Table 1.

Efficacy and practical information for systemic medication regarding SARS-Cov-2 vaccination for skin disorders

Drug	Half-life	94% elimination (4 × half-life)	Reduced efficacy of vaccination	What can we say to our patients?
Methotrexate	3–15 h	12–60 h	Mild–moderate	Vaccine-induced immunity is decreased but expected to be sufficient in most patients [14, 15]
				Stopping treatment for 2 weeks after vaccination has successfully increased the efficacy of influenza vaccination [14]
Cyclosporine	18 h	72 h	Mild–moderate	Vaccine-induced immunity is decreased but expected to be sufficient in most patients [16–18]
				Cyclosporine has a short half-life. Temporary interruption (e.g., stop 3 days before vaccination and ≥2 weeks after vaccination) might increase the efficacy of vaccination, but RWE is lacking
Mycophenolate mofetil	15–18 h	60–72 h	Moderate–severe	Decreased antibody titers after vaccination are likely [18, 20]
				Temporary interruption (e.g., stop 3 days before vaccination and ≥ 2 weeks after vaccination) might increase the efficacy of vaccination, but RWE is lacking
Corticosteroids	2–4 h	8–16 h	Mild	Vaccination responses are adequate in most patients [22–24]
Dimethyl fumarate	1 h	4h	No–mild	Vaccination responses are adequate in most patients [28]
Apremilast	6–9 h	24–36h	Unknown	No data are available, but normal responses are expected
Azathioprine	3–5 h	12–20h	Mild	Vaccination responses are adequate in most patients [17, 32, 33]
JAK inhibitors (tofacitinib; baricitinib)	3 h; 12.5 h	12h; 50h	Severe	Diminished responses have been reported, but most patients can still mount sufficient immunity [34–37]
				A 2-week interruption (1 week before and 1 week after vaccination) seems ineffective for reversing the decreased vaccine responses [34]. Therefore, a minimum treatment-free period of ≥2 weeks after vaccination could be necessary for optimal antiviral immunity. However, this is not substantiated by RWE
TNF-α blockers	4–20 d	16–80d	Mild–moderate	Modestly impaired immunity after vaccination [38–41]
				Longer intervals and starting/stopping can cause reduced long-term efficacy, except for etanercept, which also has a short half-life
				Administration of vaccine midcycle or 2 weeks before the next dosage might be considered
IL-17 inhibitors, IL-17 receptor blocker	11–27 d	44–108 d	No	Currently available vaccines (influenza, meningococcus) have excellent efficacy (only based on data for secukinumab and ixekizumab) [42–45]
				It is unclear whether the vaccine-induced protection (IgA) in the upper airways will be as effective as in healthy controls
				Ixekizumab and brodalumab have a moderately short half-life (13 and 11 days, respectively)
				No evidence is available about whether temporary interruption seems reasonable
IL-23 inhibitors	12–39 d	48–156 d	No	Currently available vaccines (influenza, tetanus, meningococcus, pneumococcus) have excellent efficacy (based only on data for ustekinumab) [50, 51]
				It is unclear whether the vaccine-induced protection (IgA) in the upper airways will be as effective as in healthy controls
				Long half-life
				No evidence is available as to whether temporary interruption seems reasonable in real life
Dupilumab	NR	NR	No	Data suggest that COVID vaccination will be as effective as in normal individuals [56]
Omalizumab	NR	NR	Unknown	No published data
				No signals that vaccination is affected
Rituximaba	NR	NR	Severe	Protective antibody formation is severely impaired [59]
				Cell-specific immunity is likely largely preserved
				Given the partial recuperation of B cells after 6–10 months, this time period is preferable for vaccination

COVID coronavirus disease 2019, d days, IgA immunoglobulin A, IL interleukin, JAK Janus kinase, NR not relevant (the drug does not decrease the efficacy of vaccination), RWE real-world evidence, TNF tumor necrosis factor

^aThe drug half-life of rituximab does not represent the duration of its immunologic effect