Don't scratch that itch
Until recently, it was almost as inevitable for children to get chickenpox as to lose their baby teeth. The Centers for Disease Control (CDC) estimates that more than 95% of Americans get chickenpox before adulthood. Chickenpox is a highly contagious viral infection, and once one of your children comes down with it, you can bet that any other children in the house will get it, too.
The worst part is the rash: itchy, red bumps that develop into blisters and then dry into scabs. Many children also have accompanying fever that you should never treat with aspirin, because aspirin treatment for viral infections has been linked to the development of Reye's syndrome, a type of encephalopathy (degeneration of brain tissue) which is sometimes fatal. While uncomfortable, chickenpox in children is usually not a serious disease. However, there are some potentially serious complications, particularly in infants or in children whose immune systems have been affected by cancer, HIV/AIDS, or medications that depress the immune system. Chickenpox in adults is more serious.
The good news: once you've had chickenpox, you're immune for life. The better news: there's a vaccine. The vaccine (Varivax) is approved for healthy children and adults who have not yet had chickenpox. The vaccine is highly effective in protecting against severe cases, and may be given as early as 12 months of age.
The characteristic symptoms of chickenpox generally begin 10 to 21 days (on average, 14 days) after exposure. In adults, fever and feeling run down (malaise) commonly begin one to two days before the rash, but this is unusual in children. Children may have symptoms of a mild cold or upper respiratory infection. Along with the rash, children often run a moderate fever of 101 F to 103 F and may complain of headache and loss of appetite.
The rash begins with splotchy red spots that can pop up just about anywhere on the body, even inside the mouth and in the genital area. Typically, they start on the trunk, then spread to the face and scalp. The spots change to blisters over a few days, and then they begin to break and crust over or scab. The itchiness is worst when the blisters break. Some children only develop a few blisters; others have hundreds of them. New spots usually stop appearing by the fifth day and most of the scabs disappear after three weeks. The worst part of the illness usually lasts four to seven days.
Children infected with chickenpox are contagious even before they break out; the contagious period begins two days before the rash shows up. If your child routinely comes into contact with someone who suddenly breaks out in chickenpox, it's probably too late to protect your child from infection. However, if your child has chronic health problems (for example, is on steroids for asthma, or has cancer or HIV infection), call your doctor so that treatment can be started to minimize complications.
Children are no longer contagious once the blisters are all scabbed over and no new spots are erupting. Most can return to school or daycare in about a week if all the blisters have dried into scabs, your child's temperature has returned to normal, and he or she feels better. The scabs don't all have to fall off first.
Any adult who contracts chickenpox should seek prompt medical attention. For adults, as well as children with impaired immune systems, chickenpox is a serious disease and may require hospitalization.
But in the vast majority of children, chickenpox is not serious. For the previously healthy child, complications are rare, and recovery usually occurs without any lasting problems. Most children get chickenpox by adolescence, survive the temporary ordeal, and remain immune for life.
How Common Is Chickenpox?
Chickenpox is extremely common among children; most have had the disease by age 10. The CDC estimates that there are 4 million cases in the United States every year. Chickenpox affects males and females equally, and most cases are reported in late winter and early spring. Chances of family-transmitted infection are high; approximately 90% of the people in a household who have not had chickenpox will get it if they are exposed to an infected family member. Individuals with in-home exposure to chickenpox tend to have worse cases because of increased viral load. Adults who were not exposed to chickenpox in childhood may also contract the virus.
Chickenpox is caused by the varicella zoster virus, a member of the herpes virus group. It is transmitted either through the air when an infected person coughs or sneezes or by direct contact with the blisters.
Drugs That Can Cause or Aggravate Chickenpox
Chickenpox is not caused by medication. However, certain drugs can suppress immunity, making it more likely for someone not previously exposed to the virus to become infected. Immunosuppressant drugs are also linked to complications that can arise from chickenpox. These medications include steroids and chemotherapy.
Chickenpox is a highly contagious virus. Risk factors for infection include the following:
- Exposure to infected individuals
- No prior history of chickenpox (because once infected, you almost always develop lifelong immunity and cannot be reinfected)
Risk factors are traits or behaviors that may make you statistically more likely than others in the general population to have a certain condition. They are not necessarily "causes" of the condition.
The most common symptoms of chickenpox:
- Blister-like rash of the skin and mucous membranes
- Low-grade fever
- Run-down feeling
- Decreased appetite
Conditions That May Be Mistaken for Chickenpox
Although chickenpox can resemble several other disorders, it's important to remember that chickenpox is far more common than any of these, especially among children. Chickenpox symptoms may be confused with those of the following conditions:
- Cold sores and fever blisters (herpes simplex)
- Shingles (herpes zoster)
- Other viral infections (echovirus, coxsackievirus)
- Hives (papular urticaria)
- Rickettsial pox (mild infectious disease accompanied by fever, swollen glands, and a blistery rash)
- Chronic skin diseases
- Drug rash
How Is Chickenpox Diagnosed?
