What emollient therapy is recommended for chickenpox in the elderly?

Emollient Therapy for Chickenpox in the Elderly

For elderly patients with chickenpox, immediately initiate high lipid-content emollients (such as 50% white soft paraffin/liquid paraffin mixture, white soft paraffin, or emulsifying ointment) applied liberally at least twice daily to manage pruritus and dry skin, while simultaneously starting oral aciclovir 800 mg four times daily for 7-10 days within 24 hours of rash onset. 1, 2, 3

Primary Emollient Recommendations

The British Association of Dermatologists specifically recommends moisturizers with high lipid content for elderly patients, as these formulations provide superior occlusion and barrier support for aging skin. 4, 1

Specific High Lipid-Content Products to Prescribe:

• 50% white soft paraffin/liquid paraffin mixture (highest lipid-to-water ratio) 1
• White soft paraffin (100% lipid base) 1
• Yellow soft paraffin 1
• Emulsifying ointment 1
• Diprobase® ointment, Cetraben®, or Hydromol® ointment 1

Application Protocol:

• Apply at least twice daily, ideally immediately after bathing to maximize skin hydration 1
• Estimated usage: 200-400 grams per week for adults with twice-daily application 1
• Continue throughout the entire course of chickenpox and for 2 weeks after to address asteatotic eczema common in elderly skin 4

Concurrent Antiviral Therapy (Critical in Elderly)

Elderly patients with chickenpox require immediate antiviral treatment due to significantly higher morbidity and mortality rates. 2, 5, 6

• Oral aciclovir 800 mg four times daily for 7-10 days must be initiated within 24 hours of rash onset for maximum efficacy 2, 3
• Treatment initiated after 24 hours shows reduced clinical benefit, though some benefit persists if started within 48 hours 3
• Elderly patients have higher rates of varicella pneumonia (28.4%), hepatitis (51.9%), and mortality (4.9% overall, 17.2% with pneumonia) compared to younger adults 6

Additional Symptomatic Management

For Pruritus Control:

• Add 1% hydrocortisone cream for 2 weeks if pruritus is severe, as elderly patients commonly develop asteatotic eczema 4
• Non-sedating antihistamines may be used for symptomatic relief 4
• Avoid sedating antihistamines due to increased fall risk, confusion, and cognitive impairment in elderly patients 4

If Emollients Alone Are Insufficient:

• Consider gabapentin for refractory pruritus in elderly patients 4
• Reassess after 2 weeks if symptoms do not improve with initial emollient and topical steroid therapy 4

Critical Caveats for Elderly Patients

Ointment-based emollients have greasy consistency that may reduce compliance, so discuss cosmetic concerns upfront and emphasize that patient preference is decisive for long-term adherence. 1

Monitor for complications aggressively in elderly patients, including:

• Varicella pneumonia (presents with cough, breathlessness, sputum) - occurs more frequently in older age groups and smokers 6
• Hepatitis (elevated ALT >10-fold normal in 4.9%) 6
• Secondary bacterial skin infections (25.4% of cases) 6
• Encephalitis/meningitis (8.8% of cases) 6

Ensure adequate hydration and monitor renal function during aciclovir therapy, as elderly patients are at higher risk for aciclovir-induced nephrotoxicity. 7

Isolate patients until all lesions have crusted over to prevent transmission to other vulnerable individuals. 2