Can a 57-year-old patient with varicella (chickenpox) be treated with dexamethasone (intramuscular) for pruritis?

Management of Pruritus in Varicella (Chickenpox) Infection

Dexamethasone IM should NOT be used to treat pruritus in a 57-year-old patient with varicella (chickenpox) infection due to the significant risk of severe or fatal varicella complications with corticosteroid use. 1, 2

Rationale Against Corticosteroid Use in Varicella

Systemic corticosteroids, including dexamethasone, are specifically contraindicated in active varicella infection for several important reasons:

• Corticosteroids significantly suppress the immune system, increasing the risk of severe varicella complications 1
• Research shows patients receiving corticosteroids have dramatically increased odds of developing severe varicella (odds ratio 178-420) 2
• The FDA label for dexamethasone specifically warns against its use in varicella infections, stating that "varicella can have a serious or even fatal course in non-immune patients taking corticosteroids" 1
• Even low-dose corticosteroids (less than 2 mg/kg/day prednisone equivalent) have been associated with severe varicella outcomes 2

Recommended Management Approach for Varicella Pruritus

First-line treatments:

1. Topical therapies:

   • Mild-moderate potency topical emollients applied regularly
   • Calamine lotion for soothing effect
   • Avoid high-potency topical corticosteroids 3

2. Oral antihistamines:

   • First-generation (e.g., diphenhydramine) for sedating effect at night
   • Second-generation (e.g., cetirizine, loratadine) for daytime relief 3

3. Cooling measures:

   • Cool compresses
   • Tepid baths with colloidal oatmeal 3

For severe pruritus:

• Consider gabapentin or pregabalin for neuropathic itch component
• Topical anti-itch remedies (e.g., refrigerated menthol and pramoxine) 4

Antiviral Therapy

For a 57-year-old with active varicella, antiviral therapy should be initiated promptly:

• Acyclovir (800 mg orally five times daily for 7-10 days) or
• Valacyclovir (1000 mg orally three times daily for 7-10 days) or
• Famciclovir (500 mg orally three times daily for 7-10 days) 4, 5

Antiviral therapy is particularly important in adults, as they are at higher risk for varicella complications than children.

Monitoring and Prevention of Complications

1. Monitor for signs of secondary bacterial infection (yellow crusting, increasing erythema, warmth)
2. Assess for systemic complications (pneumonia, encephalitis, hepatitis)
3. Avoid NSAIDs as they are associated with increased risk of severe skin and soft tissue complications in varicella 6
4. Maintain good skin hygiene to prevent secondary infection
5. Isolate the patient until all lesions have crusted over

Special Considerations

• Adults with varicella are at higher risk for complications than children
• The patient should be monitored closely for development of varicella pneumonia, which occurs in up to 20% of adults with varicella
• If respiratory symptoms develop, prompt evaluation with chest imaging is warranted

Key Takeaway

The evidence strongly indicates that systemic corticosteroids like dexamethasone IM should be avoided in patients with active varicella infection due to the significantly increased risk of severe complications and potentially fatal outcomes. Alternative symptomatic treatments for pruritus should be used instead, along with appropriate antiviral therapy.