Treatment of Chickenpox in Pediatric Patients
Primary Recommendation
For otherwise healthy pediatric patients with chickenpox, supportive care is the mainstay of treatment, with antiviral therapy reserved for high-risk groups including immunocompromised children, those over 12 years of age, and patients with chronic cutaneous or pulmonary disorders. 1
Supportive Care for Uncomplicated Cases
For healthy infants and children with uncomplicated varicella infection, antiviral therapy is not routinely indicated. 2
Symptomatic Management
- Relieve itching with lukewarm baths containing colloidal oatmeal 2
- Provide general comfort measures and monitor for complications 2
- Isolate the child until all lesions have crusted over (typically 5-7 days) to prevent transmission 2
- Most cases resolve without complications within 5-7 days 2
Critical Pitfall: Avoid Ibuprofen
- Do not use ibuprofen as an antipyretic in children with chickenpox due to risk of severe secondary bacterial infections, including Group A streptococcus and necrotizing fasciitis 3
Antiviral Therapy Indications
Acyclovir should be initiated in the following high-risk pediatric populations: 1
High-Risk Groups Requiring Treatment
- Children over 12 years of age 1
- Immunocompromised patients 1
- Patients with chronic cutaneous or pulmonary disorders 1
- Children receiving long-term salicylate therapy or corticosteroid therapy 1
- Infants who are immunocompromised or receiving immunosuppressive therapy 2
Dosing Regimens
For children under 45 kg (oral therapy):
- 20 mg/kg per dose (maximum 400 mg/dose) orally 4 times daily for 5 days 1, 4
- Treatment should be initiated within 24 hours of rash onset for maximum efficacy 4, 5
For children over 40 kg:
- 800 mg orally 4 times daily for 5 days 4
For severe disease or immunocompromised patients:
- Intravenous acyclovir 10 mg/kg IV every 8 hours for 7-10 days 2, 1
- Discontinue immunomodulator therapy if possible during active infection 1
Post-Exposure Prophylaxis
For High-Risk Exposed Individuals
Varicella-Zoster Immune Globulin (VZIG) is first-line prophylaxis for high-risk susceptible children, including immunocompromised patients: 1
- Must be administered within 96 hours (ideally within 72 hours) of exposure 1
- May prolong incubation period to 28 days, requiring extended monitoring 1
Alternative Prophylaxis
- Prophylactic oral acyclovir 20 mg/kg (maximum 800 mg) four times daily for 7 days 2
- Initiate 7-10 days after exposure 2, 1
Vaccination Post-Exposure
- Post-exposure vaccination within 3-5 days may modify disease if infection has not yet occurred 1
- Susceptible family members who have been exposed may benefit from varicella vaccine if administered within 3-5 days 2
Special Populations
Immunocompromised Children
These patients require aggressive treatment with immediate initiation of intravenous acyclovir: 1
- Do not administer live varicella vaccine to immunocompromised patients due to risk of disseminated viral infection 1
- Household contacts of immunocompromised children should be vaccinated if seronegative 1
Neonates
- Follow same supportive care principles as older infants 2
- Consider antiviral therapy if immunocompromised or if maternal infection occurred peripartum 2
Prevention Strategy
Two-dose varicella vaccination schedule is recommended: 2
- First dose at 12-15 months of age 2
- Second dose at 4-6 years of age 2
- Children with documented history of chickenpox verified by a healthcare professional do not need vaccination 6
Evidence Quality Note
The recommendation for supportive care in healthy children is based on multiple high-quality guidelines from the CDC and AAP 2, 1. The efficacy of acyclovir when initiated within 24 hours was demonstrated in a large randomized controlled trial of 815 children, showing reduced lesion count, faster healing, and shorter duration of constitutional symptoms 5. However, this trial did not demonstrate reduction in serious complications, which remain rare 5.