Paramedics are increasingly required to assess patients and determine whether they can be safely managed at home with self-care or primary care or if they need to be transferred to the hospital. In line with HCPC requirements, paramedics must use evidence-based practice to make informed clinical decisions. This post explores the key information needed to support sound, evidence-based, and patient-centred decision-making in managing chickenpox in children.
Clinical bottom line: Treat the child in front of you. Take complications of chickenpox seriously, especially in immunocompromised patients and neonates.
What is chickenpox?
Chickenpox, or varicella, is a highly contagious infection caused by the varicella-zoster virus (VZV). Patients are considered infectious from 1–2 days before the rash appears until all lesions have crusted over. Importantly, the rash may present differently on black and brown skin, appearing as subtle bumps rather than the classic red spots.
While chickenpox is usually a mild, self-limiting illness, it can lead to life-threatening complications, particularly in high-risk groups. A vaccine is available, offering protection, especially for immunocompromised patients who are at greater risk of severe disease.
Communicability
Marin et al. (2021) conducted a literature review investigating 16 studies on the communicability of varicella before rash onset. The included studies varied widely in age, with the oldest dating back to 1896, and relied primarily on epidemiological data, which is considered low-quality evidence. Only 11 of the 16 studies included laboratory data, and none were published in the 21st century. This significantly limits their validity, as older studies lacked modern diagnostic techniques—only five assessed VZV DNA presence. The scientific quality and reliability of these findings are, therefore, questionable.
The authors acknowledge that much of the existing evidence is anecdotal, making it difficult to draw firm conclusions about VZV transmission before rash onset. Many studies rely on parent-reported rash onset, introducing reporting bias and limiting the validity and generalisability of findings. While the rash itself contains high concentrations of infectious virions, it remains unclear whether respiratory secretions also play a significant role in transmission. This knowledge gap complicates our understanding of how VZV spreads.
Limited evidence exists regarding the communicability of chickenpox and the risk of transmission, particularly in immunocompromised individuals. The uncertainty surrounding the extent of pre-rash transmission makes it challenging to accurately assess the infection risk to vulnerable populations.
Burden of Chickenpox on the Health Service
Bernal et al. investigated the complications of varicella and the burden on the NHS.
The researchers used electronic health records to identify VZV complications seen in secondary care. However, this approach introduces limitations. The dataset excludes patients who were seen by primary care providers, paramedics, or outpatient services and discharged without hospital admission. As a result, milder complications are likely underrepresented.
Between 1 April 2004 and 31 March 2017, 61,024 hospital admissions related to varicella were identified. The study included patients of all ages, meaning the data must be examined further to assess paediatric-specific complications. Supplementary data suggest that while varicella is more common in children, older patients experience a higher relative rate of complications. The authors found that complications were more severe in older children and adults.
Several limitations should be noted. The study was retrospective, relying on hospital coding and admission records, which may not accurately capture the reason for admission. It remains unclear whether varicella was the primary cause of hospitalisation or an incidental finding.
Additionally, in paediatric patients—especially infants—it is possible that hospital admission thresholds were lower. This could skew the data to suggest a higher admission rate in younger children, despite their complications being less severe. However, the authors did not perform statistical analysis to explore this potential bias.
It is important for paramedics to consider the need for hospital admission, and whether conveying patients to hospital unnecessarily is damaging to the patient, and the NHS in the long run.
What are the Complications of Chickenpox?
Complications of varicella are well-documented in the NICE guidelines and include secondary bacterial infections, neurological complications, and other rarer complications.
Bernal et al., in their literature review, identified 100 different complications related to varicella, detailed in their supplementary data.
Bozzola et al. conducted a retrospective review of children admitted to hospital in Italy with varicella complications. However, they excluded children with immunodeficiency disorders, limiting the general applicability of their findings. Since immunocompromised children are at significantly higher risk of complications, excluding this group reduces the study’s relevance to the wider population.
The study found that the two most common neurological complications were cerebritis (of varying severity) and convulsions—both of which paramedics must be able to recognise.
Neurological complications were found to be statistically associated with age, with a mean age of 5 years. The authors also noted that neurological complications can occur both during the primary varicella infection and later due to virus reactivation.
Prehospital clinicians must recognise that virus reactivation can cause severe complications, particularly in immunocompromised patients.
Dooling highlights the risk of several chickenpox complications, including bacterial superinfection of lesions, particularly Group A streptococcal infection.
The use of nonsteroidal anti-inflammatory drugs (NSAIDs) increases the risk of severe skin and soft tissue complications in chickenpox. This was studied in the UK by Mikaeloff, but the findings were limited by