Shingles Risk on Oral JAKs — And the Pediatric Wrinkle
In this special conference coverage from the 2026 Elevate-Derm RAPIDS Conference, dermatology NP Victoria Garcia Albea sits down with Lisa Swanson, MD, right after her talk on JAKs and immunodermatology. They open with a practical concern for anyone starting an oral JAK: the increased, dose-dependent risk of VZV reactivation. Swanson notes that the shingles vaccine is available to patients 50 and up, or 19 and up if they're on an immunosuppressing medication — and an oral JAK counts for insurance purposes to get patients vaccinated.
The tricky group is pediatrics. When considering an oral JAK for a 12–17-year-old with alopecia areata or atopic dermatitis, patients fall below the vaccine's indicated age. Swanson tells families that children and teens with completely normal immune systems can and do get shingles these days — a trend she says became more noticeable as varicella vaccination became widespread. She offers two theories: the vaccine may confer a different level of immunity than natural infection, lowering the reactivation threshold, and there's less VZV circulating to periodically boost immunity.
Importantly, Swanson stresses that all the pediatric shingles cases she's seen have been in immunocompetent kids — none of her patients on an oral JAK have gotten shingles. She still believes the risk is real and the data support it, but her clinical experience has been that these kids 'just got shingles.'
Recognizing Pediatric Shingles
Swanson describes pediatric shingles as looking similar to the adult presentation but with less prominent blisters — more dermatomal erythema, sometimes with deeper red papules. The dermatomal pattern is what sets it apart. Unlike adults, she says shingles in kids doesn't hurt; it's either itchy or asymptomatic, and affected children often just feel sick, tired, or 'not themselves.'
Location isn't as predictable as the classic truncal adult pattern — anecdotally, Swanson says she can see it almost anywhere on a child. She warns that pediatric shingles is most commonly misdiagnosed as allergic contact dermatitis, so a 'weird streak' of rash should prompt clinicians to ask whether it could be shingles.
Swanson has never seen postherpetic neuralgia or postherpetic pruritus in a child, and notes that if missed, the child likely got better anyway. The real risk of a missed diagnosis is transmission: you can't catch shingles from shingles, but you can catch chickenpox from shingles. A child with shingles should be kept away from pregnant women and babies under one, since the first varicella vaccine is given between ages one and two. She has not had kids under 19 receive the shingles vaccine, and expects it would be difficult to push through insurance.
Heliocare (Polypodium Leucotomos) in Vitiligo and Beyond
Swanson is enthusiastic about polypodium leucotomos (Heliocare) for sun-sensitive conditions like polymorphous light eruption, solar urticaria, dermatomyositis, and cutaneous lupus — calling it the best thing she's seen for those. It's taken once daily in the morning; capsules are large but can be opened and sprinkled on food or in juice, and the same dose applies across ages.
Her signature move: she recommends Heliocare every single time she treats vitiligo with topical ruxolitinib. The logic builds on two 'betters' — topical Rux works better in sun-exposed areas, and polypodium leucotomos both protects skin from the sun and potentiates light therapy. She cites studies showing patients on narrowband UVB for psoriasis or vitiligo do better when also taking Heliocare. She pairs it with topical Rux or, for more extensive vitiligo, off-label oral JAK therapy.
It's over the counter and available year-round on Amazon (drugstores tend to stock it only in summer). Families like that it's natural — a fernleaf extract from South and Central America used for centuries. Swanson notes a patient brought in a European topical cream containing polypodium leucotomos, but she cautions that topical use hasn't been validated the way the studied brand Heliocare has, so she's sticking with what's been studied.
Maintaining Repigmentation and Treating Alopecia Areata
For a vitiligo patient who repigments 100% on topical ruxolitinib, Swanson calls long-term management an evolving conversation. In studies, patients who kept using it BID saw very little recurrence, but real-world patients lose motivation once pigment returns. Roughly 30% recur after stopping, and prior data suggest topical tacrolimus twice a day, two days a week can cut recurrence to about 10%. She often uses that tacrolimus maintenance strategy, while noting ongoing studies of ruxolitinib maintenance protocols likely to guide future practice.
For alopecia areata in patients not ready for a JAK — often due to age or still processing information — Swanson offers a pulse prednisone plus low-dose oral minoxidil bridge. Her prednisone regimen is 5 mg/kg, one weekend a month, split half Saturday and half Sunday; most kids sail right through it. For minoxidil, she uses roughly a quarter of a 2.5 mg tablet Monday/Wednesday/Friday for younger children (3–10) and a quarter tablet daily for those 10 and up, individualized by weight. The prednisone tells the immune system to stop attacking follicles; the minoxidil tells the follicles to grow.
For severity, she uses SALT scores in clinic because that's what the trials used and what insurers want in documentation. She emphasizes the enormous psychosocial impact — booking these patients at the end of the day so families aren't rushed — and describes the regrowth on oral JAKs as career-affirming and 'the closest thing to magic we can do.'
Pregnancy Planning and JAK Recapture
Swanson doesn't want patients getting pregnant on oral JAKs; teratogenicity is unknown and there's reason to believe risk could exist. For a woman of childbearing potential, she frames the conversation around family planning goals. For atopic dermatitis, if pregnancy is 3–5 years away, she'll start the JAK with a plan to stop when the patient begins planning a family — noting the drugs clear quickly enough that stopping at a positive test is likely okay, though less desirable.
Alopecia areata is a different game. Because peak regrowth hits around a year, starting a JAK in someone planning pregnancy in 1–3 years risks losing that hair right when she's trying to conceive — psychologically difficult. In that scenario Swanson might postpone, or consider dupilumab, especially if baseline serum IgE is greater than 200, which predicts a better chance of response. She doesn't routinely monitor IgE on dupilumab and does baseline QuantiFERON-Gold for JAK patients without annual repeats unless risk factors emerge.
The encouraging news: withdrawal data (from baricitinib) show that patients who relapsed after stopping recaptured beautifully on restart, with the same course. She adds a practical caveat — relapse is harder emotionally for female patients, whose longer hair takes far longer to catch up than shorter male hair after a treatment break.