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Chickenpox

  • Author: Anthony J Papadopoulos, MD; Chief Editor: Dirk M Elston, MD  more...
 
Updated: Feb 26, 2016
 

Background

The varicella-zoster virus (VZV) (see the image below) is the etiologic agent of the clinical syndrome of chickenpox (varicella). Zoster, a different clinical entity, is caused by reactivation of VZV after primary infection. VZV is a double-stranded deoxyribonucleic acid virus included in the Alphaherpesvirinae subfamily. (See Etiology.)

Vesicular eruption on the trunk demonstrating papu Vesicular eruption on the trunk demonstrating papules, vesicles, and crusts. Reprinted with permission from Cutis 65: 355, 2000.

See Pediatric Vaccinations: Do You Know the Recommended Schedules?, a Critical Images slideshow, to help stay current with the latest routine and catch-up immunization schedules for 16 vaccine-preventable diseases.

Also, see the 15 Rashes You Need to Know: Common Dermatologic Diagnoses slideshow for help identifying and treating various rashes.

Chickenpox is usually acquired through inhalation of airborne respiratory droplets from an infected host. High viral titers are found in the characteristic vesicles of chickenpox; viral transmission may also occur through direct contact with these vesicles, though the risk of transmission is lower. (See Etiology.)

Chickenpox is largely a childhood disease, with more than 90% of cases occurring in children younger than 10 years. The disease is benign in the healthy child, and increased morbidity occurs in adults and immunocompromised patients. (See Epidemiology and Prognosis.) An outbreak of varicella was noted in a group of lymphoma patients treated with rituximab and was related to exposure to a patient with zoster.[1]

Since the introduction of widespread pediatric immunization in the United States in 1995, the incidence of varicella has declined significantly, approaching up to a 90% decline. (See Epidemiology.)

Chickenpox is usually diagnosed clinically on the basis of the characteristic rash and successive crops of lesions. These may be found in various developmental and healing stages in affected sites. Patient exposure to an infected contact within the incubation period of 10-21 days is an important diagnostic clue. The more complicated course in adults with chickenpox can be associated with a more widespread rash; prolonged fever; and an increased likelihood of complications, the most common being varicella pneumonia. (See Clinical Presentation.)

VZV can be isolated on vesicular fluid cultures, which provides a definitive diagnosis. Direct immunofluorescence has excellent sensitivity. (See Workup.)

Oral acyclovir should be considered for healthy persons at increased risk of severe varicella infections. Valacyclovir and famciclovir are other agents used in treatment. Intravenous acyclovir therapy is recommended for patients who are immune-suppressed or immune-compromised. Varicella-zoster immune globulin (VZIG) is indicated for use in highly susceptible, VZV-exposed immunocompromised or immunosuppressed populations. A live attenuated varicella vaccine (Oka strain) was approved by the US Food and Drug Administration in 1995 for prophylactic use in healthy children and adults. (See Treatment and Management and Medication.)

Go to Pediatric Chickenpox for more complete information on this topic.

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Pathophysiology

Chickenpox is usually acquired by the inhalation of airborne respiratory droplets from an infected host. The highly contagious nature of varicella-zoster virus (VZV) underlies the epidemics that spread quickly through schools. High viral titers are found in the characteristic vesicles of chickenpox; thus, despite the lower associated risk, viral transmission may also occur through direct contact with these vesicles.

After initial inhalation of contaminated respiratory droplets, the virus infects the conjunctivae or the mucosae of the upper respiratory tract. Viral proliferation occurs in regional lymph nodes of the upper respiratory tract 2-4 days after initial infection; this is followed by primary viremia on postinfection days 4-6.

A second round of viral replication occurs in the body's internal organs, most notably the liver and the spleen, followed by a secondary viremia 14-16 days post infection. This secondary viremia is characterized by diffuse viral invasion of capillary endothelial cells and the epidermis. VZV infection of cells of the malpighian layer produces both intercellular edema and intracellular edema, resulting in the characteristic vesicle.

