MINNEAPOLIS — The number and types of immunosuppressive therapies offered to children to control dermatologic diseases have expanded substantially, intensifying the focus on how to best conduct infection risk screening and prophylaxis prior to initiating these drugs.

“The risk is not uniform. You need to stratify by drug class, concomitant therapies, patient-level factors, and concomitant therapies that affect risk, especially corticosteroids,” reported Beth K. Thielen, MD, PhD, assistant professor in the Division of Pediatric Infectious Diseases at the University of Minnesota, Minneapolis.

Of the strategies to reduce risk for infectious complications of immunosuppressive therapies, Thielen emphasized attention to the potential for latent infections.

“A careful exposure history is one of the highest-yield prevention strategies,” Thielen said at the Society for Pediatric Dermatology (SPD) 2026 Annual Meeting.

Citing cases in which immunosuppressive drugs resulted in severe morbidity or even mortality from potentially preventable latent infections, Thielen outlined six questions to generate a history that will prevent such complications.

Six Screening Questions Recommended

Originally developed for adult patients, Thielen suggested the questions should be posed to the child and the parent. For example, history of recent travel is an important screening tool, but the history should also be elicited from the parents because it might lead to discussion of return trips to native countries with a high risk for endemic infectious diseases. This also holds true for travel or residency in parts of the US with high relative risks for infectious diseases.

As examples, risks for fungal infection, helminth infections, and uncommon pathogens, such as Strongyloides, a “high-consequence” parasite that can reemerge after decades of dormancy, vary by region in the US. Not all immunosuppressive anti-inflammatory drugs pose the same risk for susceptibility to these infections, but Thielen encouraged clinicians to recognize relative threats. As examples, she cited cases of helminth infections developing in patients on anti-interleukin (IL)-4 inhibitors and Strongyloides-associated hyperinfections in patients taking oral steroids.

The other five questions are directed at eliciting risk for tuberculosis (TB) reactivation. This includes any history of a positive TB test or TB exposure, the risk for infections associated with soil, dust, construction, or animal dropping exposures, risks related to tropical or resource-limited settings, risks associated with exposure to animals, and risks suggested by a history of unusual, recurrent, or difficult-to-treat infections.

Again, all such questions should be posed to parents as well as children, Thielen said.

Although opportunistic or latent infections related to immunosuppression are often the most feared, Thielen warned that common infections should not be overlooked. Screening tests to consider, many of which involve ordering immunoglobulin G titers, include those for cytomegalovirus, herpes simplex virus, Epstein-Barr virus, varicella zoster, Toxoplasma gondii, and hepatitis B virus, particularly in the presence of risk factors.

Vaccination Guidance Provided by the CDC

Vaccination optimization is also a critical step for children prior to initiating an immunosuppressive therapy, many of which Thielen noted are now offered chronically to manage inflammatory or atopic dermatologic diseases. On the basis of current CDC recommendations, live vaccines should be administered at least 4 weeks before and inactivated vaccines should be administered at least 2 weeks before immunosuppressive therapies are initiated, she said.

Thielen placed particular emphasis on prioritizing vaccines protective against respiratory diseases, listing those for pneumococcal diseases, influenza, respiratory syncytial virus, and COVID.

However, in cases where immunosuppressive therapy is urgently needed, a benefit-to-risk calculation is needed. In many cases, it might be best to “vaccinate and accept the reduced immunogenicity,” she said.

The same type of benefit-to-risk calculation is also needed when considering infection prophylaxis, assuming that there is a safe and effect prophylactic agent available. Thielen indicated that prophylaxis becomes more attractive if the risks of a serious disease from infection are high and if the patient has laboratory evidence of immune dysfunction, such as a low lymphocyte count.

Referral to an infectious diseases consultant is appropriate in many cases. Examples listed by Thielen included positive screening results for TB, Strongyloides, or hepatitis B virus. A consult is also reasonable for patients on multiple immunosuppressants or with a complex exposure history. For children about to travel to areas endemic for infection, she recommended sending families to clinics that offer guidance specific by region for these risks.

Immunosuppressants in Children Are Evolving

The mix of commonly used immunosuppressive therapies has been evolving, and it is important to stay current with available information, Thielen advised.

According to Medicare data published in 2025, TNF-alpha inhibitors as a class were the dominant targeted immunosuppressive agents for dermatologic diseases in 2013, accounting for more than 80% of prescriptions. Many of the targeted agents, such as the IL-4 inhibitor dupilumab and the IL-17 inhibitor secukinumab, were not yet available. Drugs other than TNF-alpha inhibitors, which now account for less than 30% of immunosuppressive drugs used in dermatology, are now dominant. Although these data involve prescriptions in adults, Thielen said similar trends are ongoing in children.

Guidance for infection prevention in children on an immunosuppressive therapy for a dermatologic disease is still often derived from the transplant literature, Thielen acknowledged, but this is an area of active investigation. She expects many gaps in knowledge regarding infection risks for specific immunosuppressive agents to be filled with ongoing studies, another reason to say abreast of advances in this field.

Asked for her perspective, Colleen H. Cotton, MD, a pediatric dermatologist at Children’s National and assistant professor of pediatrics and dermatology at the George Washington School of Medicine and Health Sciences, both in Washington, DC, emphasized the need to tailor the screening process for the immunosuppressive anti-inflammatory drug being considered. The infection risks are not the same.

“Remembering to screen for infection risk prior to starting these drugs is important, especially as we live in an increasingly global world [but] it’s also incredibly important to understand the specific risks of the drug you are using,” Cotton told Medscape Medical News.

Cotton suggested that the importance of applying screening to different risks for different drugs can be confusing without an authoritative and evidence-based list. “We desperately need guidelines that don’t lump all immunomodulators together,” she said.

Individualization of infection screening tailored to the planned immunosuppressive agent and specific patient characteristics was also emphasized by Kelly M. Cordoro, MD, professor of dermatology and pediatrics and chief of pediatric dermatology at the University of California, San Francisco, who was also asked to comment.

“There is no one-size-fits-all approach to infection screening before starting immune-suppressing or immune-modulating therapy in children. Screening tests depend on the medication, the child’s underlying condition and medical history, and factors such as age, exposures, travel and geography,” she told Medscape Medical News.

“The goal is to identify infections that could pose a risk with a particular treatment while avoiding unnecessary testing,” Cordoro said.

Thielen reported having a financial relationship with Merck and GlaxoSmithKline. Cotton reported having financial relationships with Moonlake Immunotherapeutics, Novartis, Pfizer, and UCB. Cordoro reported having no potential conflicts of interest.

Ted Bosworth, a career medical writer based in New York City, has been covering advances in clinical medicine, including dermatology and oncology, for several decades.