What is the complete management of a generally healthy child with varicella (chickenpox)?

Complete Management of Chickenpox in a Generally Healthy Child

For an otherwise healthy child with chickenpox, supportive care is the primary treatment, with isolation until all lesions crust over, and antiviral therapy reserved for specific high-risk situations. 1

Supportive Care (First-Line for Healthy Children)

Symptomatic management is the cornerstone of treatment for immunocompetent children with uncomplicated varicella. 1

• Relieve itching with lukewarm baths containing colloidal oatmeal 1
• Maintain adequate hydration and monitor fluid intake, especially if vomiting is present 2
• Avoid ibuprofen due to association with invasive group A streptococcal infections; acetaminophen is preferred for fever control 3
• Avoid aspirin in children due to risk of Reye's syndrome 4
• Keep fingernails short to minimize scratching and secondary bacterial infection 3

Isolation and Infection Control

The child must remain isolated from 1-2 days before rash onset until all lesions have completely crusted over, typically 5-7 days after rash appearance. 1, 4

• Exclude from school/daycare during the entire contagious period 1
• Protect high-risk contacts including immunocompromised individuals, pregnant women without immunity, and newborns 1

Antiviral Therapy Indications

Oral acyclovir is NOT routinely recommended for otherwise healthy children under 12 years with uncomplicated chickenpox. 4, 1

Consider Oral Acyclovir in These Specific Situations:

• Adolescents ≥12 years of age (higher risk of moderate to severe disease) 4
• Children with chronic cutaneous or pulmonary disorders 4
• Children receiving long-term salicylate therapy 4
• Children receiving short, intermittent, or aerosolized corticosteroids 4
• Secondary household cases (may have more severe disease) 4

Dosing when indicated: Acyclovir 20 mg/kg (maximum 800 mg) orally 4 times daily for 5-7 days, started within 24 hours of rash onset 4, 5

Intravenous Acyclovir is Mandatory for:

• Immunocompromised children (leukemia, lymphoma, HIV with CD4 <15%, receiving immunosuppressive therapy) 4, 1
• Severe complications (pneumonia, encephalitis, disseminated disease) 4, 1

IV dosing: 10 mg/kg every 8 hours for 7-10 days 4, 1

Monitoring for Complications

Bacterial superinfection, particularly invasive group A streptococcal disease, is the most common complication requiring hospitalization. 1, 2

Red Flags Requiring Urgent Evaluation:

• Expanding erythema around lesions with purulent drainage 1
• Increasing pain, tenderness, or systemic toxicity 1
• Severe headache with altered consciousness (possible encephalitis) 2
• Respiratory distress (possible pneumonia) 1
• Persistent vomiting with dehydration 2
• Hemorrhagic lesions or bleeding (possible thrombocytopenia) 1

Infants under 1 year have 6-fold higher hospitalization risk and require closer monitoring. 1

Post-Exposure Prophylaxis for Contacts

Susceptible household contacts should receive varicella vaccine within 3-5 days of exposure for optimal protection. 1, 2

High-Risk Exposed Individuals Require VZIG:

• Immunocompromised persons without immunity 1
• Pregnant women without evidence of immunity 1
• Newborns whose mothers developed varicella 5 days before to 2 days after delivery 1
• Premature infants ≥28 weeks whose mothers lack immunity 1

VZIG should be administered as soon as possible, effective up to 10 days post-exposure. 1

Follow-Up and Future Prevention

Most cases resolve without complications within 5-7 days; routine follow-up is unnecessary unless complications develop. 1

• Natural infection provides lifelong immunity; no additional varicella vaccination is needed after recovery 1
• For children who have not had chickenpox: Ensure two-dose vaccination schedule (first dose at 12-15 months, second at 4-6 years) 1

Common Pitfalls to Avoid

• Do not use ibuprofen for fever control due to increased risk of invasive bacterial infection 3
• Do not delay antiviral therapy beyond 24 hours of rash onset when indicated, as efficacy diminishes significantly 4, 5
• Do not assume mild symptoms mean no risk—even healthy children can develop serious complications like necrotizing fasciitis 3
• Do not allow immunocompromised contacts exposure—they require immediate VZIG prophylaxis 1