Table I.

Author recommendations regarding administration of an additional dose of the messenger RNA COVID-19 vaccine to certain dermatology patient populations

Patient population	Evidence-based risk	Recommendation
Receiving systemic glucocorticoids	Patients receiving >20 mg prednisone or equivalent daily are at risk of inadequate response to the standard 2-dose mRNA COVID-19 vaccine series	(1)Patients receiving systemic glucocorticoids should receive an additional dose of the mRNA COVID-19 vaccine (2)Conscious efforts should be made to taper patients on prednisone below 20 mg daily
Receiving oral immunosuppressants, including methotrexate, mycophenolate mofetil, cyclosporine, and JAKis	Patients receiving oral immunosuppressants are at risk of inadequate response to the standard 2-dose mRNA COVID-19 vaccine series	(1)Patients receiving oral immunosuppressants should receive an additional dose of the mRNA COVID-19 vaccine (2)Patients who have not yet been vaccinated who are receiving these medications or who are considering initiation of these medications should be preferentially offered a less immunosuppressing biologic, if indicated clinically
Receiving B-cell depletion (ie, anti-CD20 monoclonal antibodies)	Patients receiving B-cell depletion are more likely than not to mount an inadequate response to the standard 2-dose mRNA COVID-19 vaccine series	(1)Patients undergoing B-cell depletion should receive an additional dose of the mRNA COVID-19 vaccine. The ideal timing of this additional dose is discussed in the referenced article5 (2)Patients with conditions that can be adequately treated with therapeutics other than B-cell depletion (eg, bullous pemphigoid) should be preferentially offered a less immunosuppressing biologic, if indicated clinically
Receiving TNF blockers and IL-17 inhibitors	Patients receiving TNF blockers and IL-17 inhibitors may mount lower absolute titers to the standard 2-dose mRNA COVID-19 vaccine series; however, there is insufficient evidence to suggest that these patients are at increased risk of mounting an inadequate immune response to the 2-dose series	(1)As an aggregate, patients receiving TNF blocker and IL-17 inhibitor monotherapy do not appear to need the third dose of the mRNA COVID-19 vaccine based on existing data; however, the third dose may be indicated for patients with comorbidities that predispose the patient to severe COVID-19 infection. Shared decision making with all patients on these medications is recommended. (2)There are no specific data regarding the ideal timing of vaccination; however, like other nonlive vaccinations, the mRNA COVID-19 vaccine can likely be administered without interruption in biologic therapy
Receiving IL-12/23, IL-23, and IL-4/13 inhibitors	There are inadequate real-world data to assess the effect of IL-12/23, IL-23, and IL-4/13 inhibitors on mRNA COVID-19 vaccine response	(1)Based on the mechanism of action of these medications, it is unlikely that these medications predispose patients to an increased risk of mounting an inadequate response to the standard 2-dose mRNA COVID-19 vaccine series. Additional prospective data are needed to confirm the presumed immunogenicity of the mRNA COVID-19 vaccine in patients receiving these medications. At this time, shared decision making is recommended given the paucity of available data
Patients with metastatic melanoma, squamous cell carcinoma, or other internal malignancy undergoing active treatment	Patients undergoing treatment for metastatic melanoma, squamous cell carcinoma, and other malignancies are at risk of inadequate response to the standard 2-dose mRNA COVID-19 vaccine series	(1)Patients undergoing treatment for metastatic skin cancer should be encouraged to urgently contact their oncologist about whether they should receive an additional dose of the mRNA COVID-19 vaccine

IL, Interleukin; JAKi, Janus kinase inhibitor; mRNA, messenger RNA; TNF, tumor necrosis factor.