What is the management of Varicella (chickenpox)?

From the Guidelines

Chickenpox management should focus on symptom relief and prevention of complications, with the use of antiviral medication like acyclovir for severe cases or high-risk patients, as recommended by the most recent guidelines 1.

General Management

• Start with acetaminophen (Tylenol) for fever and pain at appropriate doses based on age and weight (e.g., 10-15 mg/kg every 4-6 hours for children, not exceeding 5 doses in 24 hours) 1.
• Avoid aspirin in children with chickenpox due to the risk of Reye's syndrome.
• For itching, use calamine lotion, colloidal oatmeal baths, or oral antihistamines like diphenhydramine (Benadryl) at 1 mg/kg every 6 hours for children (maximum 50 mg per dose).
• Keep fingernails short and clean to prevent secondary bacterial infections from scratching.
• Maintain good hygiene with daily bathing using mild soap and lukewarm water.
• Stay hydrated and rest until lesions crust over, typically 5-7 days after rash onset.

High-Risk Patients

• For severe cases or high-risk patients (pregnant women, newborns, immunocompromised individuals), antiviral medication like acyclovir may be prescribed within 24 hours of rash appearance 1.
• High-dose IV acyclovir remains the treatment of choice for VZV infections in compromised hosts 1.
• Oral acyclovir, famciclovir, and valacyclovir are beneficial for VZV infections in otherwise healthy hosts, but oral therapy should be reserved for mild cases of VZV disease in patients with transient immune suppression or as treatment to complete therapy once the patient has shown a clinical response to IV acyclovir 1.

Prevention

• Chickenpox is highly contagious from 1-2 days before the rash appears until all lesions have crusted over, so isolation is necessary during this period.
• The varicella-zoster virus causes chickenpox, and the body's immune response creates the characteristic itchy rash and other symptoms while fighting the infection.
• Vaccination is an effective way to prevent chickenpox, with a 2-dose varicella immunization schedule recommended for children 1.

From the FDA Drug Label

Treatment of Chickenpox: Children (2 years of age and older):20 mg/kg per dose orally 4 times daily (80 mg/kg/day) for 5 days. Children over 40 kg should receive the adult dose for chickenpox Adults and Children over 40 kg: 800 mg 4 times daily for 5 days. When therapy is indicated, it should be initiated at the earliest sign or symptom of chickenpox. There is no information about the efficacy of therapy initiated more than 24 hours after onset of signs and symptoms

The recommended management for chickenpox using acyclovir (PO) is:

• For children (2 years of age and older) weighing less than 40 kg: 20 mg/kg per dose orally 4 times daily for 5 days
• For children over 40 kg and adults: 800 mg 4 times daily for 5 days
• Therapy should be initiated at the earliest sign or symptom of chickenpox, as there is no information about the efficacy of therapy initiated more than 24 hours after onset of signs and symptoms 2

From the Research

Chickenpox Management Overview

• Chickenpox is a highly contagious disease caused by the varicella-zoster virus, typically affecting children but can also occur in adults 3.
• The disease can range from mild to severe, with higher risks of complications in adults, immunosuppressed individuals, and neonates 4.

Treatment Approaches

• Symptomatic therapy is usually adequate for chickenpox, but in some cases, antiviral drugs and antibiotics may be necessary 3.
• Antiviral therapy, such as acyclovir, can ameliorate symptoms and decrease the severity of chickenpox if administered early in the course of the infection 5, 4.
• The use of corticosteroids in chickenpox management remains a topic of debate 3.

Timing and Duration of Antiviral Therapy

• Studies have shown that initiating antiviral therapy within 24 hours of rash onset is most effective in reducing the severity and duration of chickenpox 5, 6.
• Five days of antiviral therapy is often sufficient, with no additional benefit from a 7-day course 5.

Special Considerations

• Immunocompromised individuals, pregnant women, and neonates may require special consideration, including passive immunization with varicella zoster immunoglobulin (VZIG) or active immunization 4, 7.
• The decision to admit patients to specialist care should be guided by the severity of symptoms and the presence of underlying conditions 4.