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
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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
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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
- 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.
- 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
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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 |
Last reviewed: 19 August 2016
Next review: 25 November 2020
Author(s): Dr F Russell
Approved By: Clinical Effectiveness