• Scenario: Chickenpox - child or adult: covers the management of a child or adult with chickenpox.
• Scenario: Chickenpox - pregnant woman: covers the management of a pregnant woman with chickenpox.
• Scenario: Chickenpox - breastfeeding woman: covers the management of a breastfeeding woman with chickenpox.
• Scenario: Chickenpox - neonate: covers the management of a neonate with chickenpox.
• Scenario: Chickenpox - immunocompromised: covers the management of an immunocompromised person with chickenpox.
• Scenario: Exposure to chickenpox: covers the management of children, adults (including healthcare workers), pregnant women, breastfeeding women, neonates, and immunocompromised people who have been exposed to chickenpox.

• Offer symptomatic treatment.
• For immunocompetent adults and adolescents (aged 14 years or older), consider prescribing aciclovir if they present 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.
• For children, aciclovir is not recommended.
• 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.

In depth

• Offer paracetamol or ibuprofen to relieve pain or fever.
• To relieve itch, consider:
• Topical calamine lotion.
• Chlorphenamine for those who are 1 year of age or older.

In depth

• Advise the following simple measures:
• Encourage adequate fluid intake.
• Dress appropriately to avoid shivering or overheating.
• Wear smooth, cotton fabrics.
• Keep nails short to minimize damage from scratching.
• Advise that the most infectious period is 1–2 days before the rash appears, but infectivity continues until all the lesions have crusted over (commonly about 5–6 days after onset of illness):
• During this time, advise a person with chickenpox to avoid contact with:
• People who are immunocompromised (e.g. those receiving cancer treatment or high doses of oral steroids, or those with conditions that reduce immunity).
• Pregnant women.
• Infants aged 4 weeks or less.
• Children with chickenpox should be kept away from school or nursery for 5 days from the onset of the rash.
• Air travel is not allowed until 6 days after the last spot has appeared.
• Inform the person to seek urgent medical advice if their condition deteriorates or they develop symptoms of complications (e.g. cough, shortness of breath, decreased consciousness). Particularly advise parents of young children to be aware of:
• Bacterial superinfection — typically presents suddenly with a high temperature (often after initial improvement), redness and tenderness surrounding the original chickenpox lesions.
• Dehydration — encourage and monitor fluid intake and seek medical attention if signs of dehydration develop (e.g. reduced urine output, lethargy, cold peripheries, reduced skin turgor).

In depth

• Urgently seek specialist advice regarding the need for diagnostic tests, counselling on the risk of fetal varicella syndrome, antiviral treatment, and follow up:
• Only prescribe an antiviral drug in primary care (with the informed consent of the woman) on the advice of a specialist.
• Offer symptomatic treatment.
• Give advice about contact with other people and when to seek medical advice.
• Monitor the woman closely (review daily, or earlier if her condition deteriorates).
• Refer for urgent hospital assessment if fever persists, or cropping of the rash continues after 6 days.
• Admit to hospital (preferably somewhere with access to specialists in obstetrics, infectious diseases, and paediatrics) if the woman has chest symptoms, neurological symptoms other than headache, haemorrhagic rash or bleeding, severe disease (e.g. dense rash with or without numerous mucosal lesions), or significant immunosuppression.
• Seek specialist advice from the local obstetric unit (even in the absence of complications) if monitoring will be difficult; the woman is in the latter half of pregnancy; or the woman has a complicated obstetric history, history of smoking, chronic lung disease, or poor social circumstances, or is taking steroids.
• Notify the relevant authorities if in Scotland or Northern Ireland (chickenpox is not a notifiable disease in England or Wales).

In depth

• Offer paracetamol to relieve pain or fever. Ibuprofen may be considered but it should not be used beyond 27 weeks of gestation.
• Consider the use of topical calamine lotion to alleviate itch.

