eMedicine Specialties > Emergency Medicine > Pediatric

Pediatrics, Chicken Pox or Varicella: Treatment & Medication

Author: Richard Lichenstein, MD, Associate Professor, Pediatric Emergency Department, University of Maryland School of Medicine
Contributor Information and Disclosures

Updated: Sep 17, 2008

Treatment

Prehospital Care

Prehospital care is usually not needed, other than for symptomatic management to reduce complications, particularly secondary skin infections.

Emergency Department Care

  • Patients should be isolated from other patients. Special consideration should be given to inadvertent exposures to immunocompromised patients.
  • Oral antihistamines, such as diphenhydramine and hydroxyzine, are used for severe pruritus. Caution must be used with topical diphenhydramine; toxicity may occur from systemic absorption if it is applied to the entire body.
  • Because of the association of varicella and aspirin therapy leading to Reye syndrome, acetaminophen is recommended for use for the reduction of fever. Studies have also tried to find an association between ibuprofen and risk of fasciitis; studies have not been conclusive.
  • Intravenous acyclovir is recommended only for the treatment of varicella in immunocompromised children or in children with varicella pneumonia or encephalitis. Oral acyclovir has been variably recommended for adolescent patients who are early in their illness. Additionally, antiviral therapy should be considered for patients with recent steroid use or those with extensive eczema.
  • Varicella-zoster immune globulin (VZIG) is recommended within 96 hours of a significant exposure for high-risk susceptible patients. The dose is 125 U/10 kg body weight (minimum dose is 125 U; maximum 625 U IM).

Consultations

Consultation with a pediatric infectious disease specialist, as well as a pediatric intensivist, may be required for cases of progressive varicella (with coexisting defect in cell-mediated immunity) and for such complications as CNS involvement or invasive infection by group A beta-hemolytic streptococci such as necrotizing fasciitis.

Medication

Treatment of varicella is supportive.

Antihistamines

Act by competitive inhibition of histamine at the H1 receptor. Mediate wheal and flare reactions, bronchial constriction, mucous secretion, smooth muscle contraction, edema, hypotension, CNS depression, and cardiac arrhythmias.


Diphenhydramine (Benadryl)

First-line agent useful for symptomatic relief of symptoms (allergic dermatitis) caused by release of histamine. May be given PO/IV/IM. Available in 25- and 50-mg capsules, 12.5-mg/5 mL elixir, and 50-mg/mL for injection.

Adult

25-50 mg/dose PO q4-6h prn; 10-50 mg/dose IV/IM slow; not to exceed 400 mg/d; if given IV, administer slowly

Pediatric

0.5-1 mg/kg/dose PO/IV/IM q6h prn; if given IV, administer slowly

Potentiates effect of CNS depressants; because of alcohol content, do not give syrup dosage form to patient taking medications that can cause disulfiramlike reactions

Documented hypersensitivity, MAOIs, acute asthma

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

May exacerbate angle-closure glaucoma, hyperthyroidism, peptic ulcer, and urinary tract obstruction; causes sedation; paradoxical excitement may occur, especially in children


Hydroxyzine (Atarax)

Antagonizes H1 receptors in periphery. May suppress histamine activity in subcortical region of CNS. Second-line agent useful for pruritus when diphenhydramine is not effective. May only be given PO or IM. Available as a 25- or 50-mg capsule; 10 mg/5 mL suspension; 10-, 25-, or 50-mg tab; 50-mg/mL for IM injection.

Adult

25-100 mg/dose PO/IM q4-6h prn

Pediatric

2-4 mg/kg/d PO divided q4-6h prn; alternatively, 0.5-1 mg/kg/dose IM q4-6h prn

Epinephrine decreases its vasopressor effect; CNS depression may increase with alcohol or other CNS depressants

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Associated with clinical exacerbations of porphyria (may not be safe for patients with porphyria); ECG abnormalities (alterations in T waves) may occur; may cause drowsiness; thrombosis or digital gangrene can occur with SC and IV routes

Antiviral Agent

Used for treatment of immunocompromised children or in healthy children who develop varicella pneumonia or encephalitis. The routine use of acyclovir in healthy children is not universally recommended. In some instances acyclovir may be considered for teenagers and adults with otherwise uncomplicated varicella.


