What is the recommended treatment for a 5-year-old child presenting with initial symptoms of varicella (chickenpox)?

Treatment of Beginning Chickenpox in a 5-Year-Old Child

For an otherwise healthy 5-year-old child with beginning chickenpox, supportive care alone is the recommended treatment, as antiviral therapy is not routinely indicated in immunocompetent children with uncomplicated varicella infection. 1

Primary Treatment Approach

Supportive care measures should be the mainstay of treatment:

• Relieve itching with lukewarm baths containing colloidal oatmeal to provide symptomatic relief 1
• Keep the child's fingernails trimmed short to minimize scratching and reduce risk of bacterial superinfection 2
• Use antihistamines if needed for severe pruritus, though evidence for their effectiveness is limited 2

When Antiviral Therapy Is NOT Indicated

For this healthy 5-year-old, oral acyclovir is not routinely recommended because:

• The child is immunocompetent and at low risk for complications 1
• Antiviral therapy provides only modest benefit when started within 24 hours of rash onset in healthy children, shortening disease duration by approximately 1 day 3
• The American Academy of Pediatrics and CDC reserve antiviral therapy for specific high-risk situations 1

When to Consider Antiviral Therapy

Acyclovir should be considered only if the child has:

• Immunocompromising conditions or is receiving immunosuppressive therapy 1
• Chronic cutaneous or pulmonary disorders 4
• Long-term salicylate therapy 4
• Secondary household cases (who tend to have more severe disease) 3

If antiviral therapy is indicated, the dosing is:

• 20 mg/kg per dose orally 4 times daily (80 mg/kg/day) for 5 days, with a maximum of 800 mg per dose 4
• Treatment must be initiated within 24 hours of rash onset for maximum benefit 4, 3
• Five days of therapy is sufficient; seven days provides no additional benefit 3

Critical Monitoring for Complications

Watch carefully for signs of bacterial superinfection, the most common serious complication:

• Expanding erythema around lesions, purulent drainage, increasing pain or tenderness 1
• Invasive group A streptococcal infections are the most frequent complications requiring hospitalization 1, 5
• Other serious complications include pneumonia, dehydration, and encephalitis 1
• Children aged 5 years have lower hospitalization rates than infants but still require monitoring 1

Medication Safety

Avoid ibuprofen and aspirin:

• Do not use ibuprofen, as it has been associated with increased risk of invasive group A streptococcal infections 2
• Never give aspirin due to risk of Reye syndrome 5
• Acetaminophen may be used for fever control if needed 2

Isolation and Infection Control

Keep the child isolated until all lesions have crusted over:

• This typically takes 5-7 days from rash onset 1
• The child is contagious from 1-2 days before rash onset until all lesions are crusted 6
• Exclude from school or daycare during this infectious period 6

Post-Exposure Management of Contacts

For susceptible household contacts who have been exposed:

• Administer varicella vaccine within 3 days of exposure for >90% effectiveness in preventing disease 7, 5
• Vaccine given within 5 days is 70% effective in preventing disease and 100% effective in modifying severe disease 7, 5
• Household contacts have approximately 85% risk of developing varicella if susceptible 5

Future Vaccination Considerations

After recovery from chickenpox:

• No additional varicella vaccination is needed, as natural infection provides lifelong immunity 1
• The child does not require the routine 2-dose varicella vaccine series 1

Follow-Up

• Most cases resolve without complications within 5-7 days 1
• Follow-up is typically not necessary unless complications develop 1
• If fever persists beyond 4-5 days or worsens after initial improvement, evaluate for bacterial superinfection 1, 2