Eczema vaccinatum

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Eczema vaccinatum
8 month old with eczema vaccinatum after acquiring vaccinia from a sibling recently vaccinated for smallpox.
SpecialtyInfectious disease
SymptomsCrops of small blisters, fever, swollen glands[1]
Usual onsetSudden, 5 to 12 days post exposure[1][3]
Risk factorsAtopic dermatitis, other skin diseases[2]
Differential diagnosisEczema herpeticum, chickenpox, bacterial superinfection[4][3]
TreatmentVaccinia immune globulin (VIG), antivirals[2]
Deaths35% without treatment, 7% with treatment[2]

Eczema vaccinatum is a type of vaccinia infection, that may occur in people with atopic dermatitis (eczema) or other skin diseases.[2] Symptoms include a sudden onset of crops of small blisters, typically at sites of skin problems.[2] Typically there is also a fever and swollen glands.[1][5] Onset is 5 to 12 days post exposure.[3]

While it may occur due to direct smallpox vaccination with vaccinia; more often it occurs following spread from a household member who has had a recent vaccine.[2] While atopic dermatitis is a risk factor for the disease; it is estimated that if vaccinated, only one in a hundred would be affected.[4] The underlying mechanism involves extensive spread of the virus.[4] Diagnosis is usually based on exposure to vaccinia.[6]

Treatment is with vaccinia immune globulin (VIG) and potentially the antiviral medication cidofovir.[2][4] Prevention may include the use of the MVA-BN vaccine in those at high risk.[4] Scarring often remains after healing.[2] Without treatment around 35% die, and with treatment this is about 7%.[2]

Between 2002 and 2012 only one case was described in the United States.[4] In the United States in 1968 there were 66 cases following 14.5 million smallpox vaccinations, and 60 cases among several million contacts.[1] Males are affected twice as often as females.[3] The condition is believed to have been first described in 1882.[4]

Signs and symptoms

It is characterized by serious local or disseminated, umbilicated, vesicular, crusting skin rashes in the face, neck, chest, abdomen, upper limbs and hands, caused by widespread infection of the skin in people with previous diagnosed skin conditions such as eczema or atopic dermatitis, even if the conditions are not active at the time. Other signs and symptoms include fever and facial and supraglottic edema. The condition may be fatal if severe and left untreated. Survivors are likely to have some scarring (pockmarks).

Smallpox vaccine should not be given to patients with a history of eczema. Because of the danger of transmission of vaccinia, it also should not be given to people in close contact with anyone who has active eczema and who has not been vaccinated. People with other skin diseases (such as atopic dermatitis, burns, impetigo, or herpes zoster) also have an increased risk of contracting eczema vaccinatum and should not be vaccinated against smallpox.


A culture of vesicular fluid will grow vaccinia virus. Skin biopsy shows necrotic epidermal cells with intranuclear inclusions.

Differential diagnosis

Eczema is also associated with increased complications related to other vesiculating viruses such as chickenpox; this is called eczema herpeticum.


Eczema vaccinatum is a serious medical condition that requires immediate and intensive medical care. Therapy has been supportive, such as antibiotics, fluid replacement, antipyretics and analgesics, skin healing, etc.; vaccinia immune globulin (VIG) may be useful but supplies are deficient as of 2006. Antiviral drugs have been examined for activity in pox viruses and cidofovir is believed to display potential in this area.[7][8]

See also


  1. 1.0 1.1 1.2 1.3 1.4 Petersen, Brett W.; Damon, Inger K. (2020). "348. Smallpox, monkeypox and other poxvirus infections". In Goldman, Lee; Schafer, Andrew I. (eds.). Goldman-Cecil Medicine. Vol. 2 (26th ed.). Philadelphia: Elsevier. p. 2183. ISBN 978-0-323-53266-2.
  2. 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 James, William D.; Elston, Dirk; Treat, James R.; Rosenbach, Misha A.; Neuhaus, Isaac (2020). "19. Viral diseases". Andrews' Diseases of the Skin: Clinical Dermatology (13th ed.). Edinburgh: Elsevier. pp. 387–388. ISBN 978-0-323-54753-6. Archived from the original on 2022-06-03. Retrieved 2022-05-29.
  3. 3.0 3.1 3.2 3.3 Ruzicka, Thomas; Ring, Johannes; Przybilla, Bernhard (9 March 2013). Handbook of Atopic Eczema. Springer Science & Business Media. p. 58. ISBN 978-3-662-02671-7. Archived from the original on 28 June 2022. Retrieved 21 June 2022.
  4. 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 Reed, JL; Scott, DE; Bray, M (March 2012). "Eczema vaccinatum". Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 54 (6): 832–40. doi:10.1093/cid/cir952. PMID 22291103.
  5. "Smallpox Vaccine Adverse Events: For Healthcare Providers | CDC". 25 March 2021. Archived from the original on 28 June 2022. Retrieved 21 June 2022.
  6. Cherry, James; Demmler-Harrison, Gail J.; Kaplan, Sheldon L.; Steinbach, William J.; Hotez, Peter (29 December 2017). Feigin and Cherry's Textbook of Pediatric Infectious Diseases. Elsevier Health Sciences. p. PT5359. ISBN 978-0-323-39281-5. Archived from the original on 28 June 2022. Retrieved 21 June 2022.
  7. "CDC guidance". Archived from the original on 2015-05-03. Retrieved 2021-12-12.
  8. WHO

External links