Acyclovir (Zovirax)

Patients experience less pain and faster resolution of cutaneous lesions when used within 48 h from rash onset. May prevent recurrent outbreaks. Used for healthy nonpregnant persons >13 y, children >12 mo with chronic skin or lung disorders, patients on chronic aspirin therapy, and immunocompromised patients. Not recommended for varicella in otherwise healthy children, but may be considered in secondary household cases in which the disease is usually more severe. Available as 200- mg capsule, 200-mg/5 mL suspension, and 500-mg/mL vial for injection.

Adult

600-800 mg PO q4h for 5 doses/d for 5 d; not to exceed 3200 mg/d; alternatively, 1500 mg/m2/d IV q8h or 30 mg/kg/d IV divided q8h for 7-10 d

Pediatric

80 mg/kg/d PO divided qid for 5 d; not to exceed 3200 mg/d; alternatively, 1500 mg/m2/d IV q8h or 30 mg/kg/d IV divided q8h for 7-10 d

Concomitant use of probenecid or zidovudine prolongs half-life and increases CNS toxicity

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in renal failure, dehydration, underlying neurological disease, or when using nephrotoxic drugs

Antipyretic

Used for fever control. Unlike aspirin, acetaminophen is not associated with Reye syndrome when administered during varicella infection.


Acetaminophen (Tylenol, Tempra)

Reduces fever by acting directly on hypothalamic heat-regulating centers, which increases dissipation of body-heat via vasodilation and sweating. Available as 80-mg/0.8 mL suspension, 160-mg/5 mL suspension, 80-mg chewables, 325-mg tab, and 80-, 120-, 325-, and 650-mg suppositories.

Adult

325-650 mg PO/PR q4-6h prn or 1 g tid/qid; not to exceed 4 g/d

Pediatric

<12 years: 10-15 mg/kg/dose PO q4-6h prn; 10-20 mg/kg/dose PR q4-6h prn; not to exceed 2.6 g/d
>12 years: Administer as in adults

Rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Hepatotoxicity possible in chronic alcoholics following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; contained in many OTC products and combined use with these products may result in toxicity due to cumulative doses exceeding recommended maximum dose; caution in G-6-PD deficiency

Immune Globulin

Provides passive immunization for susceptible individuals when administered with 96 h of exposure.


Varicella zoster immune globulin, human (VZIG)

Contains IgG varicella-zoster antibodies. Provides passive immunization to exposed individuals at high risk of complications from varicella (eg, immunocompromised children or adults, newborns of mothers with varicella close to delivery, premature infants, normal susceptible adults, full-term infants <1 y). Administer by deep IM injection, preferably in gluteal muscle.

Adult

625 U IM

Pediatric

<10 kg: 125 U IM
10.1-20 kg: 250 U IM
20.1-30 kg: 375 U IM
30.1-40 kg: 500 U IM
>40 kg: Administer as in adults

Globulin preparation may interfere with immune response to live-virus vaccine (MMR) and reduce efficacy (do not administer within 3 mo of vaccine)

Documented hypersensitivity; thrombocytopenia

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Do not inject IV; caution with IgA deficiency; may cause pain, redness, or swelling at injection site

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References
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References

  1. Marin M, Guris D, Chaves SS, Schmid S, Seward JF, Advisory Committee on Immunization Practices, et al. Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. Jun 22 2007;56(RR-4):1-40. [Medline].

  2. American Academy of Pediatrics Committee on Infectious Diseases. The use of oral acyclovir in otherwise healthy children with varicella. Pediatrics. 1993;91(3):674-6. [Medline].