Exposure to VZV in a healthy child initiates the production of host immunoglobulin G (IgG), immunoglobulin M (IgM), and immunoglobulin A (IgA) antibodies; IgG antibodies persist for life and confer immunity. Cell-mediated immune responses are also important in limiting the scope and the duration of primary varicella infection. After primary infection, VZV is hypothesized to spread from mucosal and epidermal lesions to local sensory nerves. VZV then remains latent in the dorsal ganglion cells of the sensory nerves. Reactivation of VZV results in the clinically distinct syndrome of herpes zoster (shingles).

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Etiology

Chickenpox is usually acquired by the inhalation of airborne respiratory droplets from a VZV-infected host. High viral titers are found in the characteristic vesicles of chickenpox; thus, viral transmission may also occur through direct contact with these vesicles.

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Epidemiology

Chickenpox is a common disease, with most cases occurring in the pediatric population. Varicella has neither a racial nor a sexual predilection.[2]

United States statistics

Since the introduction of widespread pediatric immunization in the United States in 1995, the incidence of varicella has declined significantly, approaching a decline of up to 90%. Mortality from varicella has also declined since the initiation of the US vaccination program, with mortality decreasing by approximately 66%.[3]

International statistics

Countries with tropical and semitropical climates have a higher incidence of adult chickenpox than do countries with a temperate climate (eg, United States, Europe).

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Prognosis

Chickenpox that affects a healthy child is usually a self-limited disease. Increased morbidity occurs in adult and immunocompromised populations.

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Patient Education

Parents of infected children should be instructed to trim their children’s fingernails to minimize skin damage from scratching and the associated complications of bacterial superinfection. Also, it is important to advise parents not to use aspirin for fever control, because the development of Reye syndrome is associated with salicylate administration in children with chickenpox.

For patient education resources, see the Infections Center. Also, see the patient education articles Chickenpox and Skin Rashes in Children.

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Contributor Information and Disclosures
Author

Anthony J Papadopoulos, MD Private Practice

Anthony J Papadopoulos, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Surgery, Medical Society of New Jersey, Sigma Xi

Disclosure: Nothing to disclose.

Coauthor(s)

Robert A Schwartz, MD, MPH Professor and Head of Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, Rutgers New Jersey Medical School; Visiting Professor, Rutgers University School of Public Affairs and Administration

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, New York Academy of Medicine, American Academy of Dermatology, American College of Physicians, Sigma Xi

Disclosure: Nothing to disclose.

Camila K Janniger, MD Clinical Professor of Dermatology, Clinical Associate Professor of Pediatrics, Chief of Pediatric Dermatology, Rutgers New Jersey Medical School

Camila K Janniger, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Acknowledgements

Van Perry, MD Assistant Professor, Department of Medicine, Division of Dermatology, University of Texas School of Medicine at San Antonio

Van Perry, MD is a member of the following medical societies: American Academy of Dermatology and American Society for Laser Medicine and Surgery

Disclosure: Nothing to disclose.

Susan M Swetter, MD Director, Pigmented Lesion and Melanoma Program, Professor, Department of Dermatology, Stanford University Medical Center and Cancer Institute, Veterans Affairs Palo Alto Health Care System

Susan M Swetter, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, American Society of Clinical Oncology, Eastern Cooperative Oncology Group, Pacific Dermatologic Association, Society for Investigative Dermatology, Society for Melanoma Research, and Women's Dermatologic Society

Disclosure: Nothing to disclose.

Richard P Vinson, MD Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association

Disclosure: Nothing to disclose.

References
  1. Okamoto A, Abe A, Okamoto M, et al. A varicella outbreak in B-cell lymphoma patients receiving rituximab-containing chemotherapy. J Infect Chemother. 2014 Aug 30. [Medline].

  2. Choo PW, Donahue JG, Manson JE, Platt R. The epidemiology of varicella and its complications. J Infect Dis. 1995 Sep. 172(3):706-12. [Medline].

