Treatment and Prevention in: Varicella with Special Considerations

Kezia Marsilina1, Suswardana2, Abdul Gayum3

1

Co-Assistant of Faculty of Medicine Trisakti University

Head of Dermatology and Venereology Subdepartment

Head Department of Dermatology and Venereology, ENT, and Opthalmology

Navy Hospital dr.Mintohardjo
immunologically compromised persons of
any age, varicella is more likely to be

Introduction
Varicella or chickenpox (chicken means
weak form of smallpox, pox means no
major matter unless it becomes infected or
occurs in immunocompromised patient)1 is
an acute, highly contagious exanthema,
caused by a member of herpesvirus family,
varicella-zoster

virus

(VZV).

Varicella

occurs most often in childhood, and the rash

usually begins on the face and scalp and
spreads rapidly to the trunk (centrifugal),
with relative sparing of the extremities.
Lesions are scattered rather than clustered,
and progress from rose-colored macules to
papules, vesicles, pustules, and crusts. In
varicella, in contrast to smallpox, lesions in
all stages are usually present on the body at
the same time.
In normal children, systemic symptoms are
usually mild and serious complications are
rare.

In

adults,

pregnant

woman,

associated

with

life-threatening

complications and high rates of morbidity.2

Immunocompromised patients
The morbidity and mortality of varicella are
markedly increased in immunocompromised
patients. In these patients, continued virus
replication and dissemination result in a
prolonged

high-level

viremia,

more

extensive rash, a longer period of new

vesicle formation, and clinically significant
visceral dissemination.
Immunosuppressed

and

glucocorticoid-

treated patients may develop pneumonia,

hepatitis, encephalitis, and hemorrhagic
complications of varicella, which range in
severity from mild febrile purpura to severe
and often fatal purpura fulminans and
malignant varicella.
Controlled trials in immunocompromised
patients with varicella demonstrated that
1

treatment with IV acyclovir decreased the

varicella

incidence

visceral

immunodeficiency. Although oral therapy

complications when treatment was initiated

with famciclovir or valacyclovir might

within 72 hours of rash onset. Immune

suffice for patients with mild degrees of

compromise, however, is a continuum

immune impairment, there are no controlled

ranging from minimal to severe. Intravenous

clinical trials to guide the decision.2

of

life-threatening

in

patients

with

substantial

acyclovir has been the standard of care for

Table 1. Antiviral treatment of varicella in the Normal and Immunocompromised Host2

pneumonia
Pregnant women

mother

and

to

be

significantly

increased by pregnancy. The fetus may die

Varicella during pregnancy is a threat to

both

appear

fetus.

Disseminated

infection and varicella pneumonia may

result in maternal death, but neither the
incidence nor the severity of varicella

as a consequence of premature labor or

maternal death caused by severe varicella
pneumonia, but varicella during pregnancy
does not, otherwise, substantially increase
fetal

mortality.

Nevertheless,

even

in
2

uncomplicated varicella, maternal viremia

immunoglobulin

can result in intrauterine (congenital) VZV

complications

infection, and a characteristic constellation

rate

of congenital abnormalities.2

incidence. Administration as soon

Acyclovir has been shown to reduce the

as possible after exposure is best,

duration of fever and hasten the resolution

but VZIG can prevent or attenuate

of vesicles if commenced within 24 hours of

varicella if administered within 96

onset of rash. Although it is not licensed in

hours of contact. The expected

pregnancy, experience has shown that it is a

duration

very safe drug and no adverse fetal or

approximately

neonatal effects have been reported with its

Intravenous immunoglobulin (IVIG)

use in pregnancy (Briggs, et al. 2005). It

has been used to prevent varicella

should be used with caution in first trimester

after exposure when VZIG is not

of

(VZIG)

reduces

and the

mortality

varicella,

of

but

not

protection
three

its

is

weeks.

due to insufficient evidence on its safety.

available. Clinical efficacy is not

The guidelines from the Royal College of

exactly

Obstetricians and Gynaecologists (2007)

drugs, mortality rates may be as

restrict oral acyclovir to patients who:

a. present in the first 24 hours of rash
b. are more than 20 weeks pregnant

high as 30%. To reduce the risk of

However, acyclovir treatment may still be

postponed

considered in patients who are less than 20

antibodies to be passed to the

weeks pregnant or whose onset of rash is

baby.4

known.

