Varicella Management

Pharmacological therapy

Symptomatic Therapy  

Analgesics  

Example drugs: Paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids (may be considered in severe pain)  

Analgesics may be used for relief of pain in herpes zoster infection.  

Antipruritics  

Example drugs: Calamine lotion, tepid baths and cool compresses  

Antipyretics  

Example drug: Paracetamol  

Antipyretics provide symptomatic relief of fever. Aspirin should not be used in children because of its association with Reye’s syndrome.  

Corticosteroids  

The benefits of corticosteroids include acute pain reduction and rapid early healing. These should be administered with antiviral therapy due to their immunosuppressive properties. Their concomitant use does not reduce the incidence of postherpetic neuralgia (PHN).

Antivirals for Varicella  

Varicella in otherwise healthy adults and in immunocompromised patients tends to be more severe and may be treated with antivirals, preferably within 24 hours of rash onset. Uncomplicated varicella is treated with oral antivirals for 5-7 days but may be extended if there is delayed crusting of lesions. The typical duration of IV antiviral treatment in immunocompromised patients is 7-10 days but may be extended until no new lesions appear. Antivirals are not recommended as prophylaxis after exposure to varicella.  

Aciclovir (Oral/IV)  

Aciclovir is a guanosine analogue that is a competitive inhibitor of viral DNA polymerase. It limits viral replication and stops further spread of the virus to other cells. It shortens the duration of viral shedding, halts the formation of new lesions more quickly, and 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. Oral therapy should be given within the first 24 hours after the rash occurs. High-dose oral Aciclovir may be sufficient for mildly immunocompromised patients.  

Aciclovir is recommended in VZV infections in immunocompromised patients and pregnant HIV-infected women with uncomplicated herpes zoster. Aciclovir may be considered in patients with chronic cutaneous or pulmonary disorders, those with diseases that can be exacerbated by VZV infection (eg cystic fibrosis), otherwise healthy children >12 years or secondary household contacts and patients receiving a course of corticosteroids or chronic salicylate therapy. IV therapy should be used in severely immunocompromised patients, those with severe infection and pregnant women who exhibit signs and symptoms of VZV pneumonitis. Symptoms show clinical improvement in 48-72 hours. It can decrease the risk of contralateral eye involvement when administered for ≥3 months for patients with ARN.  

Valaciclovir  

Valaciclovir is a valine ester derivative of Aciclovir with improved oral absorption, as it is immediately transformed to Aciclovir after absorption. It has a similar mode of action and efficacy as Aciclovir. It can be administered in fewer doses compared to Aciclovir.  

Famciclovir  

Famciclovir is a diacetyl prodrug of Penciclovir that has a higher bioavailability than Penciclovir and is rapidly converted to Penciclovir in the GIT, blood and liver. Penciclovir has a similar mode of action and efficacy as Aciclovir but has a longer half-life.

Antivirals for Herpes Zoster  

Example drugs: Aciclovir, Famciclovir, Valaciclovir  

The 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, and reduce complications. Oral antiviral therapy is recommended in immunocompetent patients with ophthalmic or other non-truncal dermatomal rash, patients ≥50 years and patients suffering moderate to severe pain or rash. It may be acceptable in patients who are only mildly to moderately immunocompromised.  

When taken within 72 hours of symptom onset, oral antivirals have been shown to reduce the 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. The typical course of treatment is 7 days.  

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. Several studies have shown that high-dose oral Aciclovir accelerates resolution of acute lesions and may reduce the risk for prolonged pain. IV Aciclovir is typically recommended in immunocompromised patients or in patients with suspected visceral involvement. It should be continued until clinical improvement of extensive cutaneous lesions. IV Aciclovir may be shifted to oral once no new cutaneous lesions are noted and if signs and symptoms are improving. IV Foscarnet may be an alternative for Aciclovir-resistant VZV.

Alternative Treatment for Herpes Zoster  

Brivudine (Brivudin)  

Brivudine is a thymidine nucleoside analogue that competitively inhibits viral DNA replication by blocking DNA polymerases. It is a treatment option for immunocompetent patients with herpes zoster. Several studies have shown that patients given Brivudine shortened the time between new-lesion formation and full crusting with less pain experienced.

Nonpharmacological

Patient Education  

Educate the patient on the infectious nature of the disease and its mode of transmission. Advise the patient on the importance of early treatment and monitoring for signs and symptoms of possible complications. Avoid self-medicating with Aspirin, which has been associated with Reye’s syndrome. Assure patients about the course of the disease and provide counseling when needed.  

Skin and 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. A soft or liquid diet may be preferred for patients with lesions near the mouth. Sterile wet dressings may decrease discomfort from lesions.