Approach

Treatment type depends on the child's risk for severe disease.

Otherwise healthy children at low risk of severe disease

In healthy children, varicella is a self-limited disease and may just be treated symptomatically with acetaminophen for pyrexia, emollient lotions, and antihistamines to assist with pruritus. Calamine lotion is often used to help relieve itching;[69] however, there is no published evidence to support its use in varicella infection.[70] Aspirin is not recommended for fever due to its association with Reye syndrome.[71] There is also concern over the use of nonsteroidal anti-inflammatory drugs (NSAIDs) in varicella and an increased risk of group A streptococcal (GAS) superinfection.[72][73] Due to the potential increase in skin and soft tissue infections, NSAIDs should be avoided. Hydration is important, particularly in toddlers and children with fever.

While current US national recommendations do not advocate the routine use of antiviral therapy for this group of patients, acyclovir has been studied for primary therapy in immunocompetent children and has been shown to decrease the time to resolution of fever when given within 24 hours after onset of rash.[74] [ Cochrane Clinical Answers logo ] ​ In addition, some experts recommend the use of oral acyclovir in secondary household cases in which the disease may be more severe than in primary cases.[36]​​

Increased risk of moderate to severe disease

In addition to symptomatic treatment, oral antiviral therapy is recommended by the American Academy of Pediatrics for patients who are considered to be at increased risk for moderate to severe varicella, and this includes:[36] 

  • Otherwise healthy patients ages 13 years or over

  • Those with chronic skin disease (e.g., atopic dermatitis)

  • Those with underlying pulmonary disease

  • Patients receiving long-term salicylate therapy

  • Those receiving short-course or intermittent oral corticosteroids.

Patients receiving other types of immunosuppressive therapies, such as monoclonal antibodies and tumor necrosis factor-alpha inhibitors, may also be at increased risk, but there is limited information on the use of antiviral agents in these patients. Clinical trials among adolescents and adults have indicated that acyclovir is well tolerated and effective in reducing the duration and severity of clinical illness if the drug is administered within 24 hours of rash onset.[16]​​

High risk of severe disease

In addition to symptomatic treatment, prompt intravenous antiviral therapy is recommended for patients at high risk for severe disease and complications, and this includes:[36][53]​​

  • People who are immunocompromised, such as those with leukemia, lymphoma, or cellular immune deficiencies

  • People who are on immunosuppressive medication, such as high-dose systemic corticosteroids or chemotherapeutic agents

  • Neonates whose mothers have varicella from 5 days before to 2 days after delivery

  • Premature babies, specifically hospitalized premature infants born at 28 or more weeks of gestation whose mothers do not have evidence of immunity and hospitalized premature infants born at less than 28 weeks of gestation or who weigh 1000 grams or less at birth regardless of their mothers’ varicella immunity status

  • Pregnant women.

On the basis of the limited experimental evidence that intravenous acyclovir may reduce the severity of illness compared with placebo in immunocompromised children, experts recommend the routine use of acyclovir for all patients at high risk for developing complicated disease.[16]​​[44]​​

Pregnant women should be counseled about the risk of potential adverse maternal and fetal sequelae, options for prenatal diagnosis, and the risk of fetal transmission. Consultation with a neonatologist and an infectious disease specialist is recommended if there is peripartum varicella exposure, in order to optimize prevention or treatment strategies.[34][60]

Patients with severe disease who develop serious complications

Antiviral therapy is essential for all patients who develop serious complications from varicella infection (i.e., pneumonia, hepatitis, or encephalitis/central nervous system disease).

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