Treatment of Chickenpox in Primary Immunodeficiency, Immunosuppressive Chemotherapy or Radiotherapy, and Related High-Risk States

Clinical Scenario

Chickenpox (varicella-zoster virus infection) in patients with impaired immune function carries a substantially elevated risk of severe disease. Prompt clinical assessment and early antiviral intervention are central to management in this population.

Affected Patient Groups

This protocol applies to patients presenting with chickenpox in any of the following situations:

Primary immunodeficiency (including severe forms such as SCID or Wiskott-Aldrich syndrome)
Receiving immunosuppressive chemotherapy or radiotherapy for malignant disease, or within the last 6 months of completing treatment
Bone marrow transplantation within the last 12 months (or longer if graft-versus-host disease is present)
Solid organ transplant recipients on ongoing immunosuppressive therapy
Systemic high-dose steroid therapy (more than 40 mg prednisolone per day for more than 1 week) within the last 3 months
Other immunomodulatory drug therapy
HIV infection (particularly with low CD4 count)

These patients are considered at risk of severe VZV infection and require antiviral therapy as soon as possible after presentation.

Treatment Approach (Overview)

Management centres on early oral antiviral therapy, initiated promptly on recognition of the infection. Antiviral treatment should be administered even if new lesions or fever have appeared in the previous 24–48 hours, regardless of time since onset.

Symptomatic relief measures are also part of the approach. The specific agents, dosing, and full algorithm are detailed in the structured protocol.

Full regimen, drug selection criteria, and dosing details are available via the protocol link below.

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.1016/j.jinf.2008.03.004

Patients in the categories shown in Table 2 should be considered as being at risk of severe VZV infection, and should receive antiviral therapy as soon as possible.

Patients with severe primary immunodeficiency such as Severe Combined Immunodeficiency (SCID) or Wiskotte Aldrich syndrome.

All patients receiving immunosuppressive chemotherapy or radiotherapy for malignant disease, up to 6 months after completion of treatment.

All patients on immunosuppressive therapy following a solid organ transplant.

All patients who have undergone bone marrow transplantation, up to 12 months after completing all immunosuppressive therapy, or longer if graft versus host disease has occurred.

Patients receiving other immunomodulatory drugs such as azathioprine, cyclosporine, methotrexate, cyclophosphamide and the cytokine inhibitors, and/or chronic low dose steroid therapy.

Patients with HIV infection, particularly if the CD4 count is less than 200 cells/mm3.

New lesions may appear over several days in the immunocompromised, and antiviral treatment should be administered if new lesions or fever have been observed in the previous 24–48 h, regardless of time since onset.

Supportive therapy, such as anti-pruritic drugs can be helpful for all age groups.

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