Difference between revisions of "Varicella"
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*Contagious until last lesion crusts over | *Contagious until last lesion crusts over | ||
| − | == | + | ==Clinical Features== |
[[File:Varicela Rash.jpg|thumbnail|Male with varicella rash: lesions in various stages of development]] | [[File:Varicela Rash.jpg|thumbnail|Male with varicella rash: lesions in various stages of development]] | ||
[[File:Chickenpox blister.jpg|thumbnail|Classic blister during early stage of lesion development]] | [[File:Chickenpox blister.jpg|thumbnail|Classic blister during early stage of lesion development]] | ||
| − | *Pruritic generalized vesicular exanthem | + | *Pruritic generalized vesicular exanthem with mild systemic manifestations |
*Usually affects children <10y | *Usually affects children <10y | ||
| − | + | ||
| − | + | ===Rash=== | |
| − | * | + | *Starts on trunk or scalp as pruritic, red macules, spreads to extremities |
| − | + | *Within 24hr rash becomes vesicular (on erythematous base) | |
| − | + | *Palms/soles spared | |
| + | *Lesions in various stages of development | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Peds Rash DDX}} | {{Peds Rash DDX}} | ||
| + | {{Bullous rashes DDX}} | ||
| + | {{VZV types}} | ||
| + | |||
| + | ==Evaluation== | ||
| + | *Typically made on clinical features | ||
| + | |||
| + | ==Management== | ||
| + | ===Supportive Care=== | ||
| + | *[[Tylenol]], [[antihistamine]], oatmeal baths | ||
| + | *Avoid aspirin in young children due to the risk of [[Reye syndrome]] | ||
| − | == | + | ===Antivirals=== |
| − | + | *Routine use of antiretrovirals for uncomplicated cases in immunocompetent children is not recommended <ref>Arvin AM: Antiviral therapy for varicella and herpes zoster. Semin Pediatr Infect Dis 2002; 13:12.</ref> | |
| − | |||
| − | *Routine use of antiretrovirals for uncomplicated cases in immunocompetent children is not recommended | ||
*However, evidence shows decreased days of fever and number of lesions<ref>Klassen TP, et al. Acyclovir for treating varicella in otherwise healthy children and adolescents. Cochrane Database Syst Rev. 2005; (4):CD002980.</ref> | *However, evidence shows decreased days of fever and number of lesions<ref>Klassen TP, et al. Acyclovir for treating varicella in otherwise healthy children and adolescents. Cochrane Database Syst Rev. 2005; (4):CD002980.</ref> | ||
| − | + | AAP recommends antiviral treatment (within 24hrs) for patients at risk of increased illness severity: | |
| − | * | + | *Any patient older than 12 years of age |
| − | ** | + | *Patients with chronic cutaneous or pulmonary disorders |
| − | ** | + | *Patients receiving long-term salicylate therapy |
| + | *Patients receiving short, intermittent, or aerosolized courses of corticosteroids | ||
| + | |||
| + | Other cases to consider [[acyclovir]] | ||
| + | *Also consider in <ref>Drugs for non-HIV viral infections. Treat Guidel Med Lett. 2007; 5(59):59-70.</ref>: | ||
| + | *Pregnancy<ref name="cdc">CDC Chicken pox acyclovir treatment [http://www.cdc.gov/chickenpox/hcp/persons-risk.html#acyclovir]</ref> | ||
| + | ====Immunocompetent Adult==== | ||
| + | *[[Acyclovir]] 800mg PO q6hrs daily x 5 days '''OR''' | ||
| + | *[[Valacyclovir]] 1000mg PO q8hrs daily x 14 days '''OR''' | ||
| + | *[[Famiciclovir]] 500mg PO q8hrs x 14 days | ||
| + | ====Immunocompromised Adult==== | ||
| + | *[[Acyclovir]] 10mg/kg IV q8hrs x 7 days | ||
| + | ====At risk children <12yo child based on AAP criteria==== | ||
| + | *[[Acyclovir]] 20mg/kg PO q6hrs daily x 5 days | ||
| + | *[[Acyclovir]] 10mg/kg IV q8hrs daily x 7 days | ||
| + | |||
| + | ====VZIG==== | ||
| + | *Initiate VZIG alongside acyclovir for inpatient treatment of child or adult | ||
| + | *For immunocompromised child with exposure, give as post-exposure prophylaxis if<ref>CDC. MMWR - updated recommendations for use of VariZIG - United States, 2013. July 19, 2013 / 62(28);574-576.</ref>: | ||
| + | **Within 10 days window of exposure | ||
| + | **VZIG given IM as 125 IU/10 kg of body weight | ||
| + | ***Up to max of 625 IU | ||
| + | ***Minimum dose 62.5 IU for patients weighing ≤ 2.0 kg | ||
| + | ***Minimum dose 125 IU for weight 2.1 - 10.0 kg | ||
| + | *VZIG may prolong incubation period ≥1 week | ||
| + | **Must have patient closely follow up for signs and symptoms for 28 days after exposure | ||
| + | **If signs or symptoms of varicella occur, antiviral therapy must be started immediately | ||
| + | |||
| + | ==Disposition== | ||
| + | |||
| + | ==Vaccine== | ||
| + | *Introduced in 2006. Prior to introduction, incidence prior to adolescence approached 90% in US | ||
| + | *Vaccine is 85% effective against all disease, 90% effective against severe disease (greater than 1000 lesions) | ||
| + | *Typically given at age 5 in USA | ||
| + | *Post-exposure prophylaxis: | ||
| + | **Ideally given within 3-5 days of exposure in immunocompetent patients | ||
| + | **If immunocompromised patient is being given VZIG, varicella vaccine should be administered ≥5 months after VariZIG administration<ref>CDC. Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2007;56(No. RR-4).</ref> | ||
