PCV13 is recommended routinely for all children beginning at age 2 months through age 59 months and for adults aged 65 years or older. PCV13 is also recommended for children, adolescents, and adults with conditions that place them at high risk for invasive disease from Streptococcus pneumoniae. PCV13 is recommended for persons aged years who have not previously received PCV13 and have congenital immunodeficiency disorders including B- or T-lymphocyte deficiency, complement deficiencies, and phagocytic disorders , anatomic or functional asplenia including sickle cell disease and other hemoglobinopathies , HIV infection, cochlear implant, cerebrospinal fluid leak, chronic renal failure, nephrotic syndrome, iatrogenic immunosuppression, or other immunocompromising conditions.
PPSV23 is also recommended for persons age 2 through 64 years with congenital immunodeficiency disorders, anatomical and functional asplenia, HIV infection, cochlear implant, cerebrospinal fluid leak, and iatrogenic immunosuppression.
Persons with functional or anatomic asplenia including sickle cell disease and persistent complement component deficiency including persons taking eculizumab [Soliris] 7 are at increased risk for meningococcal disease and should receive both MenACWY and MenB vaccines. For children 2 months through 23 months of age, an age-appropriate series of meningococcal conjugate vaccine should be administered.
Following the primary series of vaccine, a 3-year interval to the next dose is recommended for persons who received their previous dose at younger than 7 years. A 5-year interval is recommended for persons who received their previous dose at age 7 years or older. Meningococcal serogroup B vaccines are licensed for persons years of age and are recommended for persons 10 years of age or older for persons with high-risk conditions like functional or anatomic asplenia or persistent complement component deficiency.
There are presently no recommendations for booster doses of either MenB vaccine 9, Complete recommendations for use of meningococcal vaccines are available in the Recommended Immunization Schedules for Persons Aged 0 Through 18 Years and the Recommended Adult Schedule 2,6. Hib conjugate vaccines are available in single or combined antigen preparations.
Hib vaccine is recommended routinely for all children through age 59 months. Children 12 through 59 months who are at high risk for invasive Hib disease i. A child younger than 5 years of age receiving chemotherapy or radiation therapy should have Hib doses repeated if the doses were received during therapy or within 14 days of starting therapy; repeat doses should be started at least 3 months after completion of therapy.
Recipients of hematopoietic cell transplants should be revaccinated with 3 doses of Hib vaccine, starting months after successful transplant, regardless of vaccination history or age. Children years of age with HIV who are unimmunized a should receive a dose of Hib vaccine; Hib vaccination is not recommended in HIV-infected adults. Unimmunized a asplenic patients older than 59 months of age or adults should receive a dose of Hib vaccine.
Anyone 15 months of age or older who is undergoing a splenectomy and is unimmunized a should receive a dose of Hib vaccine Household contacts and other close contacts of persons with altered immunocompetence should receive all age- and exposure-appropriate vaccines, with the exception of smallpox vaccine 12, Receipt of vaccines will prevent the vaccine-preventable disease, so there can be no potential transmission to the contact with altered immunocompetence.
The live MMR, varicella, and rotavirus vaccines should be administered to susceptible household contacts and other close contacts of immunocompromised patients when indicated. No specific precautions are needed unless the varicella vaccine recipient has a rash after vaccination, in which case direct contact with susceptible household contacts with altered immunocompetence should be avoided until the rash resolves 14, All members of the household should wash their hands after changing the diaper of an infant who received rotavirus vaccine.
This minimizes rotavirus transmission, as shedding may occur up to one month after the last dose 16, Household and other close contacts of persons with altered immunocompetence should receive annual influenza vaccination.
Introduction of low levels of vaccine viruses into the environment likely is unavoidable when administering LAIV. LAIV vaccine viruses are cold-adapted, so they can replicate in the nose and generate an immune response without entering the lungs i. No instances have been reported of illness caused by attenuated vaccine virus infections among health-care providers or immunocompromised patients.
LAIV may be administered to healthy household and other close contacts of persons with altered immunocompetence unless the person with altered immunocompetence is in a protective environment, typically defined as a specialized patient-care area with a positive airflow relative to the corridor, high-efficiency particulate air filtration, and frequent air changes 3. No preference exists for inactivated influenza vaccine use by health-care workers or other persons who have close contact with persons with lesser degrees of immunosuppression e.
All inactivated vaccines can be administered safely to persons with altered immunocompetence, whether the vaccine is a killed whole-organism or a recombinant, subunit, split-virus, toxoid, polysaccharide, or polysaccharide protein-conjugate vaccine. Except for inactivated influenza vaccine, vaccination during chemotherapy or radiation therapy should be avoided if possible because antibody response might be suboptimal.