In depth

• Advise the following simple measures:
• Encourage adequate fluid intake.
• Dress appropriately to avoid shivering or overheating.
• Wear smooth, cotton fabrics.
• Keep nails short to minimize damage from scratching.
• Advise that the most infectious period is 1–2 days before the rash appears, but infectivity continues until all the lesions have crusted over (commonly about 5–6 days after onset of illness):
• During this time, advise a person with chickenpox to avoid contact with:
• People who are immunocompromised (e.g. those receiving cancer treatment or high doses of oral steroids, or those with conditions that reduce immunity).
• Pregnant women.
• Infants aged 4 weeks or less.
• Children with chickenpox should be kept away from school or nursery for 5 days from the onset of the rash.
• Air travel is not allowed until 6 days after the last spot has appeared.
• Inform the person to seek urgent medical advice if their condition deteriorates or they develop symptoms of complications (e.g. cough, shortness of breath, decreased consciousness). Particularly advise parents of young children to be aware of:
• Bacterial superinfection — typically presents suddenly with a high temperature (often after initial improvement), redness and tenderness surrounding the original chickenpox lesions.
• Dehydration — encourage and monitor fluid intake and seek medical attention if signs of dehydration develop (e.g. reduced urine output, lethargy, cold peripheries, reduced skin turgor).

In depth

• Offer symptomatic treatment.
• Consider prescribing aciclovir if the woman presents within 24 hours of the onset of the rash (particularly if severe chickenpox or risk of complications).
• Seek urgent specialist advice regarding whether the mother should continue to breastfeed if she has chickenpox.
• Give advice about contact with other people and when to seek medical advice.
• Admit to hospital if serious complications (e.g. pneumonia, encephalitis) are suspected.
• Notify the relevant authorities if in Scotland or Northern Ireland (chickenpox is not a notifiable disease in England or Wales).

In depth

• Offer paracetamol or ibuprofen to relieve pain or fever.
• Consider the use of topical calamine lotion to alleviate itch.

In depth

• Advise the following simple measures:
• Encourage adequate fluid intake.
• Dress appropriately to avoid shivering or overheating.
• Wear smooth, cotton fabrics.
• Keep nails short to minimize damage from scratching.
• Advise that the most infectious period is 1–2 days before the rash appears, but infectivity continues until all the lesions have crusted over (commonly about 5–6 days after onset of illness):
• During this time, advise a person with chickenpox to avoid contact with:
• People who are immunocompromised (e.g. those receiving cancer treatment or high doses of oral steroids, or those with conditions that reduce immunity).
• Pregnant women.
• Infants aged 4 weeks or less.
• Children with chickenpox should be kept away from school or nursery for 5 days from the onset of the rash.
• Air travel is not allowed until 6 days after the last spot has appeared.
• Inform the person to seek urgent medical advice if their condition deteriorates or they develop symptoms of complications (e.g. cough, shortness of breath, decreased consciousness). Particularly advise parents of young children to be aware of:
• Bacterial superinfection — typically presents suddenly with a high temperature (often after initial improvement), redness and tenderness surrounding the original chickenpox lesions.
• Dehydration — encourage and monitor fluid intake and seek medical attention if signs of dehydration develop (e.g. reduced urine output, lethargy, cold peripheries, reduced skin turgor).

In depth

• Seek urgent specialist advice regarding further management.
• Admit to hospital if serious complications (e.g. pneumonia, encephalitis) are suspected.

In depth

• Seek immediate specialist advice regarding confirming the diagnosis of chickenpox and whether urgent antiviral treatment is required.
• Offer symptomatic treatment.
• Give advice about contact with other people and when to seek medical advice.
• Admit to hospital if serious complications (e.g. pneumonia, encephalitis) are suspected.
• Notify the relevant authorities if in Scotland or Northern Ireland (chickenpox is not a notifiable disease in England or Wales).

In depth

• Offer paracetamol or ibuprofen to relieve pain or fever.
• Consider the use of topical calamine lotion to alleviate itch.
• Chlorphenamine may be useful for itch associated with chickenpox for children aged 1 year and above.

