Chickenpox

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Objectives

The aim is to provide guidance for the management of chickenpox, including it's diagnosis, the risk factors for severe infection and its complications.

Scope

This guideline is designed to assist healthcare professionals in the management of chickenpox.

A guideline is intended to assist healthcare professionals in the choice of disease‐specific treatments.  

Clinical judgement should be exercised on the applicability of any guideline, influenced by individual patient characteristics. Clinicians should be mindful of the potential for harmful polypharmacy and increased susceptibility to adverse drug reactions in patients with multiple morbidities or frailty.  

If, after discussion with the patient or carer, there are good reasons for not following a guideline, it is good practice to record these and communicate them to others involved in the care of the patient.

 

Chickenpox is caused by the varicella-zoster virus. The diagnosis is clinical. Patients will present to the department for a primary diagnosis or because they have developed a secondary complication and are sick.

 - Fever precedes rash by 1-2 days 
   usually subsides within 4 days of the appearance of a rash 

 - Rash starts on head and trunk 
            then spreads appears in crops 
            lesion change from red macule, papule, vesicle, pustule, crust 
            continues to erupt for 3-5 days 
            lesions usually crust by 6 days 
            is intensely itchy 
            may involve the pharynx and tonsils

Always think about patients at risk of severe infection...

  • Immunocompromised
    • children with any malignancy
    • children on chemotherapy
    • children on high dose steroids
    • congenital cellular immunodeficiencies
    • children on immunosuppressive Tx
    • children with HIV
  • Neonates
  • Pregnant women
  • Children with severe eczema or dermatitis

Seek advice regarding the need for V-Z Immunoglobulin or Acyclovir!

Complications

Complications

Secondary bacterial infection: have a high index of suspicion for this consider if fever                                                        returns or worsens risk of invasive GrpA Strep or Staph eg.                                                  osteomyelitis, toxic shock, meningitis bacterial pneumonia

In ALL patients LOOK for cellulitis which may be rapidly spreading

Pneumonitis: occurs in older children and adults
                      respiratory symptoms appear 3-4 days after the rash

                      CXR diffuse bilat nodular infiltrates in primary varicella pneumonia
                      focal infiltrates are suggestive of bacterial pneumonia

Cerebellar Ataxia: sudden onset 2-3 weeks after the onset of varicella 
                            range in severity from unsteadiness to severe 
                            refer to neurology

Encephalitis: occurs during the acute phase a few days after the rash 
                     symptoms of lethargy, drowsiness and confusion 
                     may have seizures 
                     serious with a high mortality

Hepatitis: self limiting 
                significant ↑ALT in 20-50% children and resolves in 1month

Ophthalmic: if lesions noted in the eye refer to ophthalmology

What to do!
  • see the child in a cubicle
  • work out which day of illness the child is likely to be on
  • establish what the parent is concerned about
  • take a thorough history to exclude risks of severe infection
  • strip the child and thoroughly examine skin to exclude cellulitis
  • ask about contacts at risk eg. babies in the house or pregnant women
  • advise the parents the reasons to return (see below)

Any significant complications require discussion with a senior colleague as they may require admission or specialty review.

Management of Uncomplicated Chickenpox
  • cut nails
  • frequent baths, try adding Bicarbonate of soda or Balneum
  • avoid too much calamine which may cause caking and increased itching
  • try piriton for itch
  • regular paracetamol
  • increase oral fluids
  • stay off school or nursery until all lesions are crusted

There is a very small risk of ibuprofen and other Non-steroidal anti-inflammatory drugs (NSAIDs) causing adverse skin reactions during chickenpox.

Advise parents to bring their children back to hospital if they develop the following complications: 

  • unusual redness, swelling or pain over an area of the rash
  • refusal to drink fluids and reduced urine output/dry nappies
  • high fever that persists for more than 4 days or the fever was gone and then came back
  • there is a change in the child’s behaviour
  • severe headache or trouble walking
  • blisters are observed in the child’s eyes
  • the child has trouble breathing

For advice regarding patients exposed to Chickenpox see the “Green Book” public health web site.

www.dh.gov.uk/en/Publichealth/Healthprotection/Immunisation/Greenbook/DH_4097254

References
Editorial Information

Last reviewed: 19 August 2016

Next review: 13 November 2019

Author(s): Dr F Russell

Approved By: Clinical Effectiveness