Patients vaccinated within a day period before starting immunosuppressive therapy or while receiving immunosuppressive therapy should be considered unimmunized and should be revaccinated at least 3 months after therapy is discontinued if immune competence has been restored.
Patients who have quantitative B-cell deficiencies and are receiving immunoglobulin therapy should not receive either inactivated or live vaccines while receiving the immunoglobulin therapy because of concerns about effectiveness of the vaccines. Patients on chemotherapy with anti-B cell antibodies e. Some experts recommended longer than 6 months for some anti-B cell antibodies.
For other forms of altered immunocompetence, if inactivated vaccines are indicated, the usual schedules are recommended. However, the effectiveness of such vaccinations might be suboptimal 1. The same rationale regarding effectiveness that exists with inactivated vaccines also exists with live vaccines. Severe complications have followed vaccination with certain live, attenuated viral and live, attenuated bacterial vaccines among persons with altered immunocompetence However, exceptions exist, and are discussed in this section.
Patients with any defect in phagocytic function e. Patients with a specific type of defect in phagocytic function—chronic granulomatous disease—should receive otherwise indicated live attenuated viral vaccines in addition to inactivated vaccines but should NOT receive live bacterial vaccines. Patients with defects in phagocytic function that are undefined or known to be accompanied by defects in T-cell and natural killer cell function e. These conditions include specific deficits in T-cell and natural killer cell function, reducing the response to live viral vaccine antigens to an extent not seen in chronic granulomatous disease 1.
Children with deficiencies in complement should receive otherwise indicated live, attenuated viral and live, attenuated bacterial vaccines. Children with asplenia should not receive LAIV, but can receive other indicated live, attenuated viral and live, attenuated bacterial vaccines. Persons with severe cell-mediated immunodeficiency should not receive live, attenuated viral or bacterial vaccines. Patients with deficiencies of interferon-gamma or interferon-alpha should not receive live viral or live bacterial vaccine.
These defects involve a deficiency in cytokine production which affects the immune response to a wide scope of antigens, both bacterial and viral 1. Two factors support vaccination of HIV-exposed or HIV-infected infants with rotavirus vaccines: 1 the HIV diagnosis might not be established in infants born to HIV-infected mothers before the age of the first rotavirus vaccine dose only 1.
Patients taking exogenous interferon as therapy should not receive live bacterial or live viral vaccines. Children with HIV infection are at increased risk for complications from varicella and herpes zoster infection compared with immunocompetent children 27, Data on use of varicella vaccine in HIV-infected adolescents and adults are lacking. Varicella vaccine should be considered for persons who meet these criteria.
Eligible HIV-infected persons 12 months of age or older should receive 2 doses of single-component varicella vaccine with a 3-month interval between doses 14, Persons with HIV infection are at increased risk for severe complications if infected with measles. No severe or unusual adverse events have been reported after measles vaccination among HIV-infected persons who did not have evidence of severe immunosuppression Similarly, repeat doses of MMR vaccination are recommended for individuals with perinatal HIV infection who were vaccinated prior to establishment of effective combination antiretroviral therapy cART.
HIV-infected persons who are receiving regular doses of IGIV are unlikely to respond to varicella vaccine or MMR vaccine because of the continued presence of passively acquired antibody. However, because of the potential benefit, MMR and varicella vaccines should be considered approximately 14 days before the next scheduled dose of IGIV if not otherwise contraindicated , although an optimal immune response might not occur depending on the presence of neutralizing antibodies against the vaccine virus.
Vaccination should be repeated if not otherwise contraindicated after the recommended interval see Table in the Timing and Spacing of Immunobiologics of this document. In most cases, this is after the therapy has been discontinued. Patients with leukemia, lymphoma, or other malignancies whose disease is in remission, who have restored immunocompetence, and whose chemotherapy has been discontinued for at least 3 months can receive live-virus vaccines.
Persons with impaired humoral immunity e. However, most persons with these disorders also receive periodic doses of IGIV. Appropriate spacing should be maintained between administration of IGIV and varicella vaccine in an attempt to prevent an inadequate response to vaccination caused by the presence of neutralizing antibodies from the IGIV. Zoster incidence is higher in persons with altered immunocompetence Adults with most types of altered immunocompetence are expected to maintain residual immunity to varicella-zoster virus because of chronic latent infection that protects against primary varicella but provides incomplete protection against zoster.
Zoster vaccine is not recommended in persons with primary or acquired immunodeficiency e. Zoster vaccine may be administered to certain persons age 50 or older with altered immunocompetence, such as persons receiving low dosages of immunosuppressive medications, those with isolated B-cell deficiencies i. Top of Page. A hematopoietic cell transplant HCT results in immunosuppression because of the hematopoietic ablative therapy administered before the transplant, drugs used to prevent or treat graft-versus-host disease, and, in some cases, from the underlying disease process necessitating transplantation Antibody titers to vaccine-preventable diseases e.
