What can I do to treat scalp eczema during a flare?
Published On: Jan 19, 2021
Last Updated On: Feb 24, 2022
Many members of the NEA community have reached out for information about whether their experience with contracting Covid-19 could have caused their eczema to flare. As a continuation of our Ask the Ecz-perts series on Covid-19 and eczema, we reached out to Dr. Anna Fishbein, associate professor of pediatrics (allergy and immunology) at Northwestern University’s Feinberg School of Medicine, to get the scientific background on whether Covid-19 could directly lead to flaring eczema.
Dr. Fishbein: This is a good question. Any viral infection can flare eczema, and some experts suggest this is one of the biggest triggers for eczema flare. This is in part because your body is working hard to fight the viral infection so cells of all types are revved up. Additionally, people with eczema generally have too many allergic T-cells (TH22/TH2) and not enough viral-fighting T-cells (TH1). So, they are more sensitive to viral infections in their skin and body. The best way we know to try to combat eczema flares from viral infections is to take good care of your skin and yourself! Get lots of rest, drinks lots of fluids, and try your best to keep your eczema under good control.
With recent guidance from the CDC on Covid-19 booster shots, members of the eczema community have raised questions about whether having eczema qualifies an individual as “immuno-compromised.” The short answer is that eczema on its own does not suppress the immune system, but your method of treating your eczema may have an impact on your immune system. Remember that it’s important to communicate with your healthcare provider about your condition before making any changes to your eczema treatment plan. With that guidance in mind, the CDC does list “high-dose corticosteroids” as a potential cause of immune suppression.
This is the full guidance from the CDC website:
Currently, CDC is recommending that moderately to severely immunocompromised people receive an additional dose. This includes people who have:
We’ve included additional guidance below about specific medications you may be taking for your eczema.
Meet the Ecz-perts
Dr. Spergel: I would talk to your healthcare provider, as the exact details depend on your dosage. But in general Dupixent is NOT immunosuppressive. Daily oral steroids can be immunosuppressive. Methotrexate (depending on the dose) can be immunosuppressive, yes. And if you are involved in a clinical trial where you are receiving a JAK inhibitor treatment, that may be considered immunosuppressive depending on whether the treatment is administered orally, topically. In summary, be sure to consult with your healthcare provider about whether you should receive a booster.
Dr. Paller: No. The only potential issue is an allergy to an ingredient of the vaccine itself.
Dr. Spergel: No, with the one caveat that vaccines have only been given to several hundred thousand individuals at the current time. Rare issues might still arise as additional doses are given. But right now atopic dermatitis (AD) is not a risk factor for more severe adverse reactions from either vaccine.
Dr. Alexis: Per the American Academy of Allergy Asthma and Immunology (AAAAI) and the Center for Disease Control (CDC), the following are contraindications to receiving the SARS-CoV-2-mRNA vaccine: “Immediate allergic reaction of any severity to a previous dose of an mRNA Covid-19 vaccine or any of its components, including polyethylene glycol (PEG).”
If one falls into the above category, one “should not receive mRNA Covid-19 vaccination at this time unless they have been evaluated by an allergist/immunologist and it is determined that the person can safely receive the vaccine (e.g., under observation, in a setting with advanced medical care available).”1
Anyone who has an immediate allergic reaction to the first dose of an mRNA vaccine should not receive additional doses of either of the mRNA Covid-19 vaccines. Patients with food allergies or other allergies that are unrelated to vaccines or injectable medications may still get the vaccine, but like other patients should be monitored for 15 minutes after administration for any reactions. Patients with a history of anaphylaxis (not due to vaccines or injectable medications) should be monitored for 30 minutes.1 
Dr. Paller: The current thinking is that (any concern) would be if there were an allergy to the vaccine ingredients and it would be quite unusual to have a reaction to any of the ingredients in either vaccine. But take a look (ingredients listed at end of story) and it’s important to check with your primary care doctor and allergist before getting vaccinated. And to play it safe we recommend that those with allergies of any type wait an extra 15 minutes, staying nearby their medical provider, after getting the vaccine. Those people with a history of any anaphylaxis should bring their epinephrine with them – and stay for an extra 30 minutes after receiving the Covid-19 vaccine.
Dr. Alexis: Yes, you can. This is not a contraindication as the vaccine is not a live vaccine and therefore cannot infect or spread on the skin.
Dr. Paller: There is no contraindication against getting the vaccine if your eczema is flaring. However, there is a decent risk of having some side effects, and in anyone with flaring eczema these might compound how miserable you feel after getting the shot. For example, for the first vaccination with the Pfizer vaccine, the most commonly reported side effects included fatigue, headache, muscle pain, chills, joint pain and fever. The FDA has reported that “more people experience these side effects” after the second dose than the first dose.”
Dr. Spergel: Flaring eczema is not a risk. But I would not give the vaccine in a location with flaring eczema. I would just pick a different location.
