It started with a single spot on my son's chin. I saw it at bedtime, and he couldn't recall getting scratched or bumped during another active PreK day. He'd been somewhat grouchy since he'd gotten home; but wasn't feverish, and certainly didn't look sick. The next morning, however, that odd little spot was still there, but now it was in its full glory. The true "dewdrop on the rose petal" that I'd read about in residency, been tested upon, and seen on many a child (and adult) in my medical office was staring back at me accompanied by hundreds of other companion blisters. Unlike the most common head first beginnings, we had chickenpox on his chest, chickenpox on his stomach, and chickenpox on his back.

By the following morning, my 5 year old could have been the poster child in pediatrics dermatology textbook. He was running a low-grade fever and fragile blisters covered his scalp, face and neck, extended down onto his torso, arms and legs. He was scratching, grouchy, and just plain miserable.

Needless to say, being the child of a dermatologist, he wasn't going to cooperate with my well-planned tactical approach to ensuring his comfort. For some time, I'd been expecting this typical childhood eruption, and knew once it began to spread throughout his school a few weeks previously that chickenpox was about to put in an appearance at our house.

So, I'd stocked up on the necessities. However, it's one thing to tell frustrated parents how to care for their ill child, and quite another to deal with your own. My poor child was so upset about the rash itself, he wouldn't let us touch him or the spots in our efforts to help him feel better. I wasn't about to be the dermatologist who's child was scarred from chickenpox, so it took lots of ingenuity, and a few power struggles, to get him treated.

Chickenpox 101

First, some education on what chickenpox is all about. Chickenpox is a rash caused by the virus Varicella Zoster. This viral infection is highly contagious and spreads through the small air-borne droplets that are coughed and sneezed by infected individuals. Typically seen in late fall and early spring, chickenpox is considered a disease of childhood.

The incubation time, in other words, the time from exposure until appearance of the illness, ranges from 10-21 days. Usually a 24 hour flu-like period precedes the rash. This can include a low-grade fever, malaise, or muscle aches.

The blisters start on the scalp and face then move downwards. The severity of the rash and the fever go hand in hand. (However, whatever the cause, a childhood temperature over 101 degrees, Fahrenheit, is reason to notify the pediatrician.) Chickenpox blisters continue to form in new crops for 3 days. This is one of the few Dermatologic conditions in which the rash exhibits all states of development: newly formed fragile vesicles, just popped lesions, and crusted areas. (This is also a distinguishing characteristic from smallpox which all look the same).

Chickenpox is contagious from 24 hours before the blisters appear (so you have no idea you're spreading the virus) , until the last lesion is crusted. It can take up to 10 days from the initial onset for everything to crust over. At that point, there is no risk of being infectious. Chickenpox is primarily spread through the air-borne route mentioned above, however, the blisters and fluid (which contains viral particles) can spread the infection by skin-to-skin contact often through minute breaks in the skin. Wash your hands well after caring for your child.

Chickenpox should be taken seriously. One hundred patients die each year from chickenpox due to a variety of complications including Beta Strep bacterial infections (from scratching) as well as varicella pneumonia (a major concern for adults). Hawaiian Congresswoman, Patsy Mink recently succumbed to a viral pneumonia associated with chickenpox. High fevers, extreme lethargy, vomiting, complaints of severe headaches, shortness of breath and red streaks extending from an area of the rash are cause to seek medical attention quickly.

Truly, chickenpox is one of those childhood diseases best gotten as a child. Adults with chickenpox have a much higher risk of developing a much more severe case of the infection as well as serious complications including pneumonia, encephalitis and systemic spread. It's not uncommon for me to see a few adult chickenpox cases each year and these patients are typically quite ill.

Pregnancy Matters

Women who develop chickenpox while pregnant, the baby is at higher risk for developing the infection in the womb, which can be quite serious and even life threatening. Most women when contemplating pregnancy have a simple blood test to see if their titer is high, meaning they had had chickenpox in the past. For those who have not, and are planning a future pregnancy, the vaccine is recommended.

For women who have already had chickenpox and become exposed, their maternal antibodies should protect the unborn fetus. Once the baby is born, maternal antibodies only tend to provide protection for 3 months rather than the 6 months normally seen with other infections.

Treatment

What's important to have on hand to help treat the rash and soothe the skin?

