The common childhood illnesses series – Chickenpox
With the traditional Chickenpox Season just around the corner, Sonia Hall of the Practice Nurse Association discusses the varicella-zoster virus, who is most at risk and what complications can occur.
Chickenpox (Varicella) is a common communicable childhood disease. It is widely known that it is caused by the varicella zoster virus, something a lot of us will have dealt with at work and at home as well.
The varicella virus is typically transmitted by personal contact or droplet spread with an incubation period of one to three weeks. Varicella is a highly contagious virus and has a high secondary infection rate - as high as 90% within households1. The infection is most common in children below the age of ten, for whom the disease is usually mild.
Clinical Features
The illness usually starts with one or two days of fever and malaise, although this may be absent in very young children. The characteristic skin lesion typically occurs in three stages: first macule, then vesicle and finally a granular scab. Vesicles first form on the face and scalp, spreading to the rest of the body. After three or four days the vesicles dry with a granular scab. The number of vesicles present can vary from so few that they are not noticed to so many that they cover most of the body. Patients may be infectious from one to two days before the rash appears until all vesicles are dry. This may be prolonged in immunosuppressed patients2.
Varicella is typically a seasonal disease and tends to peak between March and May although it has been noted that in recent years the seasonality has become less notable. Given the notoriety of the disease in childhood it is no surprise that 90% of UK raised adults may be immune3.
Diagnosis
Diagnosis is usually straightforward due to the combination of characteristic vesicles and mild fever which are likely to be present in the patient.
Management
Treatment typically consists of a focus on easing the symptoms. Patients should be advised to avoid scratching the blisters because of the risk of infection. Young children might benefit from wearing gloves or having their nails cut short to prevent them from scratching. Antipyretic agents such as Paracetamol and Ibuprofen may be used to treat a fever with dosage instruction given carefully to the patient or parent4. Heat and sweat can make the itching worse so under these conditions, the patient may prefer a cool environment. From personal experience I found the paddling pool in the back garden to be an excellent distraction from the itching and a good way of keeping my daughter cool. In some cases the itching may be so severe that a child’s sleep is greatly disturbed. In this situation, some healthcare professionals may decide to prescribe antihistamines with sedative effects.
As the varicella virus is so easily spread it is generally recommended that patients stay at home until all lesions have scabbed over. It has been known for some mothers to hold chicken pox parties in order for groups of children to get the disease at a time that doesn’t conflict with school exams or family holidays however this is not typically the recommended way of managing a child’s health.
Possible complications which might arise from chicken pox are:
• Secondary Infection to blisters –often caused by scratching
• Occasional scars at the site of the blisters
• Conjunctivitis
• Pneumonia
• Meningitis
• Encephalitis
• Myocarditis
• Reyes syndrome5
If the disease is contracted during adulthood (especially if the patient smokes or is pregnant) there may be greater risk to the patient fulminating varicella pneumonia. The riskiest time for a mother to develop the disease is generally accepted to be from late in the second trimester to early in the third. Neonates and immunosuppressed individuals with the disease may be at a greater risk of disseminated or haemorrhagic varicella6. For patients who are classified as being high risk, such as those who are immunosuppressed, some healthcare professionals may prescribe an oral antiviral drug, such as acyclovir, and/or immunoglobulin in the early treatment process to reduce both the number of vesicles as well as the length of time they will remain7.
Risks to the foetus and neonate from maternal chickenpox is widely generally accepted to be related to the time of infection in the mother:
1. In the first 20 weeks of pregnancy foetal varicella may cause limb hypoplasia, microcephaly, cataracts, growth retardation and skin scarring
2. In the second and third trimesters of pregnancy the risk is lower than in the first however maternal infection with the herpes zoster virus may occasionally cause foetal damage comprising of chorioretinal damage, microcephaly and skin scarring.
3. Infection a week before to a week after delivery can cause severe and even fatal disease to the neonate8
Prevention
The Varicella vaccination is may be recommended for children who will often find themselves in close contact with immunocompromised patients (for example if a family member is receiving chemotherapy treatment). The vaccination may also be recommended for non immune healthcare workers9.
Shingles
Shingles is widely known to be caused by the reactivation of the dormant varicella virus. The virus may be transmitted to susceptible individuals to cause chickenpox but there is no evidence that Shingles can be acquired from a patient with chickenpox. Although typically more common in the elderly, Shingles can occur in children and is especially common in immunosuppressed individuals of any age.
Figure 1: Symptoms of shingles
Vesicles typically appear in the dermatome, representing cranial or spinal ganglia where the virus has been lying dormant. The affected area may be intensely painful with associated parasthesia. The incidence of shingles can increases with age and around one in five adults will experience an attack in their lifetime10.
References
1. http://www.hpa.org.uk/HPA/Topics/InfectiousDiseases/InfectionsAZ/1191942152833/Retrieved 07JAN2010
2. http://www.nhs.uk/conditions/Chickenpox/Pages/Introduction.aspx Retrieved 31/12/09
3. http://www.nhs.uk/conditions/Chickenpox/Pages/Introduction.aspx Retrieved 07JAN2010
4. http://www.nhs.uk/Conditions/Chickenpox/Pages/Treatment.aspx Retrieved 07Jan2010
5. http://www.nlm.nih.gov/medlineplus/ency/article/001592.htm Retrieved 07Jan2010
6. www.noc.nhs.uk/oxparc/professionals/.../chicken-pox-measles.pdfRetrieved 07Jan2010
7. http://www.hpa.org.uk/HPA/Topics/InfectiousDiseases/InfectionsAZ/1191942152833/ . Retrieved 05Jan2010
8. http://www.cks.nhs.uk/pre_conception_advice_and_management/management/detailed_answers/what_to_check_in_all_women/advice_on_immunizations Retrieved 31DEC2009
9. http://www.immunisation.nhs.uk/files/Chickenpox_Q_and_A.pdf Retrieved 05JAN2010
10. http://www.nhs.uk/conditions/Shingles/Pages/Introduction.aspx Retrieved 04JAN2010
This article is the sole work of the author and does not necessarily reflect the views of Johnson & Johnson Medical Limited or any of its affiliated business or companies, nor does the publication of this article on the CareMail website comprise an endorsement of its contents, for which Johnson & Johnson Medical Limited and its affiliated businesses and companies accept no responsibility. In particular no such Johnson & Johnson entity shall be liable for any damages or injury resulting from any reliance placed on any information provided in this article or for any possible inaccurate or misleading data or statements contained therein.
Published in partnership with the Royal College of Nursing's Practice Nurse Association
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