Non-Biologic Systemic Therapies Associated Infections in Dermatology: How to Prevent

  • Sara Casanova Departamento de Doenças Infeciosas e Medicina Tropical, Hospital de Egas Moniz - Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal
  • Joana Vasconcelos Departamento de Doenças Infeciosas e Medicina Tropical, Hospital de Egas Moniz - Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal
  • Ana Cláudia Miranda Departamento de Doenças Infeciosas e Medicina Tropical, Hospital de Egas Moniz - Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal
  • Kamal Mansinho Departamento de Doenças Infeciosas e Medicina Tropical, Hospital de Egas Moniz - Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal
  • Cândida Fernandes Departamento de Dermatologia e Venereologia, Hospital Santo António dos Capuchos – Centro Hospitalar de Lisboa Central, Lisboa, Portugal
Keywords: Cyclosporine, Immunosuppressive Agents, Methotrexate, Opportunistic Infections, Steroids


The infectious risk associated with biological therapy is well studied today and screening and prophylaxis strategies have been stablished. However, this may not be true for systemic steroids or DMARDs (disease-modifying anti-rheumatic drugs) such as methotrexate and cyclosporine, even after long term use. The dose and duration of therapy with systemic steroids are related to the occurrence of opportunistic infection. Doses above 5 mg/day are associated with bacterial infection, above 10 mg/day with herpes zoster virus (HZV) reactivation, and above 15 mg/day or for more than 2 to 4 weeks with tuberculosis reactivation, which implies proper screening and chemoprophylaxis. Systemic steroids also appear as one of the main risk factors for the development of pneumocystosis in non-HIV patients and prolonged doses, for more than 4 weeks, can lead to hepatitis B virus (HBV) infection reactivation, and justify the beginning of prophylaxis with tenofovir disoproxil fumarate or entecavir. Cases of strongyloidiasis with hyperinfection syndrome have also been reported in patients on steroids. The degree of immunosuppression conferred may contraindicate live attenuated vaccines. Methotrexate and cyclosporine have a low infectious risk when used as monotherapy. Symptom surveillance is the main preventive strategy. However, both are immunomodulators, contraindicate live attenuated vaccines administration and are associated with infectious risk. Cyclosporine can lead to bacterial infection and HZV reactivation, and methotrexate is associated with HZV and HBV reactivation, especially if administered at a dose >0.4 mg/kg/week. Both are linked with active tuberculosis when in therapeutic combination with other immunosuppressants. Understanding and studying the risk of infection when using immunosuppressive therapy allows its use in a more informed and safe manner.


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How to Cite
Casanova, S., Vasconcelos, J., Miranda, A. C., Mansinho, K., & Fernandes, C. (2021). Non-Biologic Systemic Therapies Associated Infections in Dermatology: How to Prevent. Journal of the Portuguese Society of Dermatology and Venereology, 79(2), 121-128.
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