OR 1.52; 1.22-1.90).

They observed increased odds of HZ only for lichen planus (crude OR 3.01; 95% CI 1.36-6.67), Sézary syndrome (crude OR 12.14; 95% CI, 5.20-28.31), morphea (crude OR 2.74; 95% CI, 1.36-5.51), and pyoderma gangrenosum (crude OR 2.44; 95% CI 1.16-5.13) in bivariable models.

Sensitivity analyses of individuals less than 60 years and less than 50 years showed similar results.

“We expected that most of the chronic inflammatory skin diseases would be associated with increased prevalence of HZ, owing to shared principals of systemic inflammation and immune dysregulation, and use of immunosuppressive medications,” said Dr Silverberg. “However, HZ was increased even among younger adults (age <60 years old) with chronic inflammatory skin diseases.”

The predictors of HZ included female sex, fewer chronic conditions, and long-term systemic corticosteroid use.

Implications of These Findings and Future Research

Currently, the Advisory Committee on Immunization Practices recommends the HZ vaccine only for immunocompetent adults aged 50 years and older.2 However, said Dr Silverberg, “the findings of our study suggest that younger patients with chronic inflammatory skin diseases, who fall outside the age-range of recommended HZ vaccination, may specifically warrant increased HZ vaccination.” 

Future studies are needed in outpatient and other settings to confirm the association between chronic inflammatory skin diseases and HZ, according to Dr Silverberg. “In addition, more research is needed to better understand the impact of different therapies on the risk of HZ,” he added, which “would provide evidence to guide HZ vaccine and other treatment recommendations in patients with chronic inflammatory skin diseases.”


1. Chovatiya R, Silverberg JI. Association of herpes zoster and chronic inflammatory skin disease in United States inpatients [published January 17, 2020]. J Am Acad Dermatol. doi:10.1016/j.jaad.2019.12.073

2. Dooling KL, Guo A, Patel M, et al. Recommendations of the Advisory Committee on Immunization Practices for Use of Herpes Zoster Vaccines. MMWR Morb Mortal Wkly Rep. 2018;67:103–108. doi:10.15585/mmwr.mm6703a5

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