Smallpox: What the Dermatologist Should Know

Phyllis I. Spuls, MD; Jan D. Bos, MD, PhD; Donald Rudikoff, MD


Skinmed. 2004;3(4) 

In This Article

Eczema Vaccinatum

This complication occurred commonly in vaccinees or family contacts with active or quiescent eczema or a history of eczema. It sometimes occurred in other skin diseases with barrier abnormalities. In a manner analogous to eczema herpeticum, vaccinia pustules arose at active or previous sites of dermatitis accompanied by high fever and generalized lymphadenopathy (Figure 6). The onset of skin lesions paralleled the development of the primary vaccinia pustules. Although the illness was usually mild and self-limited, some cases were quite serious and were occasionally fatal. Severity was often independent of the activity of the underlying eczema. Primary vaccinees and close contacts with a history of eczema were at the greatest risk. Eczema vaccinatum occurred in approximately one case per 26,000 primary vaccinations, and risk of mortality varied from 1% to 6%. VIG was often effective in serious cases.[47,48] In most patients, the recommended initial dose of intramuscular VIG is 0.6-1.0 mL/kg body weight. CDC recommends that as much as 5-10 mL/kg of intramuscular VIG, divided into multiple doses, be administered over several days if lesions of eczema vaccinatum are extensive on initial presentation. The current intramuscular VIG is considered an experimental drug only available under US Food and Drug Administration investigational new drug protocol. Intravenous VIG may become available in the not-too-distant future.

Eczema vaccinatum occurred in vaccinees and contacts with active, quiescent, or a history of atopic dermatitis or other skin diseases with disturbed barrier function. Reprinted with permission from Smallpox and Its Eradication.[6]

Although vaccination of individuals with atopic dermatitis is now proscribed, it is of historical interest that early in the 20th century people with eczema were routinely vaccinated, and it was also considered that vaccination could actually induce eczema.[49] Schamberg[49] disputed this contention and commented, "...there is no reason to believe that vaccination plays any material role in the causation of eczema. Eczematous children, if in good health otherwise, may usually be vaccinated without any aggravation of the existing cutaneous disease." He went on to quote Van Harlingen who had studied the effect of vaccination on previously existing skin disease: "During the smallpox epidemic of 1872, I observed all cases of skin diseases coming under my notice in which vaccination had been practiced. In a few, some aggravation of the symptoms followed; in others, an apparent improvement took place." Schamberg also noted, "French writers have reported a number of instances of diffusion of the vaccinial eruption over an extensive cutaneous area the seat of a moist eczema. Unless there is danger of exposure to smallpox, it is, indeed, advisable to postpone vaccination if the subject is suffering from a dermatosis in which there is denudation of the skin." He then stated, "...I have, from time to time, vaccinated persons with eczema and other cutaneous diseases without any injury whatsoever. On the other hand, vaccination has, on a number of occasions, been followed by improvement and even cure of eczema." Subsequent data have of course shown the danger of vaccinating persons with eczema and this should never be done unless there has been an actual credible exposure to smallpox.


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