Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

otherwise healthy children at low risk of severe disease

1st line – supportive care

Back
ACUTE
|
otherwise healthy children at low risk of severe disease
1st line – 

supportive care

Symptomatic treatment with acetaminophen, skin emollients, and antihistamines may be all that is required by children with low risk of developing severe disease. Hydration is important, particularly in toddlers and children with fever.

Aspirin is contraindicated due to its association with Reye syndrome.[71] There is also concern over the use of nonsteroidal anti-inflammatory drugs (NSAIDs) in varicella and an increased risk of group A streptococcal (GAS) superinfection.[72][73] Due to the potential increase in skin and soft tissue infections, NSAIDs should be avoided.

Calamine lotion is often used to help relieve itching;[69] however, there is no published evidence to support its use in varicella infection.[70]

Antihistamine treatment for varicella in children has been associated with ataxia, urinary retention, and other adverse effects. In addition, a warning has been issued against the use of some cough and cold medicines (many of them antihistamines) in children under the age of 2 years.[75] Risks may outweigh benefits in young children.

Primary options

acetaminophen: children <12 years of age: 15 mg/kg orally/rectally every 4-6 hours when required, maximum 75 mg/kg/day; children >12 years of age: 325-1000 mg orally/rectally every 4-6 hours when required, maximum 4000 mg/day

-- AND --

diphenhydramine: children 2-5 years of age: 6.25 mg orally every 4-6 hours when required, maximum 37.5 mg/day; children 6-12 years of age: 12.5 to 25 mg orally every 4-6 hours when required, maximum 150 mg/day; children >12 years of age: 25-50 mg orally every 4-6 hours when required, maximum 300 mg/day

More

-- AND --

diphenhydramine topical: (1-2%) apply to the affected area(s) three to four times daily when required for up to 7 days

or

emollient topical: apply to the affected area(s) when required

increased risk of moderate to severe disease

1st line – oral antiviral therapy

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ACUTE
|
increased risk of moderate to severe disease
1st line – 

oral antiviral therapy

Oral antiviral therapy is recommended by the American Academy of Pediatrics for patients who are considered to be at increased risk for moderate to severe varicella, and this includes: otherwise healthy patients ages 13 years or over; those with chronic skin disease (e.g., atopic dermatitis); those with underlying pulmonary disease; patients receiving long-term salicylate therapy; those receiving short-course or intermittent oral corticosteroids.[36] 

Oral antiviral therapy within the first 72 hours improves the time to healing of cutaneous lesions and decreases duration of fever in adolescents and adults.[76][77][78][79]

Primary options

acyclovir: children >2 years of age: 20 mg/kg orally four times daily for 5 days; children >40 kg body weight and adults: 800 mg orally four times daily for 5 days

Plus – supportive care

Back
ACUTE
|
increased risk of moderate to severe disease
Plus – 

supportive care

Treatment recommended for ALL patients in selected patient group

Symptomatic treatment with acetaminophen, skin emollients, and antihistamines can be used in these populations.

Patients admitted for varicella need to be placed in both airborne and contact isolation from potentially susceptible people for a minimum of 5 days after the onset of the rash and until all lesions are crusted.

Hydration is important, particularly in toddlers and children with fever.

Aspirin is contraindicated due to its association with Reye syndrome.[71] There is also concern over the use of nonsteroidal anti-inflammatory drugs (NSAIDs) in varicella and an increased risk of group A streptococcal (GAS) superinfection.[72][73] Due to the potential increase in skin and soft tissue infections, NSAIDs should be avoided.

Calamine lotion is often used to help relieve itching;[69] however, there is no published evidence to support its use in varicella infection.[70]

Antihistamine treatment for varicella in children has been associated with ataxia, urinary retention, and other adverse effects. In addition, a warning has been issued against the use of some cough and cold medicines (many of them antihistamines) in children under the age of 2 years.[75] Risks may outweigh benefits in young children.

Primary options

acetaminophen: children <12 years of age: 15 mg/kg orally/rectally every 4-6 hours when required, maximum 75 mg/kg/day; children >12 years of age and adults: 325-1000 mg orally/rectally every 4-6 hours when required, maximum 4000 mg/day

-- AND --

diphenhydramine: children 2-5 years of age: 6.25 mg orally every 4-6 hours when required, maximum 37.5 mg/day; children 6-12 years of age: 12.5 to 25 mg orally every 4-6 hours when required, maximum 150 mg/day; children >12 years of age and adults: 25-50 mg orally every 4-6 hours when required, maximum 300 mg/day

More

-- AND --

diphenhydramine topical: (1-2%) apply to the affected area(s) three to four times daily when required for up to 7 days

or

emollient topical: apply to the affected area(s) when required

high risk of severe disease

1st line – intravenous antiviral therapy

Back
ACUTE
|
high risk of severe disease
1st line – 

intravenous antiviral therapy

Prompt intravenous antiviral therapy is recommended for patients at high risk for severe disease and complications, and this includes: people who are immunocompromised, such as those with leukemia, lymphoma, or cellular immune deficiencies; people who are on immunosuppressive medication, such as high-dose systemic corticosteroids or chemotherapeutic agents; neonates whose mothers have varicella from 5 days before to 2 days after delivery; premature babies (specifically hospitalized premature infants born at 28 or more weeks of gestation whose mothers do not have evidence of immunity and hospitalized premature infants born at less than 28 weeks of gestation or who weigh 1000 grams or less at birth regardless of their mothers’ varicella immunity status); pregnant women.[36][53]​​

Delay in treatment can have serious consequences for these patients.

