**15. Vaccination in pemphigus patients**

Administration of live vaccines is contraindicated when using adjuvant immunosuppressants and rituximab. Vaccination against seasonal influenza, H1N1, tetanus and pneumococci are recommended in patients receiving oral corticosteroids or immunosuppressives. During systemic immunosuppression, the level of protection after vaccination raises question marks [26]. On the other hand, it has been reported in the literature that pemphigus vulgaris is seen after tetanus diphtheria, hepatitis B and influenza vaccine applications, and that the disease exacerbates after influenza vaccine use [58]. We do not have any data on which patients vaccination will cause disease reactivation [59].

Although COVID mRNA vaccines may cause autoimmune bullous disease activation, it is recommended not to abandon the vaccination and to treat the existing picture in case of disease activation [60].

Based on vaccination experience, when vaccines for COVID-19 are available, dermatologists may advise vaccination 12–20 weeks after completion of a treatment cycle with rituximab or extend dosing intervals so that a minimum time of 4 weeks precedes the next drug infusion [61].

Limited data suggest that patients with autoimmune bullous disease receiving immunomodulatory therapies are not primarily at risk for serious or fatal COVID-19 [60].