==Complications== | ==Complications== | ||
| − | *Can include encephalitis, pneumonia, hepatitis, strep/staph superinfection of ruptured vesicles | + | *Can include encephalitis, otitis media, pneumonia, hepatitis, strep/staph superinfection of ruptured vesicles |
*Perinatal infection in neonates may develop serious illness | *Perinatal infection in neonates may develop serious illness | ||
| + | |||
==See Also== | ==See Also== | ||
[[Pediatric Rashes]] | [[Pediatric Rashes]] | ||
| − | == | + | ==References== |
<references/> | <references/> | ||
| − | [[Category: | + | [[Category:Dermatology]] |
[[Category:ID]] | [[Category:ID]] | ||
| − | [[Category: | + | [[Category:Pediatrics]] |
Revision as of 21:03, 10 October 2018
Contents
Background
- Caused by varicella zoster virus causing varicella (chicken pox) and later zoster (Shingles)
- Contagious until last lesion crusts over
Clinical Features
- Pruritic generalized vesicular exanthem with mild systemic manifestations
- Usually affects children <10y
Rash
- Starts on trunk or scalp as pruritic, red macules, spreads to extremities
- Within 24hr rash becomes vesicular (on erythematous base)
- Palms/soles spared
- Lesions in various stages of development
Differential Diagnosis
Pediatric Rash
- Drug rash
- Erythema Infectiosum (Fifth disease)
- Hand-foot-and-mouth disease
- Henoch-Schonlein Purpura (HSP)
- Herpangina
- Herpes simplex virus
- Infectious Mononucleosis
- Meningitis
- Measles
- Molluscum contagiosum
- Roseola infantum
- Rubella German measles)
- Scarlet fever
- Smallpox
- Varicella (Chickenpox)
Vesiculobullous rashes
Febrile
- Diffuse distribution
- Varicella
- Smallpox
- Disseminated gonococcal disease
- DIC
- Purpural fulminans
- Localized distribution
Afebrile
- Diffuse distribution
- Bullous pemphigoid
- Drug-Induced bullous disorders
- Pemphigus vulgaris
- Phytophotodermatitis
- Erythema multiforme major
- Bullous impetigo
- Localized distribution
Varicella zoster virus
- Varicella (Chickenpox)
- Herpes zoster (Shingles)
- Herpes zoster ophthalmicus
- Herpes zoster oticus (Ramsay Hunt syndrome)
Evaluation
- Typically made on clinical features
Management
Supportive Care
- Tylenol, antihistamine, oatmeal baths
- Avoid aspirin in young children due to the risk of Reye syndrome
Antivirals
- Routine use of antiretrovirals for uncomplicated cases in immunocompetent children is not recommended [1]
- However, evidence shows decreased days of fever and number of lesions[2]
AAP recommends antiviral treatment (within 24hrs) for patients at risk of increased illness severity:
- Any patient older than 12 years of age
- Patients with chronic cutaneous or pulmonary disorders
- Patients receiving long-term salicylate therapy
- Patients receiving short, intermittent, or aerosolized courses of corticosteroids
Other cases to consider acyclovir
Immunocompetent Adult
- Acyclovir 800mg PO q6hrs daily x 5 days OR
- Valacyclovir 1000mg PO q8hrs daily x 14 days OR
- Famiciclovir 500mg PO q8hrs x 14 days
Immunocompromised Adult
- Acyclovir 10mg/kg IV q8hrs x 7 days
At risk children <12yo child based on AAP criteria
VZIG
- Initiate VZIG alongside acyclovir for inpatient treatment of child or adult
- For immunocompromised child with exposure, give as post-exposure prophylaxis if[5]:
- Within 10 days window of exposure
- VZIG given IM as 125 IU/10 kg of body weight
- Up to max of 625 IU
- Minimum dose 62.5 IU for patients weighing ≤ 2.0 kg
- Minimum dose 125 IU for weight 2.1 - 10.0 kg
- VZIG may prolong incubation period ≥1 week
- Must have patient closely follow up for signs and symptoms for 28 days after exposure
- If signs or symptoms of varicella occur, antiviral therapy must be started immediately
Disposition
Vaccine
- Introduced in 2006. Prior to introduction, incidence prior to adolescence approached 90% in US
- Vaccine is 85% effective against all disease, 90% effective against severe disease (greater than 1000 lesions)
- Typically given at age 5 in USA
- Post-exposure prophylaxis:
- Ideally given within 3-5 days of exposure in immunocompetent patients
- If immunocompromised patient is being given VZIG, varicella vaccine should be administered ≥5 months after VariZIG administration[6]
Complications
- Can include encephalitis, otitis media, pneumonia, hepatitis, strep/staph superinfection of ruptured vesicles
- Perinatal infection in neonates may develop serious illness
See Also
References
- ↑ Arvin AM: Antiviral therapy for varicella and herpes zoster. Semin Pediatr Infect Dis 2002; 13:12.
- ↑ Klassen TP, et al. Acyclovir for treating varicella in otherwise healthy children and adolescents. Cochrane Database Syst Rev. 2005; (4):CD002980.
- ↑ Drugs for non-HIV viral infections. Treat Guidel Med Lett. 2007; 5(59):59-70.
- ↑ CDC Chicken pox acyclovir treatment [1]
- ↑ CDC. MMWR - updated recommendations for use of VariZIG - United States, 2013. July 19, 2013 / 62(28);574-576.
- ↑ CDC. Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2007;56(No. RR-4).