Prospective studies that have evaluated acyclovir use in immunosuppressed children have demonstrated less risk of dissemination and a reduction in the duration of hospitalization.[80][81][82][83][84]

Alternate dosing may be required for preterm neonates.

Primary options

acyclovir: neonates: 10-20 mg/kg intravenously every 8 hours for 7-10 days; children <1 year of age: 10 mg/kg intravenously every 8 hours for 7-10 days; children >1 year of age: 500 mg/square meter of body surface area intravenously every 8 hours for 7-10 days; adults: 10 mg/kg intravenously every 8 hours for 7-10 days

Plus – supportive care

Back
ACUTE
|
high risk of severe disease
Plus – 

supportive care

Treatment recommended for ALL patients in selected patient group

Symptomatic treatment with acetaminophen, skin emollients, and antihistamines can be used in these populations.

Patients admitted for varicella need to be placed in both airborne and contact isolation from potentially susceptible people for a minimum of 5 days after the onset of the rash and until all lesions are crusted.

Hydration is important, particularly in toddlers and children with fever.

Aspirin is contraindicated due to its association with Reye syndrome.[71] There is also concern over the use of nonsteroidal anti-inflammatory drugs (NSAIDs) in varicella and an increased risk of group A streptococcal (GAS) superinfection.[72][73] Due to the potential increase in skin and soft tissue infections, NSAIDs should be avoided.

Calamine lotion is often used to help relieve itching;[69] however, there is no published evidence to support its use in varicella infection.[70]

Antihistamine treatment for varicella in children has been associated with ataxia, urinary retention, and other adverse effects. In addition, a warning has been issued against the use of some cough and cold medicines (many of them antihistamines) in children under the age of 2 years.[75] Risks may outweigh benefits in young children.

Primary options

acetaminophen: neonates: 10-15 mg/kg orally/rectally every 6-8 hours when required, maximum 60 mg/kg/day; children <12 years of age: 15 mg/kg orally/rectally every 4-6 hours when required, maximum 75 mg/kg/day; children >12 years of age and adults: 325-1000 mg orally/rectally every 4-6 hours when required, maximum 4000 mg/day

-- AND --

diphenhydramine: children 2-5 years of age: 6.25 mg orally every 4-6 hours when required, maximum 37.5 mg/day; children 6-12 years of age: 12.5 to 25 mg orally every 4-6 hours when required, maximum 150 mg/day; children >12 years of age and adults: 25-50 mg orally every 4-6 hours when required, maximum 300 mg/day

More

-- AND --

diphenhydramine topical: (1-2%) apply to the affected area(s) three to four times daily when required for up to 7 days

or

emollient topical: apply to the affected area(s) when required

Consider – counseling and referral of pregnant women

Back
ACUTE
|
high risk of severe disease
Consider – 

counseling and referral of pregnant women

Treatment recommended for SOME patients in selected patient group

Pregnant women should be counseled about the risk of potential adverse maternal and fetal sequelae, options for prenatal diagnosis, and the risk of fetal transmission. Consultation with a neonatologist and an infectious disease specialist is recommended if there is peripartum varicella exposure, in order to optimize prevention or treatment strategies.[60]

severe disease

1st line – intravenous antiviral therapy

Back
ACUTE
|
severe disease
1st line – 

intravenous antiviral therapy

Patients who develop serious complications from varicella should receive intravenous acyclovir. Treatment should begin empirically in patients with clinical symptoms suggestive of complications.[16]​​[57][85][86][87][88][89] Patients may need to be treated for longer than 7-10 days with acyclovir if they have severe disease or neurologic complications.

Primary options

acyclovir: children <1 year of age: 10 mg/kg intravenously every 8 hours for 7-10 days; children >1 year of age and adults: 500 mg/square meter of body surface area intravenously every 8 hours for 7-10 days, or 10 mg/kg intravenously every 8 hours for 7-10 days

Plus – supportive care

Back
ACUTE
|
severe disease
Plus – 

supportive care

Treatment recommended for ALL patients in selected patient group

Patients admitted for varicella need to be placed in isolation for a minimum of 5 days after the onset of the rash and until all lesions are crusted.

Symptomatic treatment with acetaminophen, skin emollients, and antihistamines can be used in these populations.

Hydration is important, particularly in toddlers and children with fever.

Aspirin is contraindicated due to its association with Reye syndrome.[71] There is also concern over the use of nonsteroidal anti-inflammatory drugs (NSAIDs) in varicella and an increased risk of group A streptococcal (GAS) superinfection.[72][73] Due to the potential increase in skin and soft tissue infections, NSAIDs should be avoided.

Calamine lotion is often used to help relieve itching;[69] however, there is no published evidence to support its use in varicella infection.[70]

Antihistamine treatment for varicella in children has been associated with ataxia, urinary retention, and other adverse effects. In addition, a warning has been issued against the use of some cough and cold medicines (many of them antihistamines) in children under the age of 2 years.[75] Risks may outweigh benefits in young children.

Primary options

acetaminophen: children <12 years of age: 15 mg/kg orally/rectally every 4-6 hours when required, maximum 75 mg/kg/day; children >12 years of age and adults: 325-1000 mg orally/rectally every 4-6 hours when required, maximum 4000 mg/day

-- AND --

diphenhydramine: children 2-5 years of age: 6.25 mg orally every 4-6 hours when required, maximum 37.5 mg/day; children 6-12 years of age: 12.5 to 25 mg orally every 4-6 hours when required, maximum 150 mg/day; children >12 years of age and adults: 25-50 mg orally every 4-6 hours when required, maximum 300 mg/day

More

-- AND --

diphenhydramine topical: (1-2%) apply to the affected area(s) three to four times daily when required for up to 7 days

or

emollient topical: apply to the affected area(s) when required

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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