Is ibuprofen (nonsteroidal anti-inflammatory drug) safe for fever and pain relief in chickenpox?

Ibuprofen Should Be Avoided in Chickenpox

Ibuprofen is not recommended for fever or pain management in chickenpox due to an increased risk of severe bacterial skin infections, particularly invasive Group A streptococcal infections; paracetamol (acetaminophen) should be used instead. 1, 2, 3

Primary Recommendation

• Avoid NSAIDs including ibuprofen in children with chickenpox due to evidence suggesting increased risk of invasive Group A streptococcal infection and severe bacterial skin complications 1, 2
• Multiple case reports, cohort studies, and case-control studies have documented this association, though the exact mechanism remains unclear 1
• Emergency department guidelines specifically recommend against ibuprofen use in chickenpox cases 2

Preferred Alternative: Acetaminophen

• Use acetaminophen (paracetamol) as the antipyretic of choice for chickenpox-related fever and discomfort 1, 3
• Acetaminophen is safe and effective for symptom control in varicella infection without the associated risks of NSAIDs 3
• Standard dosing: 10-15 mg/kg every 4-6 hours, not exceeding 4 doses in 24 hours 1

Evidence Base and Mechanism of Concern

The concern stems from multiple lines of evidence:

• Increased risk of invasive Group A streptococcal infection: Case-control and cohort studies have identified ibuprofen use during chickenpox as a risk factor for severe bacterial superinfection 1, 2
• Risk of acute renal failure: Particularly in the setting of hypovolemia or dehydration, which can occur with chickenpox due to fever and reduced oral intake 1
• Potential for necrotizing fasciitis: Serious bacterial complications including necrotizing fasciitis have been reported in association with NSAID use during varicella 2

Clinical Context

While ibuprofen is generally more effective than acetaminophen for fever reduction in other pediatric conditions 4, this advantage is outweighed by safety concerns specific to chickenpox:

• The Infectious Diseases Society of America recommends NSAIDs for moderate-to-severe symptoms in conditions like streptococcal pharyngitis 5, but this does not extend to chickenpox
• Chickenpox creates a unique risk environment due to widespread skin lesions that serve as potential portals for bacterial invasion 2

Critical Pitfalls to Avoid

• Do not prescribe ibuprofen for symptomatic relief in confirmed or suspected chickenpox, even if fever is high or discomfort is significant 1, 2, 3
• Do not assume that because ibuprofen is safe in other febrile illnesses, it is safe in chickenpox—the disease-specific risk profile changes the risk-benefit calculation 1, 3
• Avoid all NSAIDs, not just ibuprofen, as the concern extends to the entire drug class 3
• Ensure adequate hydration if using any antipyretic, as dehydration increases risk of renal complications 1

Additional Management Considerations

• Antiviral therapy with acyclovir (20 mg/kg four times daily for 5 days) reduces disease duration and severity when initiated within 24 hours of rash onset, though it does not significantly reduce complications in otherwise healthy children 6
• Monitor for signs of bacterial superinfection including increasing erythema, warmth, purulent drainage, or systemic toxicity 2
• Aspirin must also be avoided in children with chickenpox due to risk of Reye syndrome 5