A history of recent exposure and the rash's characteristic appearance usually make the diagnosis clear, and your doctor can generally diagnose the condition over the telephone. Because chickenpox is usually uncomplicated, it generally does not require a visit to the doctor. Be sure to call your doctor rather than automatically making an appointment to be seen. Management can be discussed on the telephone, and this avoids unnecessarily exposing other people to the virus.
Goals of Treatment
Chickenpox is a temporary condition. Once the infection runs its course, the illness is over, and the only real cure is to simply wait it out. For most cases of chickenpox, the goal of treatment is to control the symptoms: soothe itching, prevent scratching, and reduce the risk of bacterial infection. Treatment can help reduce the discomfort, but can't take it away completely. Antibiotics are used only to treat children who develop bacterial infections. The ante goes up for at-risk individuals; they often need antiviral therapy and may require hospitalization to help prevent or manage dangerous complications.
Most cases of chickenpox are mild and only require treatment of such symptoms as itchy skin and fever. Don't use aspirin if you think your child may have chickenpox. Aspirin, in combination with chickenpox, is associated with Reye's syndrome, an illness of the liver and brain that is rare but potentially fatal. Recent reports have also raised concerns about the development of a severe skin condition, necrotizing fasciitis, in patients who have used ibuprofen during a chickenpox infection.
There are a number of things you can do to help lessen your child's discomfort. Refer to the section on Self Care and Prevention for suggestions.
Prescription drug therapy for young children only comes into play for treating bacterial infections or for individuals with immune systems that have been weakened by other diseases or medications. Adolescents and adults, particularly pregnant women, who have no history of chickenpox are also candidates for prescription treatments.
A variety of drugs can help with symptomatic relief for an infected individual, and certain drugs may help reduce the length and severity of the disease.
Drugs most commonly prescribed
- For relief of fever, acetaminophen (Tylenol, Tempra, Panadol) is recommended. Do not give aspirin to given to children under age 18 and avoid ibuprofen, as both of these may cause serious complications in chickenpox.
- For relief of itching, topical anesthetics and antihistamines provide immediate, but temporary, relief. Creams and lotions containing colloidal oatmeal or camphor, menthol, and phenol (such as calamine lotion) can help soothe irritated skin. Antihistamine lotions (such as Benadryl) can also help ease itching. Soaking in a lukewarm bath containing colloidal oatmeal (Aveeno) is often very soothing, and relieves itching. When drying off after a bath, pat the skin dry with a towel and avoid rubbing, which tends to aggravate itching.
- To treat bacterial infections, use antibiotics as prescribed by your doctor.
- To reduce severity, acyclovir (Zovirax) is an antiviral drug that attacks the virus. If treatment is started within 24 hours after the rash appears, the drug can shorten rash duration by about a day and reduce the number of blisters. The drug is usually only prescribed for premature babies, adolescents, adults, and high-risk patients.
- To protect high-risk children, particularly newborns: varicella zoster immune globulin is made up of antibodies that protect against infection after exposure to chickenpox and is most often used for newborn babies whose mothers came down with chicken pox close to delivery, premature babies who have been exposed, children with leukemia or lymphoma, children with AIDS or other immune deficiencies, and children receiving drugs that suppress the immune system. Susceptible pregnant women should also receive varicella Zoster immune globulin (VZIG) to avoid potentially severe birth defects in the fetus.
Other antiviral drugs
Appropriate Healthcare Setting
Chickenpox patients are usually cared for at home unless complications require hospitalization.
Healthcare Professionals Who May Be Involved in Treatment
For most cases of chickenpox, the advice of a primary care practitioner should be sufficient. If complications arise, the advice of other types of doctors may be required, including infectious disease specialists.
Activity & Diet Recommendations
While bed rest is not necessary, you should restrict your child's activity and watch carefully for signs of scratching. If your child goes outside, have him or her play in the shade and not in direct sunlight. Sunlight may irritate the blisters, worsen scarring, and make your child feel tired faster. Keep an infected child away from others until all the blisters have scabbed over.
No special diet is necessary, but encourage your child to drink plenty of fluids, especially if fever is present. For children with blisters in their mouths, eating is difficult, so you've got a better chance of getting them to eat if you serve soft, bland foods. Avoid acidic juices (such as citrus), and salty or spicy foods.
Chickenpox is ordinarily a mild disease. The most common complication in healthy children is bacterial infection caused by scratching blisters. Monitor blisters for signs of infection:
- Blisters oozing thick, discolored fluid
- Blisters that are swollen and quite red
If you suspect bacterial infection, contact your doctor. Untreated, bacterial infections can be dangerous. Scratching also increases the likelihood of scarring.