• DO NOT USE ASPIRIN! ASPIRIN CAN CAUSE A POTENTIALLY FATAL CONDITION CALLED REYE'S SYNDROME.
• Baking Soda baths or AHAVA Natural Bath Salts is very soothing. If your child is amenable, you can bathe them as often as you like during the day.
• Next, Domeboro Astringent Solution damp compresses can quickly dry out the lesions. In addition to the drying affect, it acts as an astringent, so you get an antibacterial effect. I recommend using a damp washrag as the compress for newly blistered areas for 15 -20 minutes, twice a day. Make sure you keep it out of the eyes.
• I like applying Polysporin First Aid Antibiotic Ointment to the worst looking lesions to prevent secondary bacterial infection. Invasive Beta Strep is a major cause of hospitalizations every year for chickenpox patients. The major source is scratching open blisters.
• Tylenol or Ibuprofen helps control fever and other symptoms of illness.
• I was never much of a pink Calamine lotion fan. I don't like being covered in pink nor did I find it effective. However, there is now a colorless variety, which contains pramoxine, an effective topical anesthetic. I find topicals containing this ingredient such as Prax Lotion or PrameGel help provide temporary local relief from itching. They may be applied to children ages 2 and up. Check with your pediatrician for use on younger children.
• Oral nonprescription can be very helpful at controlling the itching.
• DON'T SCRATCH. The more scratching done, the more likely scar formation can occur. Luckily, my son is frightened of the lesions, so he won't scratch them, but the nonstop shrugging of the clothing and the rubbing will likely go on for another week.

Oral Zovirax

The oral use of Zovirax (generic name acyclovir) and similar medications is not normally recommended for run of the mill cases of chickenpox in otherwise healthy children. However, high-risk categories have been established where such treatment is recommended to reduce the possibility of a more complicated case. These include anyone 13 and over (nonpregnant); anyone one year or older with chronic skin or lung conditions; those on long-term aspirin therapy; and children who are on systemic steroids (including asthma inhalers). Acyclovir should be started within the first 24 hours of the rash for maximum benefit. Acyclovir may cause harm to the fetus so is not normally given to pregnant women but is rather evaluated on a case-by-case basis.

VZIG

Varicella immune globulin (VZIG) is an emergency treatment to help prevent or reduce the severity of chickenpox after known exposure. It is used in patients who are at extreme risk of developing a life threatening case of chickenpox. It is extremely expensive and only provides short-term protection so VZIG is typically only recommended for this small set of patients who are unable to receive the chickenpox vaccine.

These include pregnant women; newborns whose mothers had chickenpox within a 7 day span of birth (ranging from 5 days prior to 2 days after); patients with cellular immunodeficiencies or anyone whose system has been immune suppressed through drugs (and steroids) or other disease states (HIV/AIDS, transplant patients and some cancer patients) and unvaccinated children with lymphoma or leukemia.

As with acyclovir, VZIG should be given as soon as possible but must be within 4 days of chickenpox exposure.

Vaccination

The chicken pox vaccine is now widely accepted and recommended by the medical community. Prior to its introduction there were 4 million cases/year, 11,000 hospitalizations and 100 deaths.

The chickenpox vaccine (varicella vaccine) is made with a live attenuated virus. For children below the age of 12, a single vaccination is given. For anyone 13 and older, 2 injections are given 4-8 weeks apart. As part of the new baby round of vaccinations, it is now recommended that all children between the ages of 12 and 18 months should be vaccinated.

Again due to the risk of serious complications associated with chickenpox, all adults without a past history of the disease should be vaccinated.

Those who cannot take the vaccine include anyone with an allergy to neomycin or gelatin (there is no egg in this vaccine); illness at the time of planned vaccination (low grade fever, cold, etc.); long term steroid use; anyone who has received blood products within 5 months; pregnant women or immunosuppressed patients (there are certain exceptions to discuss with your doctor). Children on salicylates (aspirin) should not be vaccinated as they run the risk of Reye Syndrome. Aspirin should be discontinued for 6 weeks prior to vaccination.

Due to the relative newness of the vaccine, the length of immunity is not known. The vaccine was first introduced in Japan 25 years ago (and 10 years ago in the U.S. in studies). So far the protection has lasted and a booster is not recommended at this time.

While no vaccine works 100 percent of the time, between 8 and 9 patients out of every 10 vaccinated never develops the disease. The 1-2% of patients who experience this breakthrough usually have a very mild case often without fever or other symptoms. The rash is markedly reduced, usually less than 50 blisters form compared with the typical 500 blisters seen in a full-blown unvaccinated patient. A true breakthrough case must occur at least 42 days after vaccination.

Vaccinated individuals with a breakthrough case of chickenpox are still contagious to anyone who has never had chickenpox. So like normal chickenpox patients, they should remain at home until the blisters are fully scabbed over and no new spots are forming.

Shingles & Chickenpox

Despite the common misconception, there is no evidence that being exposed to someone with chickenpox stimulates an eruption of shingles. And the vaccine seems to be helping reduce the rate of developing shingles. To help compare the rates, the CDC offers these statistics. The incidence of a healthy child (below the age of 20) developing shingles (herpes zoster) after having a natural case of chickenpox is 68/100,000 person years, and for the entire population is 215/100,000 person years. Compare that with the 2.6/100,000 cases of shingles seen after vaccination.

Talk with your physician if you or your children have not had the chickenpox. You may be a candidate for the vaccine. Otherwise, stock up on your chickenpox treatment products. Chickenpox seems to be rampant this year.

Thank you for taking the time to read my newsletter. As always, I hope you have found it informative.

Audrey Kunin, M.D.

(Any topic discussed in this article is not intended as medical advice. If you have a medical concern, please check with your doctor.)

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