2026 Clinician Corner - Clinical progression of a smallpox postvaccination response

CE BROKER: For Texas physicians who have updated their EthosCE profile, credit claimed for this activity will be reported to CE Broker.

Abstract 

We present the case of a 20-year-old man with a nonnecrotic shallow, well-circumscribed ulcer on the shoulder. The patient had no significant medical history, although he noted that he was joining the military and received a smallpox vaccine injection at the same site several weeks earlier. While the differential diagnosis also included pyoderma gangrenosum, brown recluse bite, and Buruli ulcer, the patient’s presentation is characteristic of a typical postvaccination progression, which is self-limited. It is important for dermatologists for be aware of this postvaccination response to avoid misdiagnosis and unnecessary workup, given that the smallpox vaccine is still administered in healthcare workers and military recruits. 

Keywords:  Smallpox; ulcer; vaccination response

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Faculty credentials/disclosure 

The planners and faculty for this activity have no relevant financial relationships to disclose. The patient consented to the publication of this report.

Process

Click the "add to cart/begin" button, pay any relevant fee, take the quiz, complete the evaluation, and claim your CME credit.  You must achieve 100% on the quiz with unlimited attempts available.

  • By completing this process, you are attesting that you have read the journal article.

Expiration date:

Credit eligibility for this article is set to expire on November 1, 2027.

Learning Objectives

After completing the article, the learner should be able to:

  • Describe the typical progression of cutaneous findings after smallpox vaccination. 

  • Differentiate normal postvaccination reactions from vaccine-related complications. 

  • Recognize when a patient’s history supports the diagnosis of a typical postvaccination response to help avoid unnecessary diagnostic workup. 

Key Points 

  • A typical smallpox postvaccination response may appear as a papule at the inoculation site (days 3–4), progressing to a vesicle with surrounding erythema and ulceration (days 5–6). Scabs may form by days 7 to 8. 

  • Isolated ulceration at a prior inoculation site should prompt consideration of smallpox vaccination response, particularly in military or healthcare personnel, as this history alone may establish the diagnosis. 

  • Systemic symptoms, nonhealing ulcers, and generalized cutaneous involvement are key features that distinguish rare vaccine-related complications from the expected localized reaction. 

  • Prompt recognition of characteristic postvaccination progression can reduce misdiagnosis and unnecessary workup. 

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Course summary

Available credit: 
  • 1.00 American Board of Internal Medicine (ABIM) MOC Part 2

    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 1.00 MOC points in the American Board of Medicine’s (ABIM) Maintenance of Certification (MOC) program. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

  • 1.00 American Board of Surgery (ABS) Accredited CME

    Successful completion of this CME activity enables the learner to earn credit toward the CME requirement of the American Board of Surgery’s Continuous Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit.

  • 1.00 AMA PRA Category 1 Credit™
    The A. Webb Roberts Center for Continuing Medical Education of Baylor Scott & White Health is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
  • 1.00 Attendance
Course opens: 
11/01/2026
Course expires: 
11/01/2027
Cost:
$25.00

Maggie H. Zhou BS1, Shari R. Lipner, MD, PhD2, and Stephen K. Tyring, MD, PhD3 

1. Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA 

2. Department of Dermatology, Weill Cornell Medicine, New York, New York, USA 

3. Department of Dermatology, The University of Texas Health Science Center at Houston, Houston, Texas, USA 

Corresponding author: Maggie H. Zhou, BS, 630 W 168th St., New York, NY 10032 (e-mail: [email protected]) 

Dr. Lipner has served as a consultant for Moberg Pharmaceuticals and Belletorus Corporation. The planners and other faculty for this activity have no relevant financial relationships to disclose. The authors report no funding. The patient consented to publication of this case report.

Accreditation

The A. Webb Roberts Center for Continuing Medical Education of Baylor Scott & White Health is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Designation

AMA PRA Category 1 Credit™

The A. Webb Roberts Center for Continuing Medical Education of Baylor Scott & White Health designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

ABS CC

Successful completion of this CME activity enables the learner to earn credit toward the CME requirement of the American Board of Surgery’s Continuous Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit.

ABIM MOC

 Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 1.0 MOC points in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

Available Credit

  • 1.00 American Board of Internal Medicine (ABIM) MOC Part 2

    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 1.00 MOC points in the American Board of Medicine’s (ABIM) Maintenance of Certification (MOC) program. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

  • 1.00 American Board of Surgery (ABS) Accredited CME

    Successful completion of this CME activity enables the learner to earn credit toward the CME requirement of the American Board of Surgery’s Continuous Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit.

  • 1.00 AMA PRA Category 1 Credit™
    The A. Webb Roberts Center for Continuing Medical Education of Baylor Scott & White Health is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
  • 1.00 Attendance

Price

Cost:
$25.00
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