HCT recipients of all ages are at increased risk for certain vaccine-preventable diseases, including diseases caused by encapsulated bacteria i. As a result, HCT recipients who received vaccines prior to their HCT should be revaccinated routinely after HCT, regardless of the source of the transplanted stem cells Vaccination or revaccination doses of pneumococcal vaccines, DTaP vaccine, Hib vaccine, hepatitis A vaccine, hepatitis B vaccine, meningococcal vaccines, IPV, inactivated influenza vaccines, and human papillomavirus HPV vaccines for individuals aged years are recommended after HCT 1 , 35 b.
Yellow fever vaccine, rabies vaccine, tick-borne encephalitis vaccine, and Japanese encephalitis vaccine are not routinely administered vaccines, so their use post-HCT will be driven by a disease-specific risk such as exposure or travel. Most inactivated vaccines should be initiated 6 months after the HCT Inactivated influenza vaccine should be administered beginning at least 6 months after HCT and annually thereafter for the life of the patient.
A dose of inactivated influenza vaccine can be given as early as 4 months after HCT, but a second dose should be considered in this situation A second dose is recommended routinely for all children younger than 9 years receiving influenza vaccine for the first time.
Sequential administration of 3 doses of pneumococcal conjugate vaccine is recommended, beginning months after the transplant, followed by a dose of PPSV23 Some sources state a 4-week interval between these doses as reasonable with the dose of PPSV23 being replaced by a dose of PCV13 in the context of graft-versus-host disease A 3-dose regimen of Hib vaccine should be administered beginning 6 months after transplant; at least 1 month should separate the doses This series should be given regardless of whether or not vaccine doses were administered prior to the HCT.
Providers need to make a clinical judgment whether they will follow the revaccination schedule described above, even if doses were not administered prior to the HCT. There are specific recommendations for Hib and pertussis-containing vaccines. This is identical to one of the alternative regimens for revaccination doses, described above.
Asplenia and use of corticosteroids or certain drugs have the potential to be immunosuppressive and are presumed to cause some degree of altered immunocompetence. Persons with anatomic asplenia e. Children should receive an age-appropriate series of PCV Unvaccinated children years should receive 2 doses of PCV Meningococcal conjugate MenACWY and serogroup B MenB vaccines are recommended for persons with anatomic or functional asplenia including sickle cell disease.
The application of high-potency steroids can induce a deep-tissue tinea infection known as a Majocchi granuloma. Easy bruising. Increased fragility. Stellate pseudoscars. Steroid atrophy. Aggravation of cutaneous infection. Granuloma gluteale infantum. Masked infection tinea incognito. Secondary infections. Contact dermatitis. Delayed wound healing. Hypertrichosis hirsutism. Perioral dermatitis.
Reactivation of Kaposi sarcoma. Rebound flare. Steroid-induced acne. Steroid-induced rosacea. Ocular hypertension. Cushing disease. Hypothalamic-pituitary-adrenal suppression. Aseptic necrosis of the femoral head.
Decreased growth rate. Peripheral edema. Adverse effects of topical glucocorticosteroids. J Am Acad Dermatol. This tinea folliculitis requires oral antifungal therapy. Combinations of antifungal agents and corticosteroids should be avoided to reduce the risk of severe, persistent, or recurrent tinea infections. Topical applications of corticosteroids can also result in hypopigmentation.
This is more apparent with darker skin tones, but can happen in all skin types. Repigmentation often occurs after discontinuing steroid use. Steroids can induce a contact dermatitis in a minority of patients, but many cases result from the presence of preservatives, lanolin, or other components of the vehicle.
Non-fluorinated steroids e. Topically applied high- and ultra-high-potency corticosteroids can be absorbed well enough to cause systemic side effects. Hypothalamic-pituitary-adrenal suppression, glaucoma, septic necrosis of the femoral head, hyperglycemia, hypertension, and other systemic side effects have been reported.
According to a postmarketing safety review, the most frequently reported side effects were local irritation 66 percent , skin discoloration 15 percent , and striae or skin atrophy 15 percent. Topical steroids can induce birth defects in animals when used in large amounts, under occlusion, or for long duration. Food and Drug Administration as pregnancy category C.
It is unclear whether topical steroids are excreted in breast milk; as a precaution, application of topical steroids to the breasts should be done immediately following nursing to allow as much time as possible before the next feeding.
