What is the treatment for a patient presenting with a monkeypox rash?

Treatment of Monkeypox Rash

The primary treatment for monkeypox rash consists of supportive care, but for severe cases or immunocompromised patients, tecovirimat (TPOXX) is the recommended first-line antiviral therapy. 1

Supportive Care Measures

Supportive care is the foundation of monkeypox treatment and includes:

• Pain management: Use of appropriate analgesics to control pain from skin lesions
• Adequate hydration: Ensuring proper fluid intake, especially important if fever is present
• Wound care: Keeping lesions clean and dry to prevent secondary bacterial infections
• Isolation: Patient must remain isolated until all lesions have crusted over and scabs have fallen off (typically 2-4 weeks) 1

Antiviral Therapy Indications

Antiviral therapy with tecovirimat should be initiated for patients with:

• Immunocompromised status
• Severe disease (>100 lesions, high fever, significant constitutional symptoms)
• Complications (encephalitis, pneumonia, retropharyngeal abscess)
• Lesions near the eyes, mouth, or genitals 1

Tecovirimat Administration

• Dosage: 600 mg twice daily orally for 14 days 1
• Efficacy: In animal studies with monkeypox virus, tecovirimat demonstrated significant improvement in survival rates when initiated within 4-5 days of infection 2
• Mechanism: Inhibits viral envelope formation, preventing viral spread to uninfected cells

Secondary Bacterial Infections

• Monitor for signs of bacterial superinfection, which can complicate monkeypox cases even in immunocompetent patients 3
• Signs include increased pain, erythema, purulence, or systemic symptoms
• Treat with appropriate antibiotics if bacterial superinfection is suspected

Infection Control Measures

• Frequent handwashing with soap and water or alcohol-based (>60%) hand sanitizer 1
• Avoid direct contact with lesions
• Place used bandages in sealed plastic bags before disposal
• Launder clothing, bedding, and towels separately using hot water and detergent

Special Populations

• Immunocompromised patients: More likely to develop severe disease; should receive early antiviral therapy 4
• Patients with dermatologic conditions: Those with atopic dermatitis or other skin barrier disruptions may be at higher risk for severe disease 3

Alternative Antivirals

If tecovirimat is unavailable or ineffective, consider:

• Cidofovir: Used as second-line therapy, but has significant nephrotoxicity and is only available intravenously 1, 5
• Brincidofovir: Another potential option, though with less clinical experience in monkeypox 5, 4

Prevention

• Vaccination: JYNNEOS™ (preferred) or ACAM2000® vaccines can be used for pre- or post-exposure prophylaxis 1, 4
• Post-exposure vaccination is most effective when administered within 4 days of exposure 4

Clinical Course and Monitoring

• Most cases are self-limiting with symptoms lasting 2-4 weeks 5
• Monitor for progression of skin lesions and development of complications
• Follow-up until complete resolution of all lesions

The management of monkeypox requires a comprehensive approach focusing on supportive care, with antiviral therapy reserved for severe cases or high-risk patients. Proper isolation and infection control measures are essential to prevent transmission to others.