What is the management of chicken pox in patients, including children and adults, with or without compromised immune systems?

Management of Chickenpox

For healthy children and adults with chickenpox, supportive care is the mainstay of treatment, with oral acyclovir reserved for high-risk groups including adolescents, adults, immunocompromised patients, and those with complications, while intravenous acyclovir is indicated for severe or disseminated disease.

Risk Stratification and Treatment Approach

Healthy Children (Ages 2-12 Years)

• Symptomatic treatment alone is appropriate for most immunocompetent children with uncomplicated chickenpox 1, 2
• Chickenpox is typically self-limited, lasting 4-5 days with fever, malaise, and 250-500 vesicular lesions 1, 3
• Antiviral therapy is not routinely required in this population unless complications develop 2, 4

Key supportive measures include:

• Antipyretics for fever management (avoid ibuprofen due to risk of severe bacterial complications including necrotizing fasciitis) 5
• Antihistamines for pruritus control 2
• Maintaining skin hygiene to prevent secondary bacterial infections 5

Adolescents and Adults (≥13 Years)

Oral acyclovir 800 mg five times daily for 5 days should be initiated within 24 hours of rash onset 6, 7

• Adults and adolescents are at significantly higher risk for complications including pneumonia and disseminated disease 1, 3
• Treatment within 24 hours reduces time to complete crusting from 7.4 to 5.6 days and decreases fever duration by half a day 7
• Efficacy is substantially reduced if treatment begins more than 24 hours after rash onset 7

Immunocompromised Patients (All Ages)

Intravenous acyclovir is mandatory for all immunocompromised patients with chickenpox 6, 8

• This includes patients with HIV, cancer, organ transplant recipients, and those on chronic immunosuppressive therapy 1, 8
• Immunocompromised patients are at high risk for severe complications, disseminated disease, and death 1, 3
• Consider temporary reduction of immunosuppressive medications if clinically feasible 9

Specific Treatment Regimens

Oral Acyclovir Dosing

Children (2 years and older): 20 mg/kg per dose four times daily (maximum 800 mg per dose) for 5 days 6

Adults and children >40 kg: 800 mg four times daily for 5 days 6

Critical timing: Initiate at earliest sign of rash, ideally within 24 hours 6, 7

Intravenous Acyclovir Indications

Absolute indications for IV therapy include:

• All immunocompromised patients regardless of disease severity 6, 8
• Complicated varicella with pneumonia 8, 7
• Disseminated disease (multi-organ involvement) 8
• Central nervous system complications 8
• Inability to tolerate oral medications 8

Renal Dose Adjustments

For patients with renal impairment receiving oral acyclovir 800 mg dosing 6:

• CrCl >25 mL/min: 800 mg every 4 hours (5 times daily)
• CrCl 10-25 mL/min: 800 mg every 8 hours
• CrCl 0-10 mL/min: 800 mg every 12 hours
• Hemodialysis: Administer additional dose after each dialysis session 6

Post-Exposure Prophylaxis

Varicella Vaccine

Administer varicella vaccine within 3-5 days of exposure to susceptible individuals to prevent or modify disease 1, 9

• Vaccine is effective in preventing illness or modifying severity if given within 3 days, possibly up to 5 days post-exposure 1
• This approach is preferred for healthy susceptible contacts 1

Varicella-Zoster Immune Globulin (VZIG)

VZIG should be administered within 96 hours of exposure to high-risk susceptible individuals 1, 9:

• Pregnant women without immunity 1, 9
• Immunocompromised patients 1, 9
• Neonates (especially <28 weeks gestation or <1,000 g) 9
• HIV-infected individuals without VZV immunity 1

If VZIG is unavailable or >96 hours have passed: Consider 7-day course of oral acyclovir beginning 7-10 days after exposure 9

Isolation and Infection Control

Contagious Period

Patients are contagious from 1-2 days before rash onset until all lesions have completely crusted 10, 3

• This typically occurs 4-7 days after rash appearance 10, 3
• Secondary attack rates reach 90% among susceptible household contacts 3

Return to School/Work Criteria

The key criterion for ending isolation is complete crusting of ALL lesions, not a specific number of days 10

• Verify that no fluid-filled vesicles remain anywhere on the body 10
• Check hidden areas: scalp, behind ears, between fingers/toes, genital area 10
• Patient should be afebrile and feel well enough for normal activities 10

Common pitfall: Do not rely on a fixed 5-7 day timeline—some patients take longer to crust completely, and premature return spreads infection 10

Antibiotic Therapy

Secondary Bacterial Infections

Antibiotics are indicated only when secondary bacterial infection is suspected or confirmed 2, 5

• Most commonly used: Co-amoxiclav (amoxicillin-clavulanate) in adults 2
• Ceftriaxone frequently used in children with suspected bacterial complications 2
• Group A streptococcus is a particularly concerning pathogen that can cause necrotizing fasciitis 5

Warning signs of bacterial superinfection include:

• Increasing erythema, warmth, or tenderness around lesions 5
• Purulent drainage 5
• Worsening fever after initial improvement 5
• Systemic toxicity 5

Special Populations

Pregnant Women

• VZV-susceptible pregnant women exposed to chickenpox should receive VZIG within 96 hours 1, 9
• Pregnant women who develop chickenpox are at risk for severe disease affecting both mother and fetus 3
• If oral acyclovir is used, perform VZV serology to discontinue if patient is seropositive 1

Neonates

• Neonates are at higher risk for complications 1, 3
• VZIG is indicated for exposed neonates <28 weeks gestation or <1,000 g 9
• Intravenous acyclovir should be used for treatment of neonatal varicella 8

HIV-Infected Patients

• HIV-infected children and adults susceptible to VZV should avoid exposure to chickenpox 1
• VZIG should be administered within 96 hours after close contact 1
• Live varicella vaccine should NOT be administered to HIV-infected individuals due to risk of disseminated infection 1
• Household contacts of HIV-infected susceptible persons should be vaccinated against VZV 1

Vaccination Strategy

Routine Immunization

All children entering childcare facilities and elementary schools should have received varicella vaccine or have other evidence of immunity 1

• Evidence of immunity includes: physician-diagnosed varicella, reliable disease history, or serologic evidence 1
• States should consider requiring vaccination or immunity evidence for middle school entry 1

High-Risk Adults

Susceptible adults ≥13 years at high risk for exposure should be vaccinated 1:

• Healthcare workers 1
• Household contacts of immunocompromised persons 1
• Adolescents and adults living in households with children 1

Corticosteroid Controversy

The use of corticosteroids in chickenpox management remains controversial and is generally NOT recommended 2

• No clear evidence supports routine corticosteroid use 2
• Potential risks include increased susceptibility to disseminated infection and bacterial complications 9
• Corticosteroids are absolutely contraindicated in immunocompromised patients with active chickenpox 9

Monitoring and Follow-Up

Signs Requiring Escalation of Care

Seek immediate medical evaluation for:

• Respiratory symptoms suggesting pneumonitis (cough, dyspnea, chest pain) 8, 7
• Neurological symptoms (severe headache, altered mental status, seizures) 8
• Signs of bacterial superinfection 5
• Hemorrhagic or necrotic lesions 8
• Persistent high fever beyond expected timeline 5

Treatment Duration

• Continue oral acyclovir for full 5-day course even if symptoms improve 6
• For immunocompromised patients on IV therapy, continue until all lesions have completely crusted 9
• Do not discontinue treatment prematurely based on subjective improvement 6