PracticeUpdate Dermatology Best of 2018

EXPERT OPINION 26

Pearls From the Fall Clinical Dermatology Meeting 2018: Update on Vaccines in Dermatology By Stephen K. Tyring MD, PhD, Uyen Ngoc Mui MD and Ravi Patel MD

Dr. Stephen K. Tyring

Dr. Uyen Ngoc Mui

Dr. Ravi Patel

Dr. Tyring is Clinical Professor in the Departments of Dermatology, Microbiology/Molecular Genetics and Internal Medicine at the University of Texas Health Science Center in Houston, Texas.

Dr. Mui and Dr. Patel are currently Clinical Research Fellows at the Center for Clinical Studies under the direction of Dr. Stephen Tyring.

N umerous vaccines are being developed for use in diseases with dermatologic manifesta- tions. The Food and Drug Administration (FDA) recently approved a new herpes zoster (HZ) vaccine and expanded the use of a human papilloma virus (HPV) vaccine. This article addresses the indications, efficacy, and safety of the currently available HZ and HPV vaccines. Herpes Zoster vaccine There are two available HZ vaccines in the United States, Zostavax and Shingrix. Zostavax was licensed in 2006 for use in individuals over 60 years of age and in 2011 for persons at least 50 years of age. The risk of HZ is decreased by approximately half in patients older than 60 years and by 70% in patients 50 to 59 years old who receive Zostavax. 1,2 The vaccine is less effective in patients older than 70 years, and long-term follow-up data suggest that vaccine efficacy declines over time. 3,4 Zostavax is generally well-tolerated. Most commonly reported adverse events are injection-site reactions, HZ, and rash. 5 Zostavax is a live, attenuated vaccine, and it has the potential to cause HZ, which lim- its its use to immunocompetent persons. All HZ cases occurring after administration of Zostavax in clinical

trials, however, were confirmed to be caused by wild- type varicella zoster virus (VZV). 5 To date, HZ caused by the VZV vaccine strain has not been detected in immunocompetent individuals. 5 Shingrix is a new recombinant subunit HZ vaccine approved in 2017 for adults over the age of 50, includ- ing those who have already received Zostavax. In clinical trials, Shingrix demonstrated greater than 95% efficacy against HZ in adults who were 50 years of age or older. 7 Vaccine efficacy in adults older than 70 years is also greater than 95%. 7 Vaccine response is similar between individuals who have never received a zoster vaccine and adults who were vaccinated with Zostavax more than 5 years ago. 8 Furthermore, Shingrix is recommended for people with a history of HZ because clinical trials showed a strong humoral immune response of similar magnitude to that seen in people without a prior history of HZ. 9 Among Shingrix recipients in clinical trials, approxi- mately 81% reported injection-site reactions and 66% had systemic reactions. 7 Pain was the most common injection site reaction, and myalgia was the most common systemic reaction. 7 The majority of reported adverse events were transient and of mild-to-moderate intensity. 7 Based on these pivotal trials, the Advisory Committee on Immunization Practices recommends Shingrix over Zostavax for the prevention of HZ in all patient populations due to significantly higher efficacy and favorable safety profile. 6 Human Papilloma Virus vaccine To date, three HPV vaccines have been licensed by the FDA: Gardasil (quadrivalent) in 2006, Cervarix (bivalent)

" Based on these pivotal trials, the Advisory Committee on Immunization Practices recommends Shingrix over Zostavax for the prevention of HZ in all patient populations due to significantly higher efficacy and favorable safety profile. "

PRACTICEUPDATE DERMATOLOGY