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Key Features

Essentials of Diagnosis

  • Varicella (chickenpox)

    • Exposure to varicella or herpes zoster 10–21 days previously; no prior history of varicella

    • Widely scattered red macules and papules concentrated on the face and trunk, rapidly progressing to clear vesicles on an erythematous base, pustules, and then crusts, over 5–6 days

    • Variable fever and nonspecific systemic symptoms

  • Herpes zoster (shingles)

    • History of varicella

    • Dermatomal paresthesias and pain prior to eruption (more common in older children)

    • Dermatomal distribution of grouped vesicles on an erythematous base

General Considerations

  • Primary infection with varicella-zoster virus results in varicella, which generally confers lifelong immunity, but the virus remains latent lifelong in sensory ganglia

  • Herpes zoster, which represents reactivation of this latent virus, occurs in 30% of individuals at some time in their life

  • Herpes zoster is a common problem in immunocompromised children and is also common in children who had varicella in early infancy (< 1–2 years old) or whose mothers had varicella during pregnancy

Clinical Findings

  • A 1- to 3-day prodrome of fever, malaise, respiratory symptoms, and headache may occur, especially in older children

  • Varicella

    • Systemic symptoms are mild followed by crops of red macules that rapidly become small vesicles with surrounding erythema (described as a "dew drop on a rose petal"), form pustules, become crusted, and then scab

    • Lesions occur in the scalp, and sometimes in the nose, mouth (where they are nonspecific ulcers), conjunctiva, and vagina

    • Magnitude of systemic symptoms usually parallels skin involvement

    • Pruritus is often intense

  • Herpes zoster

    • The unilateral, dermatomal vesicular rash and pain of herpes zoster is very distinctive

    • Ophthalmic zoster may be associated with corneal involvement

    • The closely grouped vesicles, which resemble a localized version of varicella or herpes simplex, often coalesce

    • Crusting occurs in 7–10 days

    • Postherpetic neuralgia is rare in children


Laboratory Findings

  • Leukocyte counts are normal or low

  • Leukocytosis suggests secondary bacterial infection

  • Virus can be identified by fluorescent antibody staining of a lesion smear

  • Polymerase chain reaction is definitive when identifying the etiology is critical (eg, atypical disease in immunocompromised children)

  • Serum aminotransferase levels may be modestly elevated during typical varicella


  • Radiography

    • Varicella pneumonia classically produces numerous bilateral nodular densities and hyperinflation; seen more often in immunocompromised than in immunocompetent children


General Measures

  • Supportive measures

    • Maintenance of hydration

    • Administration of acetaminophen for discomfort

    • Cool soaks or antipruritics for itching (diphenhydramine, 1.25 mg/kg every 6 hours, or hydroxyzine, 0.5 mg/kg every 6 hours)

    • Observance of general hygiene measures (keep nails trimmed and skin clean)

  • Care must be taken to avoid overdosage with antihistaminic agents

  • Topical or systemic antibiotics may be needed for bacterial superinfection

Specific Measures


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