Stephen K. Tyring, MD, PhD, MBA, discusses caring for immunosuppressed patients during measles outbreaks. Key takeaways:

• Patients receiving immunosuppressive therapies who contract measles face a higher risk for serious complications and diagnostic challenges.
• Some are unable to receive the MMR vaccine.

The rise of measles cases in the United States has clinical implications for patients prescribed immunosuppressive therapies, who are at higher risk for serious complications and may have vaccine contraindications, according to a study.

As of Oct. 15, 4,410 confirmed measles cases and 42 new outbreaks have been reported in the U.S. in 2026, according to the most recent CDC update. Three cases have resulted in death, the CDC reported.

While many cases resolve without complication, the risk for serious outcomes is higher among patients who are immunocompromised, including those with dermatologic conditions who are receiving immunosuppressive therapies, according to a clinical review published in JAAD Reviews. The mumps, measles and rubella (MMR) vaccine is generally avoided in patients receiving biologics, such as anti-TNFs and interleukin-17 and -23 inhibitors, or JAK inhibitors and is completely contraindicated for those on high-dose steroids due to patients’ weakened immune systems, the researchers wrote.

Healio spoke with Stephen K. Tyring, MD, PhD, MBA, a dermatologist and virologist at The University of Texas McGovern Medical School, about how to approach diagnosis, vaccination and post-exposure prophylaxis in patients with immunosuppression.

Healio: How do you define “severely immunocompromised” for dermatology patients?

Tyring: In our review paper, we outlined low, moderate and high levels of immunosuppression. We listed the amounts of the most used immunosuppressive drugs and explained that patients who received a specified quantity of a drug for a specified period would be considered highly immunosuppressed.

However, that does not capture everyone. Some patients have autoimmune diseases but may not be taking these highly immunosuppressive drugs. We also see patients coming from oncology clinics who are taking drugs that are not on our list but may suppress their immune systems. Any patient receiving chemotherapy or immunotherapy could be considered immunosuppressed. Of course, organ transplant and bone marrow transplant recipients are also immunosuppressed.

In dermatology, patients receiving immunosuppressive medications are often being treated for autoimmune inflammatory conditions. These can include psoriasis, atopic dermatitis, lupus and many other autoimmune conditions treated with immunosuppressive medications. However, these patients may also be referred by rheumatologists, who prescribe these medications as well. Therefore, the patients that dermatologists see are not necessarily taking immunosuppressive medications prescribed by dermatologists; they may be receiving them from other healthcare providers.

Healio: How might measles present differently in immunocompromised patients, and what risks are associated with this presentation?

Tyring: The classic signs of measles may be more difficult to detect in immunocompromised patients. They may not develop the typical rash, or the rash may be atypical or entirely absent. It may also not progress from the head downward as it typically does in otherwise healthy individuals.

As discussed in our paper’s section on diagnosis and diagnostic testing, clinicians should be aware that an immunocompromised patient may not resemble the classic textbook presentation of measles. When the immune system is dysfunctional, the rash can change because much of the rash associated with measles and other conditions is caused by the body’s immune reaction to the virus. The virus does not necessarily directly cause the rash. If the immune system is functioning abnormally or not working well at all, the patient may not develop the typical rash. With infectious diseases affecting the skin, much of what we see is the body’s immune response.

Healio: Are immunosuppressed dermatology patients at higher risk for serious complications if they contract measles?

Tyring: Absolutely. Serious complications include death, pneumonia, encephalitis and liver failure, all of which are particularly concerning for immunocompromised patients. Blindness is another complication, although it is more common in developing countries than in the U.S. One reason is that vitamin A supplementation is used as a treatment for measles is because measles can cause blindness in people who are vitamin A deficient. Since most people in the U.S. are not vitamin A deficient, vitamin A supplementation does not provide the same benefit. That is why blindness was not included in our discussion, which is directed toward a Western audience.

Healio: What is the guidance for withholding immunosuppressive therapies when a patient needs a vaccine, and does the guidance vary by therapy?

Tyring: The guidance depends on the drug. We discussed three levels of immunosuppression and the associated risks of administering a live vaccine. The MMR vaccine is a live vaccine, so it can cause disease in certain circumstances. As outlined in our paper, the risk is relatively low with low-level immunosuppression, moderate with moderate-level immunosuppression and high with high-level immunosuppression.

