Erica Dommasch, MD, MPH
Harvard Medical School, Beth Israel Deaconess Medical Center, and Fenway Health
Boston, Massachusetts, United States
Alba Català Gonzalo, MD
Hospital Clínic de Barcelona
TERMS TO KNOW
Monkeypox is a rare but typically nonfatal disease in the same family as smallpox which causes a rash on or near the genitals (but can also appear in other places on the body).
Viral zoonoses are infectious diseases transmitted from non-human animals to humans. Monkeypox is a viral zoonosis believed to jump from rodents and primates to humans.
- As of November 9, 2022, 78,964 cases of monkeypox have been reported worldwide.
- The United States, Brazil, Spain, France, and the United Kingdom, are the top five countries with the most reported monkeypox cases.
May 6, 2022: The first known case of monkeypox is admitted to a hospital in the United Kingdom. One week later, the UK reports two lab-confirmed and one probable case of monkeypox to the World Health Organization.
July 23, 2022: The World Health Organization declared the monkeypox outbreak a public health emergency.
August 9, 2022: In the United States, the Food and Drug Administration (FDA) approved emergency use authorization for the JYNNEOS vaccine for individuals aged 18 and older at high risk for monkeypox.
Monkeypox Outbreak in Spain: Clinical and Epidemiological Findings in a Prospective Cross-sectional Study of 185 Cases. Català A, Clavo-Escribano P, Riera-Monroig J, et al. Br J Dermatol. 2022 Aug 2. doi: 10.1111/bjd.21790. Epub ahead of print. PMID: 35917191.
Clinical Features and Novel Presentations of Human Monkeypox in a Central London Centre During the 2022 Outbreak: Descriptive Case Series. Patel A, Bilinska J, Tam J C H, et al. BMJ. 2022; 378: e072410. doi:10.1136/bmj-2022-072410.
Monkeypox DNA Levels Correlate with Virus Infectivity in Clinical Samples, Israel, 2022. Paran N, Yahalom-Ronen Y, Shifman O, et al. Euro Surveill. 2022 Sep;27(35):2200636. doi: 10.2807/1560-7917.ES.2022.27.35.2200636. PMID: 36052723; PMCID: PMC9438394.
Alba Català Gonzalo, MD, specializes in General Dermatology and Venereology. She is also the Coordinator of the Sexually Transmitted Infections Unit at Centro Medico Teknon. Her medical and research interests include rosacea, acne, naevus, and skin manifestations of systemic and infectious diseases like monkeypox.
Erica Dommasch, MD, MPH, is a dermatologist at Beth Israel Deaconess Medical Center and assistant professor at Harvard Medical School. Her clinical interests include psoriasis, HIV dermatology, public health, and community medicine.
The 2022 monkeypox outbreak left dermatologists with many questions. Doctors Alba Català Gonzalo and Erica Dommash seek to answer them.
Knowing the Signs and Symptoms of Monkeypox
As a dermatologist in Spain, Dra. Alba Català Gonzalo was on the front line observing and analyzing monkeypox. Her research efforts have focused on symptoms and disease presentation — and her team was surprised by what they found.
“In late May, when we started visiting patients, we expected a rash similar to smallpox or chickenpox,” said Dra. Català Gonzalo. “We also expected that patients [would have] fever and prodromes before the rash appeared. But what we saw was different. Primary lesions in inoculation areas are pseudo-pustules (papules that simulate pustules in which it is impossible to scrape the roof and obtain pus) similar to other poxviruses.”
Lesions can appear in the following:
- In the anogenital area
- On the trunk
- On the face and scalp
- In and near the mouth, tongue, and lips
- On the fingers, palms, and arms
- On the legs and soles
These lesions and pustules are painful and take weeks to heal completely. They are also commonly accompanied by surrounding edema (severe swelling).
Studying over 1,000 patients with monkeypox, Dra. Català Gonzalo and her team found that at the time of evaluation, most patients had lesions in the anogenital area and the face, and all patients had extracutaneous symptoms.
Other extracutaneous symptoms included:
- Lymphadenopathy (swelling of the lymph nodes)
- Asthenia (lack of energy, fatigue, or weakness)
- Myalgia (muscle aches and pain)
- Throat ache
Most patients had few lesions, in the 1 to 20 range. Having just a single lesion was not exceptional, but having greater than 100 lesions was exceptional.
Supporting Individuals and Communities at Higher Risk for Monkeypox
Research suggests that some groups are at higher risk for monkeypox, including gay, bisexual, and transgender men and nonbinary individuals who have sex with men.
Anyone can get monkeypox through skin-to-skin contact, regardless of their identity or sexual orientation — and transmission does not have to occur through sexual contact or contact with the infected person’s genitals.
Additionally, some groups are at higher risk for severe cases of monkeypox, including:
- Children younger than eight years old
- People who are pregnant
- People who are immunocompromised
- People with psoriasis or eczema
Identifying and Diagnosing Monkeypox
Diagnosing monkeypox can be done with a PCR test of one of the skin lesions. Skin-to-skin contact is the most common form of transmission, but Dra. Català Gonzalo’s team also found monkeypox DNA present in saliva, rectal swab, nasopharyngeal swab, semen, urine, and feces.
Following diagnosis, patients with monkeypox should self-isolate, as they are contagious until all skin lesions have healed, crusts have separated, and a fresh layer of skin has formed. For most individuals, monkeypox is a self-limited disease with symptoms lasting from two to four weeks.
“We know that monkeypox is mostly spread through skin-to-skin contact and sexual contact,” Dr. Dommasch says, “Patients at higher risk of severe disease from monkeypox — especially men who have sex with men — should (until they are vaccinated): limit their number of sexual partners, avoid sexual contact with anyone with a new, undiagnosed rash, and avoid contact with anyone with a recent diagnosis of monkeypox until all scabs have fallen off and a fresh layer of skin has formed.”
Understanding the Impact of Monkeypox on Psoriasis Patients
When diseases have a skin-altering component, dermatologists set out to determine the impact it might have on patients with pre-existing skin conditions like psoriasis.
“Psoriasis patients may be at greater risk of severe disease from monkeypox due to the skin disease itself, and also some psoriasis medications like biologics and other immunosuppressant medications,” explains Dr. Dommasch.
While having psoriasis does not put someone at higher risk of developing monkeypox, it does increase their risk of developing a more severe case should they be exposed.
Moving Towards Prevention with Targeted Vaccinations
There are currently two vaccines available to aid in the prevention of monkeypox:
- ACAM 2000: Licensed in the United States, Australia, and Singapore. More available due to higher supply in the US, but it has more complications and contraindications than the JYNNEOS vaccine.
- It should not be administered to patients who have psoriasis or are taking immunosuppressant medications.
- JYNNEOS (also known as IMVAMUNE or IMVANEX): Licensed in the European Union, Canada, and the United States, but available in limited quantities.
- Safer for patients who have psoriasis or are taking immunosuppressant medications.
Of the two vaccines, JYNNEOS is the recommended choice for patients who also have psoriasis. “Psoriasis and medications used to treat psoriasis, including biologics, are not currently contraindications to vaccination with 3rd generation monkeypox vaccines (JYNNEOS and IMVANEX),” says Dr. Dommasch.
Mass vaccination is not the current recommendation; instead, the focus is on target groups of high-risk individuals.
Due to the nature of monkeypox and smallpox sharing some similarities, the vaccination rollout was much swifter for the monkeypox outbreak than for the COVID-19 pandemic. Although there is currently a worldwide shortage of the JYNNEOS vaccine, supply will likely increase in the future. Be sure to talk to your psoriasis patients in high-risk groups about vaccination.