Dr. Spergel: I would wait 24-72 hours due to known muscle aches, chills and fever after the Covid-19 vaccination before having your Dupixent injection.
Dr. Alexis: No, they do not.
Dr. Paller: No, not from the eczema.
Dr. Spergel: Unfortunately, not. The major risk factor is elderly, diabetes, heart disease and obesity.
Dr. Alexis: Although data are not available, immunosuppressive treatments (off-label oral immunosuppressives for AD such as cyclosporine, methotrexate, mycophenolate mofetil, azathioprine) may theoretically affect the effectiveness of the vaccination. However, in most cases, the benefit of vaccination outweighs the risk of effects on efficacy posed by these medications.
Dr. Paller: There is no increased risk of being on any medication for eczema and getting the vaccine in terms of side effects, as the vaccine is not the virus itself and cannot transmit Covid-19. The only question is whether the immune response mounted after the vaccine will be as strong as possible because of medications taken internally.
We do not think that there is suppression of the immune system from applying anything to skin. We also have evidence that dupilumab (Dupixent), the new monoclonal antibody for eczema, allows an expected response to vaccines (although the Covid-19 vaccine has not been tested previously, of course).
There is some concern about mounting the same response from the vaccine as a healthy person when taking systemic steroids or other medicines that can profoundly suppress our immune responses.
These immunosuppressant drugs do not PREVENT developing immunity but they might REDUCE immune reactivity and protection. That said, studies with methotrexate suggest that with the flu and pneumococcus (no info on Covid-19, of course) there is still good protection. Nevertheless, being off for a short period theoretically could boost that a bit. But this depends on how long can one be off the drug before flaring.
In the rheumatology world, some are saying “up to two weeks” for methotrexate, and our team recommends just holding the dose for the week after the vaccine and then starting it up again (repeating for the second one). Cyclosporine does not have as long a half life but still probably could hold for a few days to a week after and then restarting. Some are just not stopping any of them at all, and assuming there will be enough immunity even while on it.
The American Academy of Dermatology has not come out with any recommendation that I have seen. I would probably stop just for two days and restart with cyclosporine (or treat through). For Methotrexate, I would skip the one dose after the vaccine.
Dr. Spergel: The Johnson & Johnson vaccine is a different type of vaccine. The Pfizer and Moderna are mRNA based vaccines, while the Johnson & Johnson is Adenovirus vector based vaccine. All three vaccines produce the spike protein. They use very different technologies.
Dr. Spergel: I would not get any vaccine in an eczema flaring area. But, if your eczema is flaring in one location, you can get the vaccine in another area that’s not flaring.
This CDC site has information about the vaccines here.
NEA: The full list of the ingredients in the Pfizer vaccine is available here for review with your physician, in addition to the mRNA: lipids ((4-hydroxybutyl)azanediyl)bis(hexane-6,1-diyl)bis(2-hexyldecanoate), 2 [(polyethylene glycol)-2000]-N,N-ditetradecylacetamide, 1,2-Distearoyl-sn-glycero-3- phosphocholine, and cholesterol), potassium chloride, monobasic potassium phosphate, sodium chloride, dibasic sodium phosphate dihydrate, and sucrose. Sourced from the FDA.
And, additionally, the ingredients of the Moderna vaccine are listed here, in addition to the mRNA: lipids (SM-102, polyethylene glycol [PEG] 2000 dimyristoyl glycerol [DMG], cholesterol, and 1,2-distearoyl-sn-glycero-3-phosphocholine [DSPC]), tromethamine, tromethamine hydrochloride, acetic acid, sodium acetate, and sucrose. Sourced from the FDA.
Lastly, full list of the Johnson & Johnson ingredients are here: recombinant, replication-incompetent adenovirus type 26 expressing the SARS-CoV-2 spike protein, citric acid monohydrate, trisodium citrate dihydrate, ethanol, 2-hydroxypropyl-β-cyclodextrin (HBCD), polysorbate-80, sodium chloride. Sourced from FDA here.
 Williams, PV. Messages from the COVID-19 Response Task Force. AAAAI website. January 12, 2021. Accessed January 13, 2021. https://education.aaaai.org/resources-for-a-i-clinicians/task-force-messages_COVID-19
 Interim Clinical Considerations for Use of mRNA COVID-19 Vaccines Currently Authorized in the United States. CDC website. Published January 6, 2021. Accessed January 13, 2021. https://www.cdc.gov/vaccines/covid-19/info-by-product/clinical-considerations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fvaccines%2Fcovid-19%2Finfo-by-product%2Fpfizer%2Fclinical-considerations.html
 Pfizer-BioNTech COVID-19 Vaccine. FDA website. Published 1/12/21. Accessed 1/13/21. https://www.fda.gov/emergency-preparedness-and-response/coronavirus-disease-2019-covid-19/pfizer-biontech-covid-19-vaccine#:~:text=The%20most%20commonly%20reported%20side,after%20the%20second%20dose.