Although the incidence is rare, chickenpox can cause central nervous system complications. The most serious is encephalitis, which can be life-threatening. Encephalitis (occurring in less than one out of 1,000 cases) usually occurs late in the disease or within one to two weeks afterward. If your child shows any of the warning symptoms of encephalitis, call your doctor immediately:
- Fever of more than 103 F
- Difficulty awakening the child or confusion in the child
- Sensitivity to light
- Rapid heartbeat
- Loss of muscle coordination
- Severe headache
- Stiff neck
- Difficulty breathing or severe cough
If chickenpox occurs in the eye, contact your doctor immediately. In this case, treatment should be started to avoid scarring of the cornea.
Another complication, occurring primarily in adults, is varicella pneumonitis (inflammation of the lungs), a condition that can be life-threatening to women in the second or third trimester of pregnancy or to people with weakened immune systems.
Once the disease runs its course, the virus stays in the body in a dormant state, taking up residence in the nerve cells. Later in life, the virus may be reactivated, causing the painful ailment called shingles (herpes zoster).
Quality of Life
Children with chickenpox are miserable. Their skin itches like crazy, they look funny, and they're running a fever. Along with that, restricted activity can be frustrating for a child. The best you can do is soothe their discomfort as much as possible and allow quiet activities in a cool environment.
Considerations for Women
If a pregnant woman comes down with chickenpox within five days before or up to 48 hours after delivery, her baby can be born with complications from the infection, but serious cases in newborns are rare. There is also a slight chance of birth defects if she is infected early in pregnancy. Pregnant women with chickenpox have a greater chance of experiencing complications like pneumonia.
Considerations for Older People
Older people may have impaired immune systems, making them more susceptible to severe chickenpox infection. They may also experience complications such as pneumonia. For those previously infected, the virus may become reactivated, causing shingles, which are very painful and bothersome.
Considerations for Children & Adolescents
Chickenpox can be life-threatening for children who have leukemia or lymphoma. The disease is also more likely to cause complications in children who have weakened immune systems or are taking drugs that suppress the immune system (including steroids such as prednisone prescribed for asthma).
A children's multivitamin can provide extra vitamins A and C, plus other nutrients that help the body recover from viral infections.
- Echinacea: helps boost the immune system against infections, including the virus that causes chickenpox.  Discuss proper dosage with your physician.
- Lemon balm: contains antiviral compounds. Make a diluted tea using this pleasant-tasting herb.  Serve it warm or chilled.
- Garlic: also has antiviral action.  Add a fresh, chopped clove to tomato or carrot juice -- if the child will drink them.
The American Academy of Pediatrics recommends the chickenpox vaccination (Varivax) for all healthy children who have not yet contracted chickenpox. Ideally, babies should be vaccinated between the ages of 12 and 18 months. Children aged 19 months to 13 years can also be vaccinated and receive one dose, just like babies. Adolescents over age 13 require two doses of the vaccine, given 4 to 8 weeks apart.
The Advisory Committee on Immunization Practices recommends the vaccine for healthy adults who did not have chickenpox during childhood. If you're not sure, a blood test can show if you're immune or not, but the blood test is optional.
People with any of the following conditions should not receive the chickenpox vaccine:
- Moderate to severe illness
- Any type of immune system disorder
- Also, anyone taking aspirin (and other salicylates) or high doses of corticosteroids
Help avoid spreading the infection to others by keeping your infected child at home until all the blisters dry up.
- A warm bath can help soothe the itching. For extra itch-relief, add some finely ground oatmeal to the bathwater. (Use a coffee grinder to crush it.) Or buy Aveeno, which also contains finely ground oatmeal. Pat your child's skin dry; don't rub with the towel.
- Use wet compresses and anti-itch lotions and creams on your child's skin to help soothe itching and prevent scratching. Bathe the skin and hands often with antibacterial soap and water.
- For sores in the mouth, a warm water rinse or saltwater gargle may be helpful.
- Clip your young child's fingernails to prevent secondary bacterial infections from developing in pox that are repeatedly scratched open. Place light mittens or socks on a baby's hands. These measures will also help reduce scarring.
- Give the child plenty of fluids. Orange juice is high in vitamin C, which stimulates the immune system, but is too acidic for children with blisters inside their mouths. If your child will drink them, carrot and tomato juice are rich in vitamin A, which also stimulates the immune system.
Websites & Organizations
Centers for Disease Control and Prevention
Office of Communication
Division of Media Relations
Atlanta, GA 30333
4450 Gulf Blvd.
St. Petersberg, FL 33706
Healthy Lives by Glaxo Wellcome
University of Michigan Health System
1500 E. Medical Center Dr.
Ann Arbor, MI 48109
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