Highlights & Basics
- Acute varicella-zoster (chickenpox) normally presents in childhood and is usually self-limiting.
- Adults, pregnant women, immunosuppressed patients, and neonates are at high risk of complications from varicella, including pneumonia, neurologic sequelae, hepatitis, secondary bacterial infection, and death.
- Patients in high-risk categories should receive treatment with antiviral therapy.
- While most countries in Europe do not currently vaccinate children against varicella, vaccination strategies differ widely within the EU, with a few countries incorporating the vaccine into routine childhood vaccination, and others recommending it to susceptible adolescents and adults. In the US, varicella vaccine is currently recommended for immunocompetent children and susceptible adults (e.g., healthcare workers, those occupationally exposed to children, people admitted to hospital, military recruits).
- Patients with high risk for severe disease who have had significant exposure to the virus and in whom the vaccine is contraindicated (i.e., neonates, pregnant women, immunocompromised people, and those receiving high-dose systemic immunosuppressive therapy) may receive immunoprophylaxis or post-exposure antiviral prophylaxis.
Quick Reference
History & Exam
Key Factors
history of exposure
fever
vesicular rash
vesicles on mucous membranes
Other Factors
pruritus
headache
fatigue/malaise
sore throat
tachycardia
Diagnostics Tests
1st Tests to Order
clinical diagnosis
Other Tests to consider
polymerase chain reaction
viral culture
direct fluorescent antibody testing (DFA)
Tzanck smear
latex agglutination (LA)
enzyme-linked immunosorbent assay (ELISA)
complement fixation
ultrasound (pregnant women)
Treatment Options
acute
otherwise healthy children at low risk of severe disease
supportive care
increased risk of moderate to severe disease
oral antiviral therapy
supportive care
Definition
Classifications
Clinical definitions
Vignette
Common Vignette 1
Common Vignette 2
Epidemiology
Etiology
Pathophysiology
Images
Diagnostic Approach
History
Physical exam
Laboratory testing
Risk Factors
History & Exam
Tests
Differential Diagnosis
Differentiating Signs/Symptoms
- Has more prominent fever and more noticeable constitutional symptoms than varicella.
- Greatest number of lesions are on face and extremities (centrifugal distribution), and lesions present at the same stage in development.[63]
- Review history of recent smallpox vaccine or other possible exposures. Since natural transmission has been eradicated, new cases would more likely occur through laboratory exposure or as an act of bioterrorism. If smallpox is considered a possible diagnosis, immediate consultation should be sought and the patient should be placed in immediate isolation (standard, contact, and airborne). The patient should not be permitted to leave isolation until smallpox has been excluded as a diagnostic possibility. Consultation with local health departments is also highly recommended.
Differentiating Tests
- Polymerase chain reaction (PCR) test for smallpox will be positive.
- PCR test for varicella-zoster virus will be negative.
Herpes zoster infection (shingles)
Differentiating Signs/Symptoms
- Commonly presents in adulthood, particularly after the age of 60.
- Rash typically follows a dermatomal distribution of a cranial nerve or dorsal root ganglion.
Differentiating Tests
- Varicella zoster is a clinical diagnosis based on examination of the rash and history of exposure. Differentiating tests are not usually indicated.
Herpes simplex virus (HSV) infection
Differentiating Signs/Symptoms
- Usually affects the mucous membranes of the oral or genital region, but skin infections, usually localized, can also be observed.
Differentiating Tests
- Laboratory tests positive for HSV 1 or HSV 2.
Stevens-Johnson syndrome/toxic epidermal necrolysis
Differentiating Signs/Symptoms
- Lesions can look like targets initially but eventually become flaccid blisters.
- A large proportion of patients also present with diffuse erythema (erythroderma), and a significant number of patients complain of pain in involved areas.
- Blisters can become confluent and are associated with a positive Nikolsky sign (epidermal layer easily sloughs off when pressure is applied to the affected area).[64]
- Patients often have a history of exposure to an agent (medication) associated with the condition.
Differentiating Tests
- Skin biopsy can be helpful; however, most often the diagnosis is made on clinical presentation.[65]
Mpox (Monkeypox)
Differentiating Signs/Symptoms
- Recent travel to Africa or recent close contact (including sexual contact) with someone who has Mpox is likely to be present.[66]
- Lesions present in similar stages (monomorphic) but are found on the palms and the soles of the feet.
- Also associated with lymphadenopathy, which is rarely found in varicella.[67]
Differentiating Tests
- PCR test for monkeypox will be positive.
Screening
Screening for varicella-zoster virus (VZV) immunity
- Documentation of age-appropriate vaccination: (a) 1 dose for pre-school children at least 12 months of age; (b) 2 doses for school-aged children, adolescents, and adults
- Laboratory evidence of immunity or laboratory confirmation of disease
- Born in the US before 1980 (should not be considered evidence of immunity for healthcare personnel, pregnant women, and immunocompromised persons)
- A healthcare provider's diagnosis or verification of history of varicella disease
- A healthcare provider's diagnosis or verification of herpes zoster.
Treatment Approach
Otherwise healthy children at low risk of severe disease
Increased risk of moderate to severe disease
- 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.
High risk of severe disease
- 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.
Patients with severe disease who develop serious complications
Treatment Options
otherwise healthy children at low risk of severe disease
supportive care
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
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
- acetaminophen
Comments
- 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.[70] 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.[71] [72] Due to the potential increase in skin and soft tissue infections, NSAIDs should be avoided.
- 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.[74] Risks may outweigh benefits in young children.
increased risk of moderate to severe disease
oral antiviral therapy
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
- acyclovir
Comments
- 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]
supportive care
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
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
- acetaminophen
Comments
- 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.[70] 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.[71] [72] Due to the potential increase in skin and soft tissue infections, NSAIDs should be avoided.
