Eczema May Raise Shingles Risk Even Without Systemic Treatment
A study involving more than 13 million people found that atopic dermatitis was associated with a higher risk of herpes zoster, with the strongest association seen in severe disease.
Topline
Atopic dermatitis may carry a shingles risk of its own, separate from the medications used to treat it. In a large English electronic health record study, adults with atopic dermatitis had a 28% higher adjusted risk of herpes zoster, and the association became substantially stronger as eczema severity increased.
The finding does not mean that most people with eczema will develop shingles. It does suggest that infection risk may deserve more attention as part of long-term atopic dermatitis care.
Study Details
Atopic dermatitis, commonly called eczema, is an inflammatory skin disease involving both disruption of the skin barrier and altered immune responses. Patients with the disease are already known to have increased susceptibility to some infections.
The relationship with shingles has been harder to interpret because several systemic eczema treatments can themselves alter infection risk. JAK inhibitors, for example, have been associated with higher herpes zoster rates in some studies, while dupilumab has not shown the same pattern.
The new study, published in JDDG: Journal der Deutschen Dermatologischen Gesellschaft, specifically investigated whether atopic dermatitis itself was associated with herpes zoster after accounting for treatment and other potential risk factors.
Methodology
Researchers performed a matched cohort study using primary care electronic health records from England.
The dataset contained more than 14 million observations representing approximately 13.4 million people, including about 2.45 million observations involving people with atopic dermatitis.
Researchers compared the occurrence of a first episode of herpes zoster among people with and without atopic dermatitis. Their statistical models adjusted for age, sex, obesity, comorbidities, and treatments that could potentially influence shingles risk. Disease severity was also examined.
Because this was an observational study rather than a randomized trial, it can identify an association but cannot prove that eczema directly causes shingles.
Key Findings
Atopic dermatitis was associated with a 28% higher adjusted risk of shingles compared with people without atopic dermatitis.
Risk increased with eczema severity. Compared with people without atopic dermatitis, the adjusted hazard ratio was 1.22 for mild disease, 1.28 for moderate disease, and 2.33 for severe atopic dermatitis.
Treatment did not fully explain the association. After accounting for topical corticosteroid use, people with atopic dermatitis still had an elevated risk.
The relative association was strongest in younger adults. The hazard ratio was 1.51 among people aged 30 to 40 and 1.42 among those aged 40 to 50.
Absolute risk still increased with age. Shingles remained much more common among older adults overall, despite the larger relative effect associated with eczema in younger groups.
What This Means for Patients
The 28% increase is a relative increase in risk, not a statement that 28% of people with eczema will develop shingles.
That distinction matters.
Younger adults normally have relatively low rates of shingles, so even a noticeable increase in relative risk can correspond to a fairly small increase in the number of actual cases. For patients with severe eczema, however, the finding is worth discussing with a clinician, particularly when other risk factors or immunosuppressive treatments are present.
It also reinforces the importance of recognizing shingles early. A painful, burning, tingling, or blistering rash, particularly when limited to one side of the body, warrants prompt medical evaluation.
Implications for Practice
The study adds evidence that herpes zoster risk in atopic dermatitis may not simply be an adverse effect of systemic therapy. The underlying disease may contribute independently.
For clinicians, that makes infectious-risk assessment increasingly relevant when choosing treatment for moderate-to-severe disease. The risk profile of the disease and the risk profile of the therapy should be considered separately.
Vaccination is another important consideration, but these findings do not by themselves expand current US shingles-vaccine recommendations. CDC guidance currently recommends two doses of recombinant zoster vaccine for adults aged 50 years and older and for adults aged 19 years and older who are or will become immunodeficient or immunosuppressed because of disease or therapy.
Whether atopic dermatitis alone should eventually influence vaccination decisions in younger immunocompetent adults remains an unanswered question.
The larger message is simpler: eczema may be more than a skin-barrier disease when it comes to infection risk. As treatments become increasingly targeted, understanding the contribution of the disease itself will be important for deciding how aggressively clinicians should monitor, prevent, and manage infections.