The Role of Dermatology in Identifying and Reporting a Primary Varicella Outbreak
Practice Points
- Primary varicella is a relatively infrequent occurrence since the introduction of vaccination, creating the need for a reminder on the importance of including it in the differential when clinically appropriate.
- When outbreaks do happen, typically among unvaccinated communities, swift identification via physical examination and histology is imperative to allow infection control teams and public health officials to quickly take action.
Individuals who had face-to-face indoor contact for at least 5 minutes or who shared a living space with an infected individual should be assessed for VZV immunity, which is defined as confirmed prior immunization or infection.5,13 Lack of VZV immunity requires postexposure prophylaxis—active immunization for the immunocompetent and passive immunization for the immunocompromised.13 Ultimately, no additional cases were reported in the community where our patients resided.
Immunocompetent children with primary VZV require supportive care only. Oral antiviral therapy is the treatment of choice for immunocompetent adults or anyone at increased risk for complications, while intravenous antivirals are recommended for the immunocompromised or those with VZV-related complications.14 A similar approach is used for HZ. Uncomplicated cases are treated with oral antivirals, and complicated cases (eg, HZ ophthalmicus) are treated with intravenous antivirals.15 Commonly used antivirals include acyclovir, valacyclovir, and famciclovir.14
Our cases highlight the ongoing risk for varicella outbreaks in unvaccinated or undervaccinated communities. Physician vigilance is necessary, and dermatology plays a particularly important role in swift and accurate detection of VZV, as demonstrated in our cases by the recognition of classic physical examination findings of erythematous and vesicular papules in each of the patients. Because primary VZV infection can result in life-threatening complications including hepatitis, encephalitis, and pancreatitis, prompt identification and initiation of therapy is important.6 Similarly, quick notification of public health officials about detected primary VZV cases is vital to containing potential community outbreaks.