Ideally, the vaccine should be administered before immunosuppressive treatment begins. However, many patients are already receiving immunosuppressive medications. In those cases, the medication may need to be stopped for two or three half-lives, which can be found in the drug’s package labeling. The timing of treatment around vaccination is therefore important.

There are two recommended MMR vaccine doses: the first at 12 months of age and the second between 4 and 6 years. Some people receive only one dose, leaving them partially protected rather than having the full recommended vaccination series. Medications associated with the highest risk require the most careful consideration around vaccination. Ultimately, the approach depends to some degree on the drug and dosage.

Healio: What is the recommended post-exposure prophylaxis for immunocompromised patients, and does vaccination status matter?

Tyring: Post-exposure prophylaxis involves one of two options, which should not be given together: immunoglobulins or vaccination. Immunoglobulins provide passive immunity, which is temporary and lasts only days to weeks. Alternatively, the MMR vaccine can be administered after exposure. The MMR vaccine should be administered within 72 hours of exposure to stimulate the patient’s own immune system. After 72 hours, it is less effective. Immunoglobulins, on the other hand, can be administered within 6 days of exposure.

People may wonder why they cannot receive both for double protection. That is because administering immunoglobulins can interfere with the vaccine’s effectiveness and may increase the likelihood of infection from the vaccine itself. Therefore, clinicians must choose one option rather than administering both.

Healio: What conversations should dermatologists have with patients receiving immunosuppressive therapy about measles risk?

Tyring: These conversations should be tailored to the patient, their family and their surroundings. Vaccination status is particularly important for patients who have not been vaccinated and have not previously had measles. The vaccine has been available since the 1960s, so many older adults may have acquired immunity through prior infection, whereas younger generations are more likely to have been vaccinated.

The risk for severe complications, including death, should be discussed. Worldwide, measles-related deaths frequently occur among immunocompromised people, often because of immunocompromise associated with malnutrition. In the U.S., immunocompromise is more commonly associated with autoimmune disease. So, cancer, HIV and iatrogenic immunosuppression are the three major categories of immunocompromising situations to consider.

Patients, or parents when the patient is a child, need to understand that measles can cause severe illness or death. They should also consider the risks to relatives, friends and others in their environment. For example, an unvaccinated child could contract measles from school-aged siblings who bring the virus home. Infants younger than 1 year may also be exposed when taken to public places such as shopping malls or grocery stores. Exposure is not limited to healthcare settings.

Healio: What is the diagnostic approach for immunocompromised patients, given that measles may not present typically?

Tyring: Laboratory testing is essential. In immunocompromised patients, clinicians cannot rely on serology alone because these patients may not mount an adequate immune response. Instead, throat swabs and potentially blood samples should be collected and sent to a laboratory for polymerase chain reaction testing.

In otherwise healthy individuals, serology can help determine whether the patient is mounting an immune response. For example, high levels of immunoglobulin G may indicate prior infection or vaccination, whereas high levels of immunoglobulin M with little G may indicate recent exposure or infection. However, in immunocompromised patients, polymerase chain reaction is necessary because serology may not be reliable.

Healio: Why should dermatologists be involved in measles awareness and prevention?

Tyring: Measles usually produces a rash, but not always. Dermatologists see patients across all age groups and, unlike many other physicians, often encounter multiple generations of the same family.

Dermatologists therefore have an opportunity to emphasize the seriousness of measles to parents and grandparents. People who are having children today did not grow up during the period when measles was widespread and caused serious illness and death; many have only heard about these risks from older generations.

This can make it more difficult to convince young parents to vaccinate their children against a disease they may never have encountered themselves. Because vaccination was widely used and accepted for many years, measles became very uncommon in the U.S. and was considered nearly eliminated from the country. However, imported cases can still occur, and outbreaks can follow. One infected person can initiate a local epidemic, as seen in Texas, Pennsylvania and other states.

For more information:

Stephen K. Tyring, MD, PhD, MBA, is a dermatologist and virologist at The University of Texas McGovern Medical School and medical director of Houston Skin and the Center for Clinical Studies in Texas. Tyring can reached at stephen.k.tyring@uth.tmc.edu.