Medication Summary
Medications used in the treatment of varicella include antivirals, antipyretics, antihistamines, and immune globulin.
Antivirals
Class Summary
Chickenpox is usually a benign disease in children, and almost all children recover uneventfully. However, adulthood, adolescence, and pregnancy increase the risk for severe disease. Such patients are often treated with antiviral drugs. Other groups that require specific treatment are children who are immunocompromised, those who are otherwise at risk for severe disease, and those who already have severe disease. Acyclovir is the drug of choice for these situations. Other drugs are famciclovir (not approved for children) and foscarnet.
These agents are 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)
Acyclovir is an antiviral agent that acts by inhibiting herpes virus DNA polymerase and terminating viral replication. It reduces the number of lesions and duration of fever if it is started within 24 hours of rash appearance. In young children with uncomplicated varicella, the benefit of acyclovir therapy is only marginal, and its use is not routinely recommended. It does not affect the incidence of pruritus, complications, or secondary transmission. It is always used for complications of varicella (eg, encephalitis, pneumonia) and for immunocompromised individuals with varicella.
Antipyretics
Class Summary
These agents inhibit central synthesis and release of prostaglandins that mediate the effect of endogenous pyrogens in the hypothalamus; thus, they promote the return of the set-point temperature to normal.
The fever is usually low grade but may be elevated. Acetaminophen is probably the safest drug to use for this purpose. Salicylate usage for varicella is associated with Reye syndrome; therefore, never prescribe these agents. Nonsteroidal anti-inflammatory drugs (NSAIDs) have been suspected of suppressing immune function and promoting infection progress in patients infected with invasive group A streptococci.
Acetaminophen (Tylenol, Feverall, Tempra, Aspirin-Free Anacin)
Acetaminophen is the drug of choice because it has no association with Reye syndrome. It is available as drops containing 80 mg/0.8 mL; a suspension containing 160 mg/5 mL; a chewable tablet or capsule containing 80 mg; and a tablet containing 160 mg, 325 mg, or 500 mg.
Ibuprofen (Motrin, Ibuprin)
Ibuprofen A is a propionic acid–derivative NSAID. It acts by inhibiting prostaglandin synthesis and also has anti-inflammatory and analgesic properties. It is available as an oral suspension (100 mg/5 mL) and a tab containing 200 mg, 400 mg, 600 mg, or 800 mg.
Antihistamines
Class Summary
These agents may control pruritus by blocking the effects of endogenous release of histamine. Pruritus can be severe in varicella, preventing sleep and possibly leading to scarring or secondary infection. Nonsedating antihistaminics lack sufficient antipruritic action. The value of local preparations (eg, calamine, antihistamines) is unproved. Topical antihistamines can cause significant sedation from absorption through injured skin.
These agents act by competitive inhibition of histamine at the H1 receptor and mediate wheal and flare reactions, bronchial constriction, mucous secretion, smooth muscle contraction, edema, hypotension, central nervous system (CNS) depression, and cardiac arrhythmias.
Diphenhydramine (Benadryl)
Diphenhydramine is an antihistamine that has a sedating effect and is effective for pruritus. It is available as a liquid containing 12.5 mg/5 mL, capsule containing 25 and 50 mg, and injection containing 50 mg/mL.
Hydroxyzine (Vistaril)
Hydroxyzine antagonizes H1 receptors in the periphery. It may suppress histamine activity in subcortical region of the CNS. It is a second-line agent useful for pruritus when diphenhydramine is ineffective.
Hydroxyzine may only be given orally or intramuscularly (IM). It is available as a 25- or 50-mg capsule; 10 mg/5 mL suspension; 10-, 25-, or 50-mg tablet; or 25-mg/mL and 50-mg/mL for intramuscular injection.
Immune Globulins
Class Summary
The specific immune globulin with IgG varicella zoster antibodies provides passive immunization for susceptible individuals when administered within 10 days (ideally within 96 hours) of exposure. [29]
Varicella zoster immune globulin, human (VariZIG)
Varicella zoster immune globulin (VZIG) contains immunoglobulin G (IgG) varicella-zoster antibodies. It provides passive immunization to exposed individuals at high risk of complications from varicella (eg, immunocompromised children or adults, pregnant women, newborns of mothers with varicella close to delivery, premature infants, normal susceptible adults, full-term infants < 1 year). Administer by deep IM injection, preferably in deltoid muscle. For neonates or infants, administer IM in anterolateral aspect of thigh.
Vaccines
Class Summary
Varicella vaccine consists of live-attenuated Oka strain varicella virus. The vaccine is safe and highly immunogenic. It was approved for use in the United States in 1995 and has greatly reduced the incidence of and mortality from varicella. [6] The vaccine has a protective efficacy of 71-100% against varicella. However, it affords a much greater degree of protection against moderate and severe varicella (95-100%). [30]
Varicella virus vaccine (Varivax)
The varicella virus vaccine is indicated for children aged between 12 months and 12 years.
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The pleomorphic rash characteristic of varicella. Papules, vesicles, and pustules are concurrently present.
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Papulovesicular lesions on arm in varying stages of healing in this infant with varicella. Photograph courtesy of Susan Feigelman, MD.
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- Overview
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- DDx
- Workup
- Treatment
- Approach Considerations
- Supportive Therapy
- Antiviral Therapy
- Varicella-Zoster Immune Globulin Therapy
- Treatment of Neonatal Varicella
- Treatment of Secondary Bacterial Infections
- Varicella Vaccination
- Admission to Intensive Care Unit
- Transfer to Tertiary Care Facility
- Dietary Measures
- Restriction of Activity
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