What is the recommended treatment for chicken pox in pediatric patients?

Treatment of Chickenpox in Pediatrics

Primary Treatment Approach

For otherwise healthy children with uncomplicated chickenpox, supportive care alone is the recommended treatment, and oral acyclovir is not routinely indicated. 1, 2

Supportive Care Measures

• Symptomatic management includes lukewarm baths with colloidal oatmeal to relieve itching 1
• Antipyretics for fever control (avoid aspirin due to Reye syndrome risk) 2
• Isolation until all lesions have crusted over (typically 5-7 days) to prevent transmission 1
• Most cases resolve without complications within 5-7 days 1

When to Consider Antiviral Therapy

High-Risk Groups Requiring Acyclovir

Oral acyclovir (20 mg/kg four times daily for 5 days, maximum 800 mg per dose) should be initiated within 24 hours of rash onset for: 3, 2

• Adolescents ≥13 years of age (otherwise healthy, nonpregnant) 2
• Children >12 months with chronic cutaneous or pulmonary disorders 2
• Children receiving long-term salicylate therapy 2
• Immunocompromised patients (require intravenous acyclovir, not oral) 4, 5
• Neonates during first 2 weeks of life 5
• Severe varicella in any patient 5

Timing and Efficacy Considerations

• Treatment initiated within 24 hours of rash onset provides maximum benefit: reduces fever duration by approximately 1 day and decreases severity of cutaneous/systemic symptoms by 15-30% 6, 2
• Treatment started 24-48 hours after rash onset shows diminished but still measurable benefit in some outcomes 7
• Treatment beyond 48 hours results in minimal to no therapeutic effect 7, 2
• Five days of therapy is sufficient; 7-day courses provide no additional benefit 7

Important Caveats

• Oral acyclovir has not been shown to reduce acute complications, pruritus, or duration of school absence in otherwise healthy children 2
• The effect on long-term zoster occurrence remains unknown 2
• Intravenous acyclovir (not oral) is indicated for immunocompromised patients, severe disease, and children <2 years at high risk 4, 5

Special Populations

Immunocompromised Children

• Intravenous high-dose acyclovir for 7-10 days is recommended 4
• This includes children with congenital nephrotic syndrome and hypogammaglobulinemia 4
• HIV-infected children in CDC class 1 with CD4 ≥15% may receive varicella vaccine (not treatment) 4

Postexposure Prophylaxis

• Varicella-zoster immune globulin (VZIG) should be given to susceptible high-risk patients as soon as possible after exposure, effective up to 10 days post-exposure 4
• Prophylactic oral acyclovir (10 mg/kg four times daily for 7 days) within 7-10 days of exposure if VZIG unavailable 4
• Varicella vaccine administered within 3-5 days of exposure may benefit susceptible family members 1

Dosing Specifics

Oral Acyclovir for Treatment 3

• Children 2 years and older: 20 mg/kg per dose, 4 times daily (maximum 80 mg/kg/day) for 5 days
• Children >40 kg and adults: 800 mg 4 times daily for 5 days
• Renal impairment: Dose adjustment required based on creatinine clearance 3

Contraindications to Routine Use

• Not recommended for otherwise healthy children with uncomplicated varicella due to marginal therapeutic effect, cost, and feasibility challenges of initiating therapy within 24 hours 2
• The American Academy of Pediatrics emphasizes this decision should be based on informed discussion among physician, parent, and patient 2

Prevention Strategy

• Two-dose varicella vaccination schedule: First dose at 12-15 months, second dose at 4-6 years 4
• Children who recover from chickenpox should receive catch-up vaccination if not previously immunized (once ≥12 months of age) 1
• Natural infection provides immunity; children with documented chickenpox do not need vaccination 8