Supportive Care for Uncomplicated Varicella in Healthy Children
Topical Anti-Itch Treatment
For pruritus relief in children with varicella, use calamine lotion applied as often as needed; avoid diphenhydramine-containing creams due to significant risk of systemic toxicity through absorption via open lesions. 1, 2
Calamine Lotion (Recommended)
- Shake well before each application and cleanse skin with soap and water, allowing it to dry completely 2
- Apply to affected areas using cotton or soft cloth as frequently as needed for comfort 2
- Safe for children ≥2 years of age; consult physician before use in children under 2 years 2
- No systemic absorption or toxicity concerns 1
Diphenhydramine Products (Avoid)
- Do not use topical diphenhydramine creams or lotions (e.g., Caladryl) in children with varicella 3, 4
- Varicella lesions dramatically increase systemic absorption, leading to toxic serum levels (>1948 ng/mL documented; toxicity occurs >100 ng/mL) 3
- Toxicity manifests as dilated pupils, ataxia, urinary retention, facial grimacing, bizarre behavior, and visual/auditory hallucinations 3, 4
- Even when combined with oral diphenhydramine, topical application over extensive skin surfaces causes dangerous accumulation 4
General Supportive Measures
Itch Relief and Skin Care
- Administer lukewarm baths with colloidal oatmeal to soothe pruritus 1
- Keep fingernails trimmed short to minimize secondary bacterial infection from scratching 1
Fever Management
- Use acetaminophen for fever control; this is the preferred antipyretic 1
- Never give aspirin to children with varicella—it precipitates Reye syndrome 1
- Avoid ibuprofen and all NSAIDs—they are associated with increased risk of invasive group A streptococcal infection, the most common serious complication requiring hospitalization 1, 5
- NSAIDs increase the risk of severe secondary bacterial skin complications 4.8-fold (adjusted OR 4.8; 95% CI 1.6-14.4) 5
Hydration and Nutrition
- Maintain adequate fluid intake throughout illness 1
- Monitor closely for dehydration, especially if vomiting occurs 1
Isolation Requirements
- Isolate child from 1–2 days before rash onset until all lesions have crusted (typically 5–7 days after rash appearance) 1
- Exclude from school or daycare for the entire contagious period 1
- Protect high-risk contacts: immunocompromised persons, pregnant women without immunity, and newborns 1
Red Flags Requiring Urgent Evaluation
Watch for complications that mandate immediate medical assessment 1:
- Expanding erythema with purulent drainage around lesions (bacterial superinfection)
- Increasing pain, tenderness, or systemic toxicity (possible invasive streptococcal disease)
- Severe headache with altered consciousness (possible encephalitis)
- Respiratory distress (possible pneumonia)
- Persistent vomiting with dehydration signs
- Hemorrhagic lesions or bleeding (possible thrombocytopenia)
- Fever persisting or recurring ≥38.5°C for ≥3 days after varicella onset (8.1-fold increased risk of severe bacterial complication) 5
When Antiviral Therapy Is NOT Needed
Routine oral acyclovir is not recommended for otherwise healthy children <12 years with uncomplicated varicella 1, 6, 7
- The marginal benefit (1-day reduction in fever, 15–30% reduction in symptom severity) does not justify routine use 7
- Acyclovir does not reduce acute complications, pruritus, transmission, or school absence duration 7
- Treatment must begin within 24 hours of rash onset to have any effect; this narrow window is often impractical 8, 6