Without

these

neonatal varicella
date

of

delivery
to

may
allow

also

be

varicella

more than 24 hours but still developing new

lesions if there is a significant risk(s) of
complications.

Based on research done by Vernassiere et al.

Neonates
Intravenous

(2003), acyclovir allergy reaction probably

acyclovir

has

been

used in cases of neonatal and

complicated varicella infection in
children.

Acyclovir allergy

was provoked by a chemical structure called

2-aminopurine nucleus. The only antiviral
drugs not having this core are foscarnet and

Varicella-zoster
3

cidofovir. And between those, foscamet can

associated with cessation of viral shedding

be used against VZV strains.5

and with complete healing of lesions in

Lower doses of foscarnet IV (40 mg/kg

about three-quarters of patients.6

every 8 hours for 7 days or longer) are

Table 4. Antiherpesvirus agents6

Prophylaxis and vaccine
Post-exposure Prophylaxis:
Univalent Varicella Vaccine:
Univalent varicella vaccine given as soon

considered for the following susceptible

as possible, within three days but up to five

more than 96 hours have elapsed since the

days

is

last exposure, the benefit of administering

recommended for susceptible, healthy, non-

VarIg is uncertain. If VarIg is being

pregnant persons who are 12 months of age

considered, consultation with an infectious

or older. Varicella vaccination is not

diseases or infection control specialist is

recommended.

after

significant

exposure,

indicated for post-exposure management of

infants less than 12 months of age, as the
vaccine is not authorized for this age group

individuals if it can be given within 96 hours

of the most recent significant exposure. If

Pregnant women

Newborn infants of mothers who

develop varicella during the five

and these infants are generally protected by

days before to 48 hours after

maternal antibodies. There are no data on

the use of MMRV (measles-mumps-rubella
varicella) vaccine in varicella post-exposure
or outbreak situations.5
Varicella-Zoster
Immune

delivery.
Children exposed to varicella in
neonatal or pediatric intensive care

Globulin

(VarIg):
Varicella-zoster immune globulin should be

settings.
Immunocompromised
except

those

receiving

persons,
regular
4

monthly infusions of 400 mg/kg or

immune suppressed, post-exposure

more

vaccination

of

intravenous

immune

recommended

as

globulin and whose most recent dose

detailed above. Post-exposure VarIg

was within three weeks before

is not necessary for HIV-infected

exposure

persons

to

varicella.

For

without

severe

immune

immunocompromised persons who

suppression who have completed an

are outside the 96-hour window for

appropriate

VarIg

series or who have had natural

administration,

antiviral

prophylaxis from days seven to 14

is

postexposure could be considered.

HIV-infected persons who are
severely immune suppressed (CD4
cell count < 200 x 106 /L or CD4
percentage < 15%). For HIV-infected
persons

who

are

not

two-dose

vaccination

varicella infection.
Recipients of hematopoietic stem
cell

transplantation

(HSCT)

regardless of a history of varicella

disease or vaccination or positive
serologic test results.

severely

Table 2. Varicella vaccination algorithm for Individuals 12 Months2

The recommended dose of VarIg is 125

of 625 IU. The minimum dose is 125 IU. In

IU/10 kg of body weight up to a maximum

immunocompromised persons, more than

5

this amount may be required; consultation

approximately

three

weeks,

subsequent

with an expert is recommended. VarIg

exposures occurring more than three weeks

should be given by the intramuscular (IM)

after a dose of VarIg require additional doses

route. As protection conferred by VarIg lasts

of VarIg.7

Table 3. Varicella vaccination algorithm for immunocompromised individuals2

References

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Last

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