In depth

• Advise the following simple measures:
• Encourage adequate fluid intake.
• Dress appropriately to avoid shivering or overheating.
• Wear smooth, cotton fabrics.
• Keep nails short to minimize damage from scratching.
• Advise that the most infectious period is 1–2 days before the rash appears, but infectivity continues until all the lesions have crusted over (commonly about 5–6 days after onset of illness):
• During this time, advise a person with chickenpox to avoid contact with:
• People who are immunocompromised (e.g. those receiving cancer treatment or high doses of oral steroids, or those with conditions that reduce immunity).
• Pregnant women.
• Infants aged 4 weeks or less.
• Children with chickenpox should be kept away from school or nursery for 5 days from the onset of the rash.
• Air travel is not allowed until 6 days after the last spot has appeared.
• Inform the person to seek urgent medical advice if their condition deteriorates or they develop symptoms of complications (e.g. cough, shortness of breath, decreased consciousness). Particularly advise parents of young children to be aware of:
• Bacterial superinfection — typically presents suddenly with a high temperature (often after initial improvement), redness and tenderness surrounding the original chickenpox lesions.
• Dehydration — encourage and monitor fluid intake and seek medical attention if signs of dehydration develop (e.g. reduced urine output, lethargy, cold peripheries, reduced skin turgor).

In depth

• Type of varicella-zoster infection in the index case:
• Exposure is significant if contact with: chickenpox, disseminated zoster, immunocompetent people with exposed lesions (e.g. ophthalmic zoster), or immunosuppressed people with localized zoster on any part of the body.
• Timing of exposure in relation to the rash onset in the index case — exposure is significant if in contact with:
• Chickenpox — between 48 hours before onset of rash to crusting of lesions.
• Disseminated zoster — from 48 hours before onset of rash to crusting of lesions.
• Localized zoster — day of onset of rash until crusting of lesions.
• Closeness of contact:
• Exposure is significant if: maternal/neonatal contact, continuous home contact, contact in the same room (e.g. house or classroom, or 2- to 4-bed hospital bay) for 15 minutes or more, contact on large open wards (particularly paediatric wards), or face-to-face contact (e.g. having a conversation).

• If the exposure to chickenpox is not significant, or the person has a definite history of chickenpox or herpes zoster, reassure.
• If the person has no definite history and exposure is significant, warn them that they may develop chickenpox.
• For healthcare workers:
• If the person is vaccinated or has a definite history of chickenpox or herpes zoster, they can continue working, but advise them to contact their occupational health department if they feel unwell or develop a rash.
• If there is a negative or uncertain history of chickenpox or herpes zoster, test to determine immunity and advise that the person may develop chickenpox. Advise to avoid contact with high-risk patients for 8–21 days after contact with chickenpox and to report to occupational health before patient contact if they feel unwell or develop a fever or rash.
• Healthcare workers without varicella-zoster antibody should be offered varicella vaccine to reduce the risk of exposing patients to the varicella-zoster virus in the future.

In depth

• If the woman has a definite history of chickenpox or shingles, assume immunity.
• If the woman has no history of chickenpox or shingles (or is uncertain) and has a history of significant contact:
• Establish the stage of gestation (weeks from the last menstrual period).
• Test for varicella-zoster immunoglobulin G (IgG) antibodies in primary care if test results can be available within 2 working days of first exposure. If this is not possible, urgently seek specialist advice because testing in secondary care and/or varicella-zoster immunoglobulin prophylaxis may be needed.
• If the test shows varicella-zoster IgG, reassure the woman that she is immune.
• If the woman's antibody status is negative, urgently seek specialist advice.
• Advise the woman to promptly seek medical advice if she develops a rash and has had contact with chickenpox, regardless of whether she has received varicella-zoster immunoglobulin.

In depth

• Seek urgent specialist advice regarding the need for testing and further management, and whether the mother should continue to breastfeed if she has chickenpox.
• All neonates exposed to chickenpox must be followed up and monitored for signs of infection for 14–16 days by a GP, midwife, or health visitor, or in hospital.

In depth

• Establish whether the person fulfils the criteria for immunosuppression (if in doubt, seek specialist advice).
• Urgently seek specialist advice regarding further management.
• People who have had a significant exposure to chickenpox and who are immunocompromised should be tested for varicella-zoster antibody, regardless of their history of chickenpox. Test for varicella-zoster immunoglobulin G (IgG) antibodies in primary care if test results can be available within 2 working days of first exposure. If this is not possible, urgently seek specialist advice because testing in secondary care and/or varicella-zoster immunoglobulin prophylaxis may be needed.

In depth