- 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.[74] Risks may outweigh benefits in young children.
high risk of severe disease
intravenous antiviral therapy
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
- acyclovir
Comments
- 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.
- Alternate dosing may be required for preterm neonates.
supportive care
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
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
- acetaminophen
Comments
- 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.[70] 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.[71] [72] Due to the potential increase in skin and soft tissue infections, NSAIDs should be avoided.
- 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.[74] Risks may outweigh benefits in young children.
counseling and referral of pregnant women
Comments
- 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
intravenous antiviral therapy
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
- acyclovir
Comments
- 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] [84] [85] [86] [87] [88] Patients may need to be treated for longer than 7-10 days with acyclovir if they have severe disease or neurologic complications.
supportive care
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
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
- acetaminophen
Comments
- 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.[70] 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.[71] [72] Due to the potential increase in skin and soft tissue infections, NSAIDs should be avoided.
- 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.[74] Risks may outweigh benefits in young children.
Prevention
Primary Prevention
Secondary Prevention
- US guidelines recommend administering varicella vaccine to healthy people without evidence of immunity who are ages 12 months or older (including adults), as soon as possible after exposure, preferably within 3 days and up to 5 days.[36] Effectiveness has been demonstrated to be more than 90% when given within 3 days of exposure, and about 70% at 5 days.[16]
- US guidelines recommend use of varicella-zoster immunoglobulin (VariZIG) for high-risk patients who do not have evidence of varicella immunity and in whom varicella vaccination is contraindicated.[36] [44][90][91][92] [93] Specific groups where VariZIG is recommended include:[36][92]
- Immunocompromised patients
- Neonates whose mothers have signs and symptoms of varicella around the time of delivery (i.e., 5 days before to 2 days after)
- Premature infants born at ≥28 weeks of gestation who are exposed during the neonatal period and whose mothers have no evidence of immunity to varicella
- Premature infants born at <28 weeks of gestation or who weigh ≤1 kg at birth and were exposed during the neonatal period, regardless of their mothers' evidence of immunity to varicella
- Pregnant women without evidence of immunity.
- US guidelines note that pre-emptive antiviral therapy may be used in select patients if VariZIG and IVIG are not available.[36]
Follow-Up Overview
Prognosis
Monitoring
Complications
Citations
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Royal College of Obstetricians and Gynaecologists. Chickenpox in pregnancy (Green-top guideline no. 13). January 2015 [internet publication].[Full Text]
American Academy of Pediatrics. Varicella-zoster virus infections. In: Kimberlin DW, ed. Red book 2021-2024: report of the Committee on Infectious Diseases. 32nd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2021; 831-43.[Full Text]
Pergam SA, Limaye AP, AST Infectious Diseases Community of Practice. Varicella zoster virus in solid organ transplantation: guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant. 2019 Sep;33(9):e13622.[Abstract]
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Centers for Disease Control and Prevention. Updated recommendations for use of VariZIG - United States, 2013. MMWR Morb Mortal Wkly Rep. 2013 Jul 19;62(28):574-6.[Abstract][Full Text]
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Key Articles
Other Online Resources
Referenced Articles
Guidelines
Treatment
Summary
Indications and guidance for the use of human varicella zoster immune globulin and antivirals as postexposure prophylaxis.Published by
The American College of Obstetricians and Gynecologists
Published
2016 (reaffirmed 2024)
Summary
Recommendations on the use of licensed vaccines in adults, including varicella and herpes zoster vaccines.Published by
Centers for Disease Control and Prevention
Published
2023
Summary
Recommendations on the use of licensed vaccines in children, including a routine 2-dose varicella immunization.Published by
Centers for Disease Control and Prevention
Published
2023
Summary
Includes recommendations for the management of varicella-zoster virus.Published by
Centers for Disease Control and Prevention; National Institutes for Health; HIV Medicine Association of the Infectious Diseases Society of America
Published
2022
Summary
Recommendations on diagnosis, prevention, and management of varicella zoster virus in the pre- and post-transplant period.Published by
American Society of Transplantation
Published
2019
Summary
Includes recommendations for the management of varicella-zoster virus.Published by
Centers for Disease Control and Prevention; National Institutes for Health; HIV Medicine Association of the Infectious Diseases Society of America
Published
2019
Summary
An update to the CDC's Prevention of varicella guideline (2007) regarding the updated recommendations for the use of VariZIG in the US.Published by
Centers for Disease Control and Prevention
Published
2013
Summary
An update to the CDC's Prevention of varicella guideline (2007) regarding the FDA approval of an extended period for administering VariZIG for postexposure prophylaxis of varicella.Published by
Centers for Disease Control and Prevention
Published
2012
Summary
This report provides the recommendation of the Advisory Committee on Immunization Practices for prevention of varicella.Published by
Centers for Disease Control and Prevention
Published
2007
Summary
Provides recommendations on the use of varicella and herpes zoster vaccines. Also includes information on the safety, immunogenicity, efficacy and effectiveness of these vaccines, as well as cost-effectiveness considerations.Published by
World Health Organization
Published
2014
Summary
Guidance for EU member states on decision making with regard to varicella zoster vaccination.Published by
European Centre for Disease Prevention and Control
Published
2015
Summary
Information about varicella (chickenpox) disease, vaccines and recommendations for vaccination from the Australian Immunisation Handbook.Published by
Australian Government Department of Health and Aged Care
Published
2023
Summary
Assessment of the evidence regarding the maternal and fetal risks of varicella zoster virus infection in pregnancy and the role of vaccination in susceptible women of reproductive age.Published by
Royal College of Obstetricians and Gynaecologists (UK)
Published
2015