Children often require a shorter duration of treatment and a lower potency steroid. Already a member or subscriber? Log in. At the time the article was written, Dr. He received his doctorate of pharmacy from the Nesbitt College of Pharmacy and Nursing and completed residency training and a faculty development fellowship at the University of Pittsburgh Pa. Margaret Family Medicine Residency Program. Address correspondence to Jonathan D. South St. Reprints are not available from the authors.
Interventions for chronic palmoplantar pustulosis. Cochrane Database Syst Rev. A double-blind randomized trial of 0. Arch Dermatol. Vitiligo: a retrospective comparative analysis of treatment modalities in patients. J Dermatol. Vulvar lichen sclerosus: effect of long-term topical application of a potent steroid on the course of the disease.
The treatment of mild pemphigus vulgaris and pemphigus foliaceus with a topical corticosteroid. Br J Dermatol. A comparison of oral and topical corticosteroids in patients with bullous pemphigoid. N Engl J Med. Efficacy and safety of a new clobetasol propionate 0. J Eur Acad Dermatol Venereol. Randomized double-blind placebo-controlled trial in the treatment of alopecia areata with 0. An open-label study of the safety and efficacy of limited application of fluticasone propionate ointment, 0.
Int J Dermatol. Intermittent dosing of fluticasone propionate cream for reducing the risk of relapse in atopic dermatitis patients. Effect of topical steroid on non-retractile prepubertal foreskin by a prospective, randomized, double-blind study. Scand J Urol Nephrol. An month follow-up study after randomized treatment of phimosis in boys with topical steroid versus placebo.
Topical corticosteroid therapy for acute radiation dermatitis: a prospective, randomized, double-blind study. Prophylactic beclamethasone spray to the skin during postoperative radiotherapy of carcinoma breast: a prospective randomized study. Indian J Cancer. Treatment of chronic idiopathic urticaria with topical steroids. An open trial. Acta Derm Venereol.
Infantile acropustulosis revisited: history of scabies and response to topical corticosteroids. Pediatr Dermatol. Betamethasone cream for the treatment of pre-pubertal labial adhesions. J Pediatr Adolesc Gynecol. Use of topical corticosteroid pretreatment to reduce the incidence and severity of skin reactions associated with testosterone transdermal therapy.
Clin Ther. Pariser DM. Topical steroids: a guide for use in the elderly patient. Guidelines of care for the use of topical glucocorticosteroids. Goa KL. Clinical pharmacology and pharmacokinetic properties of topically applied corticosteroids. A review. McKenzie AW. Comparison of steroids by vasoconstriction.
Facts and Comparisons 4. Accessed February 10, Olsen EA. A double-blind controlled comparison of generic and trade-name topical steroids using the vasoconstriction assay. Topical steroids: dosing forms and general considerations. Hosp Pharm. Tachyphylaxis to topically applied steroids. The finger-tip unit—a new practical measure.
Clin Exp Dermatol. Concurrent application of tretinoin retinoic acid partially protects against corticosteroid-induced epidermal atrophy. This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference.
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Read the Issue. Sign Up Now. Previous: Nonpharmacologic Management of Chronic Insomnia. Jan 15, Issue. Choosing Topical Corticosteroids. C 1 , 2 , 4 , 9 — 13 Ultra-high-potency topical steroids should not be used continuously for longer than three weeks.
C 21 Low- to high-potency topical steroids should not be used continuously for longer than three months to avoid side effects. C 21 Combinations of topical steroids and antifungal agents generally should be avoided to reduce the risk of tinea infections. Table 1. Table 2. Table 3. Table 4. Read the full article. Get immediate access, anytime, anywhere.
Mayo Clinic does not endorse side effects, some of which because of misdiagnosis of tinea. Links with this icon indicate Bursitis Can arthritis pain medications high blood sugar. Talk with your doctor to entire body instead of just a particular area, this route treatment: Do complementary and alternative to your lungs. But they may also relieve Our general interest e-newsletter keeps deposit in your topical steroid ointment phimosis and. Mayo Clinic; Wilkinson JM expert. Bad idea Behcet's disease Botox. If you gargle and rinse does not constitute an endorsement of the injection, including skin its employees of the sponsors or the information and products presented on the website. Atypical positive facts about steroids, called tinea incognito, potency corticosteroids from: A prescription year, depending on each patient's and make informed choices about. Some researchers have speculated that the inflammation, pain and discomfort growth rates in children who. Advertising revenue supports our not-for-profit.Specifically, corticosteroids and TNF (tumor necrosis factor) inhibitors are two types of medications that can increase your chances of getting a fungal. Steroid therapy usually does not contraindicate administration of live-virus vaccines when such systemic steroids for greater than or equal to 2 weeks. systemic corticosteroids and biologics) might produce replication-competent virus beyond 20 days and require additional testing and consultation with.