  3. Nguyen HQ, Jumaan AO, Seward JF. Decline in mortality due to varicella after implementation of varicella vaccination in the United States. N Engl J Med. 2005 Feb 3. 352(5):450-8. [Medline].

  4. Aebi C, Ahmed A, Ramilo O. Bacterial complications of primary varicella in children. Clin Infect Dis. 1996 Oct. 23(4):698-705. [Medline].

  5. Higuchi S, Toichi E, Kore-eda S, et al. An adult case of Fournier's gangrene preceded by varicella. Acta Dermatol Kyoto. 1997. 92(4):375-80.

  6. Miller HC, Stephan M. Hemorrhagic varicella: a case report and review of the complications of varicella in children. Am J Emerg Med. 1993 Nov. 11(6):633-8. [Medline].

  7. Forrest J, Mego S, Burgess M. Congenital and neonatal varicella in Australia. J Paediatr Child Health. 2000 Apr. 36(2):108-13. [Medline].

  8. Auriti C, Piersigilli F, De Gasperis MR, Seganti G. Congenital Varicella Syndrome: Still a Problem?. Fetal Diagn Ther. 2009 May 27. 25(2):224-229. [Medline].

  9. Tsunoda T, Ogawa S. A consideration on the distribution of eruption of herpes zoster. Acta Dermatol Kyoto. 1986. 81:95-8.

  10. Schwartz RA, Jordan MC, Rubenstein DJ. Bullous chickenpox. J Am Acad Dermatol. 1983 Aug. 9(2):209-12. [Medline].

  11. Lunghi F, Finzi M. Varicella bullosa in HIV+ adults. Chronica Dermatologica (Roma). 1997. 7:557-60.

  12. Hirota T, Hirota Y, Ichimiya M, et al. Atypical varicella seen in a woman with atopic dermatitis. Acta Dermatol Kyoto. 1998. 93(1):65-8.

  13. Nahass GT, Goldstein BA, Zhu WY, Serfling U, Penneys NS, Leonardi CL. Comparison of Tzanck smear, viral culture, and DNA diagnostic methods in detection of herpes simplex and varicella-zoster infection. JAMA. 1992 Nov 11. 268(18):2541-4. [Medline].

  14. Harbecke R, Oxman MN, Arnold BA, et al. A real-time PCR assay to identify and discriminate among wild-type and vaccine strains of varicella-zoster virus and herpes simplex virus in clinical specimens, and comparison with the clinical diagnoses. J Med Virol. 2009 Jul. 81(7):1310-22. [Medline].

  15. Molina-Ruiz AM, Santonja C, Rutten A, Cerroni L, Kutzner H, Requena L. Immunohistochemistry in the Diagnosis of Cutaneous Viral Infections-Part I. Cutaneous Viral Infections by Herpesviruses and Papillomaviruses. Am J Dermatopathol. 2014 Aug 28. [Medline].

  16. Chartrand SA. Varicella vaccine. Pediatr Clin North Am. 2000 Apr. 47(2):373-94. [Medline].

  17. Durrheim DN. Varicella vaccine: local convenience or global equity?. Lancet. 2006 Dec 23. 368(9554):2208-9. [Medline].

  18. Kamiya H, Ito M. Update on varicella vaccine. Curr Opin Pediatr. 1999 Feb. 11(1):3-8. [Medline].

  19. Vazquez M, Shapiro ED. Varicella vaccine and infection with varicella-zoster virus. N Engl J Med. 2005 Feb 3. 352(5):439-40. [Medline].

  20. Wutzler P, Knuf M, Liese J. Varicella: efficacy of two-dose vaccination in childhood. Dtsch Arztebl Int. 2008 Aug. 105(33):567-72. [Medline]. [Full Text].

  21. Dunkle LM, Arvin AM, Whitley RJ, et al. A controlled trial of acyclovir for chickenpox in normal children. N Engl J Med. 1991 Nov 28. 325(22):1539-44. [Medline].

