Varicella 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

Corticosteroids

• Benefits include acute pain reduction and rapid early healing
• Should be administered with antiviral therapy due to its immunosuppressive properties
  
  • Concomitant use does not reduce incidence of postherpetic neuralgia (PHN)

Antivirals for Varicella

• Varicella in otherwise healthy adults and in immunocompromised patients tends to be more severe and they may be treated with antivirals preferably within 24 hours of rash onset
• Not recommended as prophylaxis after exposure to varicella

Aciclovir [Oral/Intravenous (IV)]

• Aciclovir is recommended in varicella-zoster virus (VZV) infections in immunocompromised patients and pregnant human immunodeficiency virus (HIV)-infected women with uncomplicated shingles
  
  • 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), otherwise healthy children >12 years or secondary household contacts, adolescents and adults, patients receiving a course of corticosteroids or chronic salicylate therapy
• Oral therapy should be given within the 1st 24 hours after rash occurs 
• IV therapy should be used in severely immunocompromised patients, with severe infections and in pregnant women who exhibit signs and symptoms of VZV pneumonitis
  
  • High-dose oral Aciclovir may be sufficient for mildly immunocompromised patients
  • Show clinical improvement in 48-72 hours
  • Can decrease the risk of contralateral eye involvement when administered for ≥3 months for patients with acute retinal necrosis
• Actions: 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
• Effects: 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 adults

Antivirals for Herpes Zoster

• Oral antiviral therapy is recommended in immunocompetent patients with ophthalmic or other nontruncal dermatomal rash, patients ≥50 years, and in patients suffering moderate to severe pain or rash
• IV Aciclovir is typically recommended in immunocompromised patients
  
  • Oral antivirals may be acceptable in patients who are only mildly to moderately immunocompromised
  • IV Foscarnet may be an alternative for Aciclovir-resistant VZV
• 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 viral 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 or if complications arise
• Choice of agent depends on availability, cost, dosing schedule and patient preference
  • Famciclovir or Valaciclovir is preferable to Aciclovir because of convenient dosing and higher antiviral drug activity

Aciclovir

• Actions: Guanosine analogue that is a competitive inhibitor of viral DNA polymerase
  
  • Limits viral replication and stops further spread of the virus to other cells
• Effects: Several studies have shown that high-dose oral Aciclovir accelerates resolution of acute lesions and may reduce the risk for prolonged pain
• IV Aciclovir should be initiated and continued until clinical improvement of extensive cutaneous lesions or patients with suspected visceral involvement
• IV route may be shifted oral once no new cutaneous lesions are noted and signs and symptoms are improving

Famciclovir

• Actions: Diacetyl prodrug of Penciclovir; has higher bioavailability than Penciclovir and is rapidly converted to Penciclovir in gastrointestinal tract (GIT), blood and liver
  
  • Penciclovir has similar mechanism of action as Aciclovir but has a longer half-life
• Effects: Efficacy is similar to Aciclovir

Valaciclovir

• Actions: Valine ester derivative of Aciclovir with improved oral absorption and it is immediately transformed to Aciclovir after absorption
  
  • Has the same mode of action as Aciclovir
• Effects: Efficacy is similar to Aciclovir

Alternative Treatment for Herpes Zoster

Brivudine (Brivudin)

• Actions: A thymidine nucleoside analogue that competitively inhibits viral DNA replication by blocking DNA polymerases
• A treatment option for immunocompetent patients with herpes zoster
• Effects: Several studies have shown that patients given Brivudine had shorter time to last new-lesion formation and full crusting, and with less experienced pain

Skin/Wound Care

• Keep skin lesions dry and clean to prevent bacterial superinfection
  
  • Shower at least twice a day with soap and water
• Nails should always be trimmed short and kept clean
• Avoid peeling lesion crust and let it slough off naturally
• Soft or liquid diet may be preferred for patients with lesions near the mouth
• Sterile wet dressings may decrease discomfort from lesions