What is the recommended treatment for a child with chicken pox?

Treatment of Chickenpox in Children

Primary Treatment Approach

For otherwise healthy children with chickenpox, supportive care alone is the recommended treatment, as antiviral therapy is not routinely indicated in immunocompetent children with uncomplicated varicella infection. 1, 2

Supportive Care Measures

The cornerstone of management includes:

• Symptomatic relief of itching with lukewarm baths containing colloidal oatmeal 2, 3
• Adequate hydration and monitoring for signs of dehydration 2, 3
• Fever management with acetaminophen (NOT aspirin or ibuprofen due to risk of Reye syndrome and potential association with invasive bacterial infections) 2, 3, 4
• Keeping fingernails trimmed to minimize scratching and secondary bacterial infection 4

When Antiviral Therapy IS Indicated

Oral acyclovir should be considered in specific high-risk situations, not for routine uncomplicated cases:

High-Risk Groups Requiring Acyclovir

• Immunocompromised children (primary or acquired immunodeficiency, neoplastic disease, immunosuppressive therapy) - these patients require intravenous acyclovir 10 mg/kg every 8 hours for 7-10 days 2, 3, 5
• Infants under 1 year of age (particularly those without maternal antibody protection) 2, 6
• Adolescents and adults (higher complication rates) 1
• Children with chronic cutaneous or pulmonary disorders 2, 3
• Children receiving long-term salicylate therapy 2

Acyclovir Dosing for Chickenpox (When Indicated)

For children over 2 years and over 40 kg: 800 mg orally 4 times daily for 5 days 5

For children 2 years and older under 40 kg: 20 mg/kg per dose orally 4 times daily (maximum 800 mg per dose) for 5 days 5

Critical timing: Therapy must be initiated within 24 hours of rash onset for maximum benefit 5, 7

The evidence shows acyclovir reduces lesion count (294 vs 347 lesions), accelerates healing, and limits constitutional symptoms to 3-4 days in treated children versus prolonged illness in 20% of untreated children 7. However, it did not significantly reduce serious complications in the studied population 7.

Monitoring for Complications

Bacterial superinfection is the most common serious complication requiring hospitalization and must be monitored vigilantly 2, 3:

Warning Signs of Bacterial Superinfection

• Expanding erythema around lesions 2, 3
• Purulent drainage from lesions 2, 3
• Increasing pain, tenderness, or warmth 2, 3
• Systemic toxicity (high fever, lethargy, hemodynamic instability) 2, 3

Other Serious Complications to Monitor

• Pneumonia (more common in infants, adolescents, and adults) 1, 2
• Encephalitis 1, 2
• Dehydration 2, 3
• Invasive group A streptococcal infections 2, 3, 4

Important caveat: Infants under 1 year are 6 times more likely to be hospitalized than children aged 5-9 years, but infants under 1 month typically have mild disease due to maternal antibodies 2, 6.

Isolation and Infection Control

Children must be isolated until ALL lesions have completely crusted over, typically 5-7 days after rash onset 2, 8, 3:

• Contagious period: Begins 1-2 days before rash onset and continues until all lesions are crusted 8
• Return to school/daycare: Only when all lesions are dry and crusted (not just scabbed), including hidden areas like scalp, behind ears, and genital area 8
• High-risk contacts to avoid: Immunocompromised individuals, pregnant women without immunity, and newborns 2, 3

Post-Exposure Prophylaxis for Contacts

For Susceptible Household Contacts

Varicella vaccine is effective if administered within 3-5 days of exposure and should be offered to susceptible family members 1, 2, 3

For High-Risk Exposed Individuals

Varicella-zoster immune globulin (VZIG) should be given within 96 hours (up to 10 days) after exposure to: 1, 2, 3

• Immunocompromised contacts without immunity 1, 3
• Pregnant women without evidence of immunity 1, 3
• Newborns whose mothers developed varicella 5 days before to 2 days after delivery 2, 3
• Hospitalized premature infants exposed postnatally 2

Common Pitfalls to Avoid

• Never use aspirin or salicylates in children with chickenpox due to Reye syndrome risk 2, 3
• Avoid ibuprofen as some evidence suggests association with invasive group A streptococcal infections 4
• Do not start acyclovir after 24 hours of rash onset in routine cases - efficacy is significantly reduced 5, 7
• Do not rely on fixed number of days for school return - verify ALL lesions are crusted, including hidden areas 8
• Do not routinely prescribe acyclovir for healthy children - supportive care is appropriate for uncomplicated cases 1, 2

Future Prevention

Once the child fully recovers from varicella, no additional varicella vaccination is needed, as natural infection provides lifelong immunity 2. However, children who have not had chickenpox should receive varicella vaccine at 12-15 months of age with a second dose at 4-6 years 2, 9.