Treating Chickenpox and Shingles in Contemporary Clinics

Felicia Spadini, APRN, MSN, NP-C
Tuesday August 30, 2016

Varicella-zoster virus (VZV) is a herpesvirus that causes 2 related but separate clinical illnesses. Primary exposure to VZV causes varicella infection (chickenpox). Once chickenpox resolves, VZV resides latent in neurons within the regional ganglia and may re-emerge at any time to cause herpes zoster infection (shingles).1

The incidence of chickenpox in the United States has decreased significantly since universal varicella vaccination began in 1995.2 However, herpes zoster infection remains very common, with almost 1 of 3 individuals in the United States developing it in their lifetime.1 Primary care providers should be able to diagnose both conditions and begin treatment promptly for uncomplicated infections. Moreover, clinicians should be able to recognize patients with signs and symptoms of severe VZV infection, as well as those at high risk for developing complications, and refer them to appropriate specialists.

Chickenpox

Presentation and Pathogenesis

Following exposure, chickenpox has an incubation period ranging from 10 to 21 days.1 Clinical illness starts with a short prodromal period of fever and malaise followed by the hallmark pruritic vesicular rash.3 The lesions associated with the rash form crusts in about 6 days and then fall off after 1 to 2 weeks. Once the lesions have crusted, the individual is no longer considered contagious.4 Usually, chickenpox confers lifelong immunity, although rare cases of reinfection have been reported.5

Transmission

Humans are the only VZV reservoir, so chickenpox can only be transmitted from patient to patient.1 It is highly contagious and may be transmitted via respiratory droplets and vesicular fluids; less commonly, the virus may become airborne.1,6 Transmission of chickenpox is also possible from infected mother to her fetus in utero and to her newborn during birth.7 If an immunized individual develops breakthrough varicella infection, transmission to others is possible but uncommon.1

Infection

In healthy children, chickenpox is generally a mild, self-limiting illness that requires only symptomatic management. Typical symptoms include fever, malaise, and pruritic vesicular rash that starts on the head and face and spreads to the rest of the body.8 However, in certain populations, varicella may cause significant morbidity and mortality. Groups at increased risk for complications include unvaccinated adolescents and adults, neonates, immunocompromised individuals, and pregnant women. Common serious complications from chickenpox include encephalitis, hepatitis, varicella pneumonia, and infection.9 Additionally, maternal VZV infection during the first or second trimesters of pregnancy may lead to the fetus developing congenital varicella syndrome, which can cause severe birth defects.10

Breakthrough Varicella

Mild varicella-like syndrome (MVLS), also called breakthrough varicella, is a milder version of varicella infection that develops occasionally when vaccinated patients are exposed to wild-type

VZV. Breakthrough infection may be caused by a failure to develop an effective immune response to the vaccine or by immunity diminishing over time.11 Although the symptoms of MVLS are mild, the infected individual is still contagious to susceptible individuals.12

Complications

Complications from chickenpox include secondary bacterial skin infection, meningitis, encephalitis, cerebellar ataxia, pneumonia, glomerulonephritis, myocarditis, ocular disease, adrenal insufficiency, sepsis, and death.13 Additionally, grave complications may develop if chickenpox is contracted during pregnancy, the most common of which is the aggressive varicella pneumonia, characterized by diffuse infiltration that often compromises both lungs and rapidly causes respiratory failure.14 The fetus is also at risk of developing congenital varicella syndrome, which has a 30% mortality rate and can result in multiple birth defects. Common abnormalities caused by congenital varicella syndrome include mental retardation, microcephaly, hydrocephalus, seizures, limb hypoplasia or paresis, cataracts, optic nerve atrophy, micropthalmos, nystagmus, stenotic bowel, scarring, and low birth weight. Neonatal chickenpox may also cause severe disease and has a high mortality rate.15

Complicated Chickenpox Treatment

Groups considered to be at high risk for complications include immunocompromised patients, unvaccinated adults, pregnant women, and adolescents older than 12 years. For immunocompetent patients, oral valacyclovir or acyclovir are the treatments of choice. Immunocompromised patients should receive intravenous acyclovir. For greatest benefit, treatment should be started within 24 hours of development of rash. Regardless of age, treatment

should be initiated for any patient that presents with varicella-related complications such as encephalitis, hepatitis, or varicella pneumonia.16

Uncomplicated Chickenpox Treatment

The treatment for chickenpox varies widely based on the patient’s age and overall state of health. In general, symptomatic management is all that is required for immunocompetent children up to 12 years old. Recommended treatment for this group includes acetaminophen, antihistamines, and trimming fingernails to help discourage secondary skin infections.17 Due to concerns of Reye syndrome, salicylates should be avoided with children and adolescents.18

Post-Exposure Prophylaxis

Following exposure to VZV, pregnant women who have never received varicella vaccination and show no serologic proof of past VZV infection have a 96-hour window to receive post-exposure prophylaxis.19 In the United States, the only FDA-approved product for passive immunity is VariZIG, which is used to prevent or attenuate varicella infection.20 For pregnant women who develop varicella infection despite prophylaxis, there is no evidence that it prevents congenital varicella syndrome.19 VariZIG may also be used prophylactically in newborns who have been exposed to VZV to prevent or attenuate varicella infection.20

Chickenpox in Primary Care

When chickenpox is suspected, primary care providers should obtain vaccine history. If the patient has received 1 or 2 doses of vaccine, infection will likely be mild.11 For patients older than 12 years, oral antivirals should be initiated within 24 hours of rash onset.17 Patients should be advised that they are highly contagious until the lesions have crusted over, which usually takes 7 to 10 days.16,18 They should be counseled to avoid unvaccinated individuals, immunocompromised individuals, newborns, and pregnant women since these groups have the greatest risk of complications.9 If an immunocompromised patient develops chickenpox, the individual should be closely monitored for prolonged fevers, extensive rashes, confusion, or other signs of distress.6 If chickenpox is suspected in a newborn, prompt referral for monitoring and treatment is warranted.4 In general, once an individual has had chicken pox, immunity is conferred for life.7 However, after varicella infection, the individual may develop shingles at any age.21



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