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Chickenpox - Management
How should I manage an otherwise healthy person with chickenpox?

  • Offer symptomatic treatment.
  • Consider prescribing aciclovir for an immunocompetent adult or adolescent (aged 14 years or older) with chickenpox who presents within 24 hours of rash onset, particularly for people with severe chickenpox or those at risk of complications, such as smokers or people using corticosteroids.
  • Aciclovir is not recommended for otherwise healthy children with chickenpox.
  • Give advice about contact with other people and when to seek medical advice.
  • If serious complications (such as pneumonia, encephalitis, or dehydration) are suspected, admit to hospital.
  • If the person develops a high temperature (particularly after initial improvement) with redness and pain surrounding the chickenpox lesions, consider bacterial superinfection and manage accordingly.
    • This may be more common in people with eczema.
  • Notify the relevant authorities if in Scotland or Northern Ireland (chickenpox is not a notifiable disease in England or Wales).
  • For more information on managing a person who has been in contact with but not yet developed chickenpox, see the section Healthy person.
Basis for recommendation
  • These recommendations are pragmatic advice, based on recommendations from the Health Protection Agency [HPA, 2006; HPA and Association of Medical Microbiologists, 2010], the UK advisory group on chickenpox on behalf of the British Society for the Study of Infection [Ogilvie, 1998; Wilkins et al, 1998], the British National Formulary [BNF 54, 2007], and a review of the management of varicella-zoster infection [Allen, 2006].
  • A Cochrane review on aciclovir for treating varicella in otherwise healthy children and adolescents [Klassen et al, 2005] did not find sufficient evidence to support the use of aciclovir in young, immunocompetent children with self-limiting, uncomplicated chickenpox. From the three studies identified, aciclovir was associated with a reduction in the maximum number of lesions and the number of days with fever, but there were no differences in the occurrence of complications of chickenpox in people taking aciclovir compared with placebo.
  • Adults are more likely to develop complications of chickenpox than children. There is an indication that smokers and people with severe lung or cardiovascular disease, or those with a chronic skin disorder, are particularly at risk from complicated chickenpox [Wilkins et al, 1998; BNF 54, 2007].
    • Recommendations vary between UK organizations regarding the use of aciclovir in immunocompetent adults with chickenpox [Ogilvie, 1998; Wilkins et al, 1998; HPA, 2006; BNF 54, 2007].
    • A review by BMJ Clinical Evidence [Swingler, 2007] identified an RCT (n = 148) that found aciclovir given within 24 hours of rash onset reduced the number of lesions and time to full crusting of lesions compared with placebo (no significant difference in time to crusting of lesions if aciclovir was given 24–72 hours after rash onset). Two other RCTs identified did not find a significant difference in time to no new lesions with aciclovir given more than 24 hours after rash onset compared with placebo.
    • CKS could find no recent trials looking specifically at the effect of aciclovir on preventing complications of chickenpox in an adult population.
  • The recommendation to consider the possibility of bacterial superinfection is based on studies that have reviewed people admitted to hospital with chickenpox.
    • In one UK study (n = 613), 32% of children and 17% of adults admitted to hospital with chickenpox had secondary bacterial skin infection [Bovill and Bannister, 1998]. Of the 25 children with secondary bacterial infection, three had toxin-mediated scarlet fever and one child had scalded skin syndrome. Five of the children with secondary bacterial infection had eczema. Bacteriaemia and toxic shock syndrome, although not seen in this study, may also occasionally occur.
    • It is plausible that secondary bacterial superinfection is more common in people with eczema. Secondary bacterial infection is itself a common complication of eczema, and use of topical corticosteroids may exacerbate this. Clinical data are sparse, but a small case series supports this view: secondary bacterial infection was more common in children with eczema (31%; 10 of 32 children) than in healthy children (6%; 2 of 34 children) [Kubeyinje, 1995].
  • The recommendation on reporting cases of chickenpox is from the Department of Health and the Health Protection Agency [DH, 2006; HPA, 2006].

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