Chickenpox and shingles

• Both chickenpox and shingles are notifiable diseases
• Prevented by immunisation — but immunisation must not be given to immunocompromised people
• Chickenpox can cause 
• Severe sickness in neonates
• Problems with new born babies if it occurs within the first 28 weeks of pregnancy (foetal varicella syndrome) — refer to obstetrician
• Mild sickness in children or severe sickness if the child already has a bad skin condition
• Severe sickness in adults and shingles later in life

Varicella immunity

Ask

• The patient and any high-risk contacts if they have ever had chickenpox or been vaccinated against it

Check

• Immunisation records
• Immune status for women who are pregnant or planning pregnancy

Do — for non-immune contacts exposed to chickenpox or shingles

• If over 12 months AND not immunised or had chickenpox — give varicella vaccine. Do not give if pregnant
• If contraindications — medical consult
• If person at high risk (see Red Flags) — medical consult
• Will need varicella zoster immunoglobulin (VZIG) within 10 days of exposure
• If more than 10 days since exposure — may need antiviral prophylaxis especially if in second half of pregnancy or if pregnant and underlying lung disease, weakened immune system or smoker

Chickenpox (varicella zoster)

Ask

• Is person at high risk of severe infection — see red flags
• Any contact with people at high risk in last 10 days 

Check

• Pregnancy test
• Head-to-toe exam — with attention to
• Rash — usually itchy, goes from spots to small blisters to dry scabs. The 3 stages can happen together — can take 5–7 days for blisters to dry out
• Child — any significant pre-existing skin disease, eg eczema

Do

• Medical consult for
• Anyone with severe illness
• People at high risk (see Red flags) — may need antiviral treatment
• Child with significant pre-existing skin disease
• Viral swab of a skin lesion — open a blister and rub swab on the base with the swab tip. Request 'varicella PCR'
• For itch
• Cool bath with bicarbonate of soda
• Crotamiton 10% cream — but only once a day
  
• Keep skin moisturised, eg sorbolene cream
• Can give loratadine oral — 1–2 years 2.5mg, 2–12 years 5mg, over 12 years 10mg, once a day
• Keep fingernails cut short — less damage from scratching
• Give paracetamol — adult 1g, child 15mg/kg/dose up to 1g — doses — up to 4 times a day (qid)
• Advise to avoid contact with people at high risk until rash completely scabbed over — avoid schools, childcare, work

 Antivirals

Adult

• If not pregnant — treat if 36 hours or less since rash started. If pregnant — treat if 72 hours or less since rash started. If more than 72 hours since rash started and lesions still developing antivirals may still help
• Give valaciclovir oral — 1g, 3 times a day (tds) for 7 days OR aciclovir oral — 800mg, 5 times a day for 7 days 

Child

• Only treat if significant pre-existing skin disease regardless of when rash started
• Give aciclovir oral — 20mg/kg/dose up to 800mg — doses — 5 times a day for 7 days
• If secondary infection of rash give antibiotics — see School sores

Shingles (herpes zoster)

Ask

• Any contact with people at high risk in last 10 days — they will need follow-up
• Is person at high risk of severe infection — medical consult
• Face — any tingling, pain or rash involving the eyes, eyebrow, forehead or nose
• Eyes — sore or any change to vision

Check

• Pregnancy test
• Head-to-toe exam — with attention to
• Rash — starts with burning pain then redness and blistering rash usually only on 1 area on 1 side of body
• Eye involvement — can cause serious complications or Herpes Zoster Ophthalmicus (blindness)
• Blisters on ear and Herpes Zoster Oticus (muscle weakness one side of face) 
• Eyes at risk if
• Rash on or around the eyes, eyebrow, forehead, nose or nose-tip 
• Eye swollen, red, eyelid shut, facial droop

Do

Medical consult 

• If under 50 years with shingles — may have weakened immune system
• About pain relief and antiviral treatment

• If more than 1 area OR both sides of body OR person at high risk — may need to send to hospital
• If eyes involved — Refer to ophthalmologist (eye doctor) for treatment of any corneal ulcer
  
• If ear involved or facial droop

Antiviral treatment

• Can lessen pain and other symptoms
• Best if started within 72 hours of rash appearing
• May still be useful after 72 hours for person who
• Has weakened immune system
• Is over 50 years
• Has severe pain
• Has rash around eyes, genitals, limb, neck
• Give valaciclovir oral — adult 1g, child 20mg/kg/dose up to 1g — doses — 3 times a day (tds) for 7 days OR aciclovir oral — adult 800mg, child 20mg/kg/dose up to 800mg — doses— 5 times a day for 7 days — not as good at reducing pain but better for children or if pregnant

Give pain relief

• Paracetamol — adult 1g, child 15mg/kg/dose up to 1g — doses — up to 4 times a day (qid)
• If pain severe — medical consult about neuropathic pain management
• Ice packs and/or protective dressings may help

If secondary infection of rash give antibiotics — see School sores

Follow-up

• Herpes Zoster vaccine can be given if
• 1 year after episode of shingles AND age 50-69 years
• Age 70 years and over AND if no contraindications to live-attenuated vaccines or to any product in the vaccine
• See Australian Immunisation Handbook