Varicella%20(pediatric) Treatment

Symptomatic Therapy

Antipruritics

• Calamine lotion, tepid baths, cool compresses

Antipyretics

• Eg Paracetamol
  
  • Aspirin should not be used in children because of its association with Reye’s syndrome
• Provide symptomatic relief of fever

Analgesics

• Eg Paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs); opioids may be considered in severe pain
• May be used for relief of pain in herpes zoster infections

Local Therapy for Herpes zoster Lesions

• Eg saline solution, mild antiseptics (Polyhexanide solution, Zinc oxide lotion)
• May be used for acute vesicular or necrotizing herpes zoster lesions

Antivirals for Varicella

• In otherwise healthy children, varicella is often benign and requires symptomatic care only
• Varicella in otherwise healthy adolescents and in immunocompromised patients tends to be more severe and they may be treated with antivirals preferably within 24 hours
• Considering that varicella is a self-limited disease, antivirals are not recommended for immunocompetent children ≤12 years of age; benefits should be weighed against adverse events and treatment cost

Aciclovir (PO/IV)

• Aciclovir is recommended in VZV infections in immunocompromised patients
  
  • May be considered in patients with chronic cutaneous or pulmonary disorders, in patients with diseases that can be exacerbated by VZV infection (eg cystic fibrosis), patients receiving corticosteroids or long-term salicylate therapy, otherwise healthy patients >12 years old or secondary household contacts, adolescents and adults
• IV therapy should be used in severely immunocompromised patients and in severe infections
  
  • High-dose oral Aciclovir may be sufficient for mildly immunocompromised patients
• Aciclovir is a guanosine analogue that is a competitive inhibitor of viral DNA polymerase
  
  • Limits viral replication and stops further spread of the virus to other cells
• Shortens the duration of viral shedding, halts the formation of new lesions more quickly, accelerates the rate of healing in both immunocompetent and immunocompromised patients
  
  • This improvement is modest in the healthy individual but can reduce life-threatening complications in high-risk individuals

Famciclovir/Valaciclovir

• Have been used in place of Aciclovir in otherwise healthy adolescents (>12 years of age)

Antivirals for Herpes zoster

• Antiviral therapy is recommended in immunocompetent pediatric patients that are on chronic salicylic acid or glucocorticoid therapy
• Also recommended for patients <50 years old at low risk or without complications but with trunk or extremities involvement
• Primary goal of treatment in herpes zoster is to reduce acute pain and PHN
• Therapy for herpes zoster should accelerate healing; limit the severity and duration of acute and chronic pain; reduce complications
• When taken within 72 hours of symptom onset, oral antivirals have been shown to reduce severity and duration of symptoms
  
  • Most virus replication has ceased by 72 hours after the onset of rash but this may be substantially extended in immunocompromised patients
  • After 72 hours, antivirals should be considered if new vesicular lesions are continuing to appear 
• Choice of agent depends on availability, cost, dosing schedule and patient preference
• Options for patients with uncomplicated herpes zoster and at low risk for visceral dissemination are oral Aciclovir, Famciclovir and Valacyclovir

Aciclovir

• Guanosine analogue that is a competitive inhibitor of viral DNA polymerase
  
  • Limits viral replication and stops further spread of the virus to other cells
• May shorten the duration of illness
• Several studies have shown that high-dose oral Aciclovir accelerates resolution of acute lesions and may reduce the risk for prolonged pain
• IV Aciclovir is typically recommended in those with or at risk for complicated herpes zoster:
  • Head and/or neck involvement
  • Hemorrhagic/necrotizing lesions, involvement of >1 segment, aberrant vesicles/satellite lesions, or mucous membrane involvement
  • Immunocompromised patients
  • Visceral or CNS involvement