Acyclovir Ointment is NOT Recommended for Varicella Lesions
Topical acyclovir ointment should not be used for varicella (chickenpox) lesions—systemic therapy (oral or intravenous acyclovir) is the appropriate route when antiviral treatment is indicated. 1
Why Topical Acyclovir is Inappropriate
Topical acyclovir has no established role in varicella treatment. The FDA has approved topical acyclovir only for limited mucocutaneous herpes simplex infections, not for varicella-zoster virus infections. 2
Varicella is a systemic viral infection requiring systemic antiviral therapy to reduce viremia, prevent complications, and decrease morbidity and mortality—topical therapy cannot achieve these outcomes. 1
When Systemic Acyclovir IS Indicated for Varicella
Immunocompromised Patients (ALWAYS TREAT)
Intravenous acyclovir 10 mg/kg every 8 hours is mandatory for immunocompromised patients with varicella, as it significantly reduces morbidity and mortality when started within 24 hours of rash onset. 1, 3
Treatment should continue for 7-14 days minimum or until clinical improvement occurs, then may switch to oral therapy to complete the course. 3
This is life-saving therapy—disseminated varicella carries high mortality risk in immunocompromised hosts. 4, 5
Otherwise Healthy Patients at Higher Risk
Oral acyclovir should be considered (not topical) for otherwise healthy persons at increased risk for moderate to severe varicella, specifically: 1
- Persons aged >12 years (adolescents and adults)
- Persons with chronic cutaneous or pulmonary disorders
- Persons receiving long-term salicylate therapy
- Persons receiving short, intermittent, or aerosolized corticosteroids
- Secondary household contacts (some experts recommend)
Dosing for Systemic Therapy
Oral acyclovir dosing for varicella: 2
- Children (2 years and older): 20 mg/kg per dose orally 4 times daily (80 mg/kg/day) for 5 days
- Adults and children >40 kg: 800 mg orally 4 times daily for 5 days
- Must be initiated within 24 hours of rash onset for maximum benefit 1
Intravenous acyclovir dosing: 3, 2
- 10 mg/kg IV every 8 hours for immunocompromised or disseminated disease
- Adjust for renal impairment 2
Healthy Children Without Risk Factors
The American Academy of Pediatrics does NOT recommend routine acyclovir (oral or otherwise) for otherwise healthy children with varicella, as the clinical benefit does not justify routine administration. 1
Oral acyclovir in healthy children reduces fever duration and new lesion formation by approximately 1 day but does not prevent complications or reduce school absence. 1
Critical Pitfalls to Avoid
Never delay systemic IV acyclovir in immunocompromised patients while considering alternative routes—this is a critical error that increases mortality. 3
Do not use oral antivirals for suspected disseminated disease—IV therapy is mandatory. 3
Topical acyclovir has no role in varicella treatment and should not be prescribed, as it provides no systemic antiviral effect and may create false reassurance. 1, 2
The 24-hour window for treatment initiation is crucial for optimal outcomes in those who warrant therapy. 1