What can be given to an elderly patient with chickenpox (varicella) for itchiness relief?

Management of Itchiness in Elderly Patients with Chickenpox

For an elderly patient with chickenpox, use oral acyclovir 800 mg five times daily for symptomatic relief and to prevent complications, combined with high lipid-content emollients applied liberally multiple times daily, and avoid all antihistamines—particularly sedating ones like diphenhydramine—due to toxicity risks and lack of efficacy. 1, 2, 3

Primary Treatment Strategy

Antiviral Therapy (Essential in Elderly)

• Start oral acyclovir 800 mg five times daily immediately, as elderly patients are at significantly higher risk for severe complications including varicella pneumonia, hepatitis, and death compared to younger adults 1, 4
• Acyclovir must be initiated early in the disease course to be effective and requires adequate hydration with monitoring of renal function given age-related kidney impairment 1
• Elderly patients, particularly smokers and those with respiratory symptoms, have mortality rates up to 17.2% with varicella pneumonia, making antiviral treatment critical 4

Topical Management for Pruritus

• Apply emollients with high lipid content (preferably containing 5-10% urea) liberally to all affected areas at least 3-4 times daily, as elderly skin has impaired barrier function and increased transepidermal water loss 2, 5
• Consider adding 1% hydrocortisone ointment to areas of intense itching, applied 3-4 times daily for localized inflammation 2
• Keep nails short to minimize trauma from scratching and prevent secondary bacterial skin infections 2

Critical Medications to AVOID

Antihistamines Are Contraindicated

• Do NOT use diphenhydramine (oral or topical) in elderly patients with chickenpox, as significant systemic absorption occurs through varicella lesions, causing toxicity with hallucinations, bizarre behavior, and altered mental status 3
• Do NOT prescribe any sedating antihistamines (hydroxyzine, diphenhydramine) in elderly patients due to increased fall risk, confusion, and potential contribution to dementia 2, 5
• Non-sedating antihistamines (fexofenadine, loratadine) have limited evidence for chickenpox-related pruritus and should not be first-line 2, 5

NSAIDs Must Be Avoided

• Do NOT prescribe NSAIDs (ibuprofen, naproxen, indomethacin) in patients with active chickenpox due to increased risk of severe bacterial skin infections and necrotizing fasciitis 6
• Use paracetamol (acetaminophen) instead for fever control if needed 6

Monitoring for Complications

High-Risk Features in Elderly Patients

• Monitor closely for respiratory symptoms (cough, breathlessness, sputum production), as varicella pneumonia occurs in 28.4% of hospitalized adults and has 17.2% mortality 4
• Check baseline liver function tests, as elevated ALT occurs in 51.9% of adult chickenpox cases, with 4.9% showing levels >10-fold normal 4
• Monitor for thrombocytopenia (occurs in 42.1%), secondary bacterial skin infections (25.4%), and neurological symptoms suggesting encephalitis/meningitis (8.8%) 4

When to Escalate Care

• Hospitalize immediately if respiratory symptoms develop, as mechanical ventilation carries 45.5% mortality in varicella pneumonia 4
• Refer urgently for any signs of septicemia, acute renal failure, or altered mental status 4

Additional Supportive Measures

• Avoid hot water bathing and harsh soaps, as these worsen xerosis and increase pruritus 5
• Ensure adequate hydration to support renal clearance of acyclovir and prevent nephrotoxicity 1
• Consider gabapentin (starting 100-300 mg at bedtime) only if pruritus remains refractory after 48-72 hours of emollient therapy, though evidence is limited for acute varicella 2, 5