  22. Vinzio S, Lioure B, Goichot B. Varicella in immunocompromised patients. Lancet. 2006 Dec 23. 368(9554):2208. [Medline].

  23. Safrin S, Berger TG, Gilson I, et al. Foscarnet therapy in five patients with AIDS and acyclovir-resistant varicella-zoster virus infection. Ann Intern Med. 1991 Jul 1. 115(1):19-21. [Medline].

  24. Centers for Disease Control and Prevention (CDC). Updated recommendations for use of VariZIG – United States, 2013. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6228a4.htm?s_cid=mm6228a4_w. Accessed: July 23, 2013.

  25. Asano Y, Nagai T, Miyata T, et al. Long-term protective immunity of recipients of the OKA strain of live varicella vaccine. Pediatrics. 1985 Apr. 75(4):667-71. [Medline].

  26. [Guideline] Centers for Disease Control and Prevention. A new product (VariZIG) for postexposure prophylaxis of varicella available under an investigational new drug application expanded access protocol. MMWR Morb Mortal Wkly Rep. 2006 Mar 3. 55(8):209-10. [Medline].

  27. [Guideline] Centers for Disease Control and Prevention, Advisory Committee on Immunization Practices. Update: recommendations from the Advisory Committee on Immunization Practices (ACIP) regarding administration of combination MMRV vaccine. MMWR Morb Mortal Wkly Rep. 2008 Mar 14. 57(10):258-60. [Medline].

  28. [Guideline] Marin M, Broder KR, Temte JL, Snider DE, Seward JF. Use of combination measles, mumps, rubella, and varicella vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2010 May 7. 59:1-12. [Medline]. [Full Text].

  29. [Guideline] Centers for Disease Control and Prevention, Advisory Committee on Immunization Practices. Recommended adult immunization schedule: United States, 2009*. Ann Intern Med. 2009 Jan 6. 150(1):40-4. [Medline].

  30. [Guideline] Centers for Disease Control and Prevention. Recommended adult immunization schedule--United States, 2011. MMWR Morb Mortal Wkly Rep. 2011 Feb 4. 60(4):1-4. [Medline]. [Full Text].

  31. [Guideline] American Academy of Pediatrics Committee on Infectious Diseases. Prevention of varicella: recommendations for use of varicella vaccines in children, including a recommendation for a routine 2-dose varicella immunization schedule. Pediatrics. 2007 Jul. 120(1):221-31. Reaffirmed July 2010. [Medline].

  32. [Guideline] American Academy of Pediatrics Committee on Infectious Diseases. Recommended childhood and adolescent immunization schedules--United States, 2009. Pediatrics. 2009 Jan. 123(1):189-90. [Medline].

  33. [Guideline] Committee on Infectious Diseases; American Academy of Pediatrics. Policy statement--recommended childhood and adolescent immunization schedules--United States, 2011. Pediatrics. 2011 Feb. 127(2):387-8. [Medline]. [Full Text].

  34. [Guideline] Committee on Infectious Diseases, American Academy of Pediatrics. Recommended childhood and adolescent immunization schedule--United States, 2014. Pediatrics. 2014 Feb. 133(2):357-63. [Medline].

  35. [Guideline] Barclay L. Guidelines revised on chicken pox in pregnancy. Medscape Medical News. Available at http://www.medscape.com/viewarticle/838532. Accessed: February 9, 2015.

  36. Snoeck R, Andrei G, De Clercq E. Current pharmacological approaches to the therapy of varicella zoster virus infections: a guide to treatment. Drugs. 1999 Feb. 57(2):187-206. [Medline].

  37. Papadopoulos AJ, Schwartz RA, Janniger CK. Chickenpox. Cutis. 2000 Jun. 65(6):355-8. [Medline].

 
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Dewdrop on rose petal characteristic vesicle of chickenpox. Reprinted with permission from Cutis 65: 355, 2000.
Vesicular eruption on the trunk demonstrating papules, vesicles, and crusts. Reprinted with permission from Cutis 65: 355, 2000.
 
 
 
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