Varicella

Background

• Caused by varicella zoster virus causing varicella (chicken pox) and later zoster (Shingles)
• Contagious until last lesion crusts over

Clinical Features

Male with varicella rash: lesions in various stages of development

Classic blister during early stage of lesion development

• 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
  • Necrotizing fasciitis
  • Hand-foot-and-mouth disease

Afebrile

• Diffuse distribution
  • Bullous pemphigoid
  • Drug-Induced bullous disorders
  • Pemphigus vulgaris
  • Phytophotodermatitis
  • Erythema multiforme major
• Localized distribution
  • Contact dermatitis
  • Herpes zoster
  • Dyshidrotic eczema
  • Burn
  • Dermatitis herpetiformis
  • Erythema multiforme minor
  • Poison Oak, Ivy, Sumac dermatitis
  • Bullosis diabeticorum

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
• However, evidence shows decreased days of fever and number of lesions

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 :
• Pregnancy

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

Complications

• Can include encephalitis, otitis media, pneumonia, hepatitis, strep/staph superinfection of ruptured vesicles
• Perinatal infection in neonates may develop serious illness

See Also

Pediatric Rashes

References

Authors

Ross Donaldson, Daniel Ostermayer, Neil Young, Kenn Ghaffarian, Claire, Kevin Lu, Aaron Snyder