  3. Arvin A. Progress in the treatment and prevention of varicella. Curr Opin Infect Dis. 1993;6:553-557.

  4. Braun I. Varicella zoster virus: trends and treatment. MCN Am J Matern Child Nurs. Jul-Aug 1996;21(4):187-90. [Medline].

  5. Cowan MR, Primm PA, Scott SM, et al. Serious group A beta-hemolytic streptococcal infections complicating varicella. Ann Emerg Med. Apr 1994;23(4):818-22. [Medline].

  6. Davis MM, Patel MS, Gebremariam A. Decline in varicella-related hospitalizations and expenditures for children and adults after introduction of varicella vaccine in the United States. Pediatrics. Sep 2004;114(3):786-92. [Medline].

  7. Doctor A, Harper MB, Fleisher GR. Group A beta-hemolytic streptococcal bacteremia: historical overview, changing incidence, and recent association with varicella. Pediatrics. Sep 1995;96(3 Pt 1):428-33. [Medline].

  8. Drwal-Klein LA, O'Donovan CA. Varicella in pediatric patients. Ann Pharmacother. Jul-Aug 1993;27(7-8):938-49. [Medline].

  9. Georges P, ed. Varicella-zoster infections. In: 1997 Red Book Report of the Committee on Infectious Diseases. 1997:573-85.

  10. Hall S, Maupin T, Seward J, et al. Second varicella infections: are they more common than previously thought?. Pediatrics. Jun 2002;109(6):1068-73. [Medline].

  11. Lesko SM, O'Brien KL, Schwartz B, Vezina R, Mitchell AA. Invasive group A streptococcal infection and nonsteroidal antiinflammatory drug use among children with primary varicella. Pediatrics. May 2001;107(5):1108-15. [Medline].

  12. Newman RD, Taylor JA. Reactions of pediatricians to the recommendation for universal varicella vaccination. Arch Pediatr Adolesc Med. Aug 1998;152(8):792-6. [Medline].

  13. 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. Feb 3 2005;352(5):450-8. [Medline].

  14. Resnick SD. New aspects of exanthematous diseases of childhood. Dermatol Clin. 1997;15:257-66. [Medline].

  15. Rockley PF, Tyring SK. Pathophysiology and clinical manifestations of varicella zoster virus infections. Int J Dermatol. Apr 1994;33(4):227-32. [Medline].

  16. Seward JF, Watson BM, Peterson CL. Varicella disease after introduction of varicella vaccine in the United States, 1995-2000. JAMA. Feb 6 2002;287(5):606-11. [Medline].

  17. Seward JF, Zhang JX, Maupin TJ. Contagiousness of varicella in vaccinated cases: a household contact study. JAMA. Aug 11 2004;292(6):704-8. [Medline].

  18. Ziebold C, von Kries R, Lang R, Weigl J, Schmitt HJ. Severe complications of varicella in previously healthy children in Germany: a 1-year survey. Pediatrics. Nov 2001;108(5):E79. [Medline].

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Further Reading

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Contributor Information and Disclosures

Author

Richard Lichenstein, MD, Associate Professor, Pediatric Emergency Department, University of Maryland School of Medicine
Richard Lichenstein, MD is a member of the following medical societies: American Academy of Pediatrics and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Kirsten A Bechtel, MD, Associate Professor, Department of Pediatrics, Yale University School of Medicine; Attending Physician, Department of Pediatric Emergency Medicine, Yale-New Haven Children's Hospital
Kirsten A Bechtel, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Wayne Wolfram, MD, MPH, Clinical Associate Professor, Departments of Pediatrics, Children's Hospital and University of Cincinnati
Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Richard G Bachur, MD, Associate Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston
Richard G Bachur, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Academic Emergency Medicine, and Society for Pediatric Research
Disclosure: Nothing to disclose.

 
 
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