Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Varicella (Chickenpox)
A benign, highly contagious viral disease characterized by a mild constitutional prodrome, followed by a pruritic rash consisting of macules, papules, vesicles, and crusted lesions. The lesions appear in crops and rapidly progress through various stages. More than 90% of unvaccinated people become infected with exposure to the virus.
I. Etiology
A. Varicella-zoster virus (VZV, primary infection)
B. Virus establishes latency in dorsal root of ganglia during primary infection. Reactivation of the virus results in herpes zoster.
II. Incidence
A. In the prevaccine era (prior to 1995) most children contracted the disease, and there were about 4 million cases annually. There is no national data available yet, but small studies demonstrate that the vaccine is effective in reducing the numbers and severity of cases.
B. In 2003, national vaccine coverage was 85% in children 19 to 35 months of age.
C. The majority of cases now are vaccine-modified varicella syndrome (VMS) or breakthrough chickenpox.
D. About 20% of vaccine recipients do not generate adequate antibodies with the first dose of vaccine.
E. Peak incidence: Most cases of breakthrough disease are found in school-aged children
F. A second dose of vaccine is now recommended for children 12 months through 12 years of age, to be administered at least 3 months apart.
G. Epidemics are seen in 3to 4-year cycles, mainly from January to May.
III. Incubation period: Can vary from 10 to 21 days; average period is 14 to 16 days.
IV. Communicability
A. One day prior to appearance of rash until up to 6 days after
B. Transmitted by droplet infection and by direct contact
C. Dried crusts are not infectious.
D. Chickenpox can be contracted from patients with herpes zoster.
V. Subjective data
A. History of exposure about 2 weeks prior to appearance of lesions or a history of chickenpox in the community
B. Lesions appear in crops.
C. Lesions in various stages of development at one time
D. Prodrome: Child may have low-grade temperature, upper respiratory infection, anorexia, headache, and malaise for 24 to 48 hours prior to appearance of lesions, or constitutional symptoms may appear simultaneously with exanthem. Prodrome may be recognized in retrospect only.
E. Lesions
1. A few spots on trunk or face initially; then a 3to 4-day period during which successive crops erupt on trunk, face, scalp, extremities, and mucous membranes
2. Lesions are seen in greatest concentration centrally and on proximal portions of the extremities. They tend to be more abundant on clothed areas and in areas of local inflammation (e.g., diaper area in a child with diaper rash).
3. Lesions may be found on the scalp, the mucous membranes, and the conjunctiva, and less commonly on the palms and soles.
VI. Objective data
A. Skin
1. Lesions appear as small red macules and rapidly progress to papules to clear vesicles on an erythematous base to umbilicated to cloudy vesicles to crusted lesions. (Drying occurs in the center of the vesicle, producing an umbilicated appearance prior to crusting.)
2. Lesions are seen in various stages in one area. (They progress through the stages in 6 to 8 hours, with crusts forming in 2 to 4 days.)
3. Total number of lesions is generally 200 to 400.
B. Mucous membranes
1. Vesicles rupture rapidly, so they are most commonly seen as shallow white ulcers 2 to 3 mm in diameter.
2. Lesions may be present on genital mucosa, palpebral conjunctiva, ear canals, and mouth.
C. Lymphadenopathy may be generalized.
D. Severity
1. Varies from mild cases with a few lesions and no systemic symptoms to severe toxicity with hundreds of lesions and elevated temperature (approximately 104F or 40C).
2. Systemic manifestations subside after the first 3 days as new crops of lesions cease to appear.
VII. Assessment
A. Diagnosis is usually made by history of contact and development of an exanthem that rapidly progresses through stages (macule to papule to vesicle to crusting) and is found in various stages in one area.
B. Breakthrough disease may have atypical rash: Maculopapular with few or no vesicles, and less than 50 lesions
C. Diagnosis may be confirmed by positive serologic test for varicella zoster immunoglobulin M (IGM) antibody, but is not routinely recommended.
D. Differential diagnosis
1. Smallpox: Severe prodrome; lesions are seen in the same stage, are more prominent peripherally, and progress more slowly (5 to
6 days) through stages. Note: Variola has virtually been eradicated throughout the world and is not a diagnostic consideration in the United States at this time absent a threat of bioterrorism.
2. Impetigo: Lesions do not appear in crops, differ in appearance and distribution, and do not involve mucous membranes of the mouth. There are no constitutional symptoms.
3. Insect bites: Lesions do not have vesicular appearance and are not present on mucous membranes. Constitutional symptoms are not present.
4. Scabies: Lesions do not have characteristic appearance, are not present on mucous membranes, but are characteristically present in the interdigital spaces.
5. Herpes zoster: Lesions are painful and usually confined to dermatome.
VIII. Plan
A. Symptomatic treatment to alleviate itching
1. Baking soda or Aveeno oatmeal baths
2. Calamine lotion as needed to skin
3. Antihistamines for pruritus
a. Benadryl: >10 kg, 5 mg/kg/d in 3 or 4 doses or
b. Atarax: >6 years, 50 to 100 mg/d in divided doses; <6 years, 50 mg/d in divided doses
B. Acetaminophen as indicated for temperature elevation, 10 to 15 mg/kg every 4 hours. Do not use aspirin.
C. Oral lesions: Warm saline or hydrogen peroxide mouth rinses
D. Genital lesions: Warm saline or hydrogen peroxide compresses
E. Infected lesions
1. One or two lesions: Wash lesions well and apply the following:
a. Neosporin ointment 4 times daily or
b. Bacitracin ointment 4 times daily
2. Many lesions (see Impetigo, p. 322)
F. Zovirax (acyclovir): Infectious disease experts do not recommend routine use of acyclovir in varicella in an otherwise healthy child. There are instances, however, when administration may be indicated: If given within 24 hours of onset of rash, it results in a milder illness. Some indications for uses are varicella in a secondary family member, child under 12 years of age, child with chronic disease, child with eczema. These indications should be defined and included in guidelines for individual health centers.
IX. Education
A. Transmitted by direct contact or inhalation from nose and throat secretions
B. Communicable for 24 to 48 hours prior to first lesion and until all lesions have crusted
C. Crusts do not contain active virus.
D. Second attacks are rare. Lifelong immunity is generally conferred.
E. In mild cases, crusting occurs within 5 days. In severe cases, crusting occurs in 10 days.
F. Keep child home from school until all vesicles are crusted; this generally takes 7 days.
G. Do not expose to pregnant women or infants.
H. Do not expose to children with eczema or malignancies or those on immunosuppressive therapy.
I. Call immediately if cough, dyspnea, or chest pain occurs within 2 to 5 days of onset of exanthem.
J. Call immediately if child develops high fever, stiff neck, headache, listlessness, or hyperirritability.
K. Keep nails trimmed. Put gloves on child if scratching is a problem.
L. Use careful hygiene to prevent superimposed infection; keep nails clean, bathe child daily, and change clothing daily.
M. Encourage fluids.
N. If genital lesions cause dysuria, encourage child to void in tub.
O. Crusts fall off in 5 to 20 days.
P. When scabs fall off, a shallow pink depression remains. This eventually becomes white, and repigmentation occurs later.
Q. Scarring is caused by premature removal of scabs or secondarily infected lesions.
R. Do not use aspirin.
S. Aveeno baths: Mix 1 cup Aveeno with 2 cups cold water. Shake until well mixed, then pour in tub of tepid water.
T. Children with subsequent infection in a household may have more serious disease than the index case.
U. Vaccination is 80%–85% effective in preventing severe disease. However, a significant number of children vaccinated may have breakthrough disease.
V. Immunized children with breakthrough varicella may potentially be infectious.
W.CDC recommendation as of June 2006: For a second dose of vaccine for children 12 months through 12 years, administered separately at least 3 months apart.
X. Giving the vaccine within 72 hours of exposure will probably prevent or significantly reduce the severity of the disease.
X. Follow-up
A. Generally not indicated in uncomplicated cases
B. Return to office if there is
1. Any question of secondary infection
2. Cough, dyspnea, or chest pain
3. Persistent vomiting, abdominal pain
4. Headache, fever, stiff neck, lethargy, or irritability
5. Fever over 104F (40C), or any fever after 1 week
6. Continued development of lesions after 1 week
XI. Complications
A. Most common: Secondary bacterial infection
B. Rare: Encephalitis, pneumonia, Guillain-Barré syndrome, hemorrhagic varicella, Reye’s syndrome
C. Disseminated varicella
XII. Consultation/referral
A. Suspected complications
B. Infants and children with debilitating conditions or on prednisone for prophylaxis if exposed to, or for antiviral therapy if infected by, varicella
1. Varicella-zoster immune globulin (VZIG) should be given within 96 hours of exposure to:
a. Newborns whose mothers had varicella less than 5 days prior to delivery or 48 hours after delivery
b. Premature infants
c. Children with cancer or collagen-vascular disease
d. Organ or bone marrow transplant recipients
e. Children being treated with steroids, cytotoxic chemotherapy, or radiation
f. Immunodeficient children
g. Children with severe burns or eczema
h. Pregnant women
2. Zovirax is given to the VZV susceptible “high-risk” child if he or she is beyond the fourth day postexposure when there would be no beneficial effect of passive immunization with VZIG. It is generally given IV to:
a. Children with an immunodeficiency syndrome
b. Children with cancer undergoing chemotherapy