Letters to the Editor

Reconsideration of the Smallpox Vaccination Administration Site


Am Fam Physician. 2005 Aug 1;72(3).

to the editor: Following the terrorist attacks of September 11, 2001, concerns of smallpox being used as a biologic weapon increased, prompting the federal government to immunize 500,000 public health care workers and all deployable U.S. military forces. The smallpox vaccine available in the United States is a live-virus preparation of vaccinia virus, which contains the antibiotics polymyxin B, streptomycin, tetracycline, and neomycin, with glycerin and phenol as a preservative. Using a bifurcated needle, the dermis in the region of the deltoid of the non-dominant arm is injected multiple times with the vaccine, with the intention of limiting the territory to a 5-mm circle. Although many of the adverse sequelae following vaccine administration have been well documented, the poor aesthetic outcomes and painful scarring following vaccination in the shoulder region have been neglected (Figures 1a and 1b).1 For the reconstructive surgeon, treatment of a post-vaccination hypertrophic scar or keloid in the deltoid region often gives disappointing results, despite different treatment modalities including: irradiation, corticosteroid injection, excision, dermabrasion, laser therapy, silicone gel sheeting, or a combination of these methods.2 The shoulder region, the chest, and the earlobes have long been known to be areas associated with an increased incidence of hypertrophic scarring and keloid formation, especially in patients with darker complexions. An initial recommendation was made to avoid the problem of upper shoulder scarring by lowering the location of vaccine administration to well below the tip of the shoulder3; however, because routine vaccination was no longer deemed necessary at that time, dealing with problems related to optimal methods of vaccine administration was no longer important.4

Figure 1a. Young girl with keloid scar after smallpox vaccination as a young child and subsequent re-vaccination in the same region.

Figure 1b. Young girl with hypertrophic scar after smallpox vaccination in deltoid region.

The inner aspect of the forearm, outer aspect of the thigh, and abdominal wall have been used as sites for vaccination in the past, yielding an improvement in scar aesthetics as well as the ability to conceal a scar when present. The deltoid region, however, continues to be favored as the site for smallpox vaccination, as was seen during the most recent smallpox alarm.

A plea is made for shifting the location of smallpox vaccine administration away from the shoulder region, because many persons today are troubled by this minor, yet occasionally discomforting and distressing disfigurement that could so easily be circumvented. This contention is particularly valuable in individuals with a history of hypertrophic scarring or keloid formation or in individuals prone to increased scarring because of a genetic predisposition.


show all references

1. Cono J, Casey CG, Bell DM; Centers for Disease Control and Prevention. Smallpox vaccination and adverse reactions. Guidance for clinicians. MMWR Recomm Rep 2003;52(RR-4):1-28. ...

2. Musgrave RM. The pitfall of surgical excision of vaccination scars in the deltoid area. Plast Reconstr Surg 1973;51:198-9.

3. Mulliken JB, Gifford GH Jr, Goldwyn RM. Vaccination caveat. The off-the-shoulder look. Am J Dis Child 1976;130:1094-5.

4. Karzon DT. Smallpox vaccination in the United States: the end of an era. J Pediatr 1972;81:600-8.

Send letters to afplet@aafp.org, or 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2680. Include your complete address, e-mail address, and telephone number. Letters should be fewer than 400 words and limited to six references, one table or figure, and three authors.

Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the AAFP permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.

This series is coordinated by Kenny Lin, MD, MPH, Associate Deputy Editor for AFP Online.



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