Varicella, or chickenpox, is a result of infection with varicella-zoster virus, a herpes virus. In normal children it is characterized by a pruritic generalized vesicular exanthem with mild systemic manifestations. Cases generally occur in late winter and early spring. It is highly contagious in the prodromal and vesicular stage. Varicella most frequently occurs in children less than 10 years old, but it may occur at any age.

The exanthem starts on the trunk or scalp and first appears as faint, red macules. Within 24 h, the rash acquires the typical vesicular appearance of varicella. The rash consists of teardrop vesicles on an erythematous base, which then dry and crust over (see Fig 131-3). Successive fresh crops may appear for a few days. The extent of the rash may be minimal but usually will spread centrifugally and become widespread. Palms and soles are spared. Vesicles may occur on mucous membranes and proceed to rupture and form shallow ulcers. Low-grade fever, malaise, and headache are frequently present but are usually mild. The diagnosis of varicella is usually made clinically on the basis of its distinctive rash. A Tzanck smear of the vesicle contents will demonstrate varicella giant cells with inclusion bodies.

FIG. 131-3. Varicella. [From Burnett JW, Crutcher WA: Viral and rickettsial infections, in Moschella SL, Hurley HJ (eds): Dermatology. Philadelphia, Saunders, 1985, vol 1, chap 12, pp 673-738, with permission.]

Complications of varicella can occur, including encephalitis, pneumonia, nephritis, and infection of the vesicles with staphylococci or streptococci. Neonates born to mothers with perinatal varicella infection may develop serious illness.

Uncomplicated varicella requires no specific therapy. Acetaminophen may be used as needed, but aspirin should be avoided as it may predispose to the development of Reye syndrome. Oral antihistamines may be useful to reduce itching. Most importantly, lesions should be cleansed regularly to prevent secondary infection. In the absence of central nervous system complications, the prognosis is excellent. Routine use of acyclovir for uncomplicated varicella infections in children is not recommended. While limited data are available on pediatric use, no unusual toxicity or problems have been noted.

Immunocompromised patients with varicella require aggressive treatment with antiviral drugs such as acyclovir. The dose of acyclovir is 80 mg/kg per day in four divided doses up to 800 mg/dose. Administration of varicella zoster immune globulin (VZIG) should be considered for immunocompromised patients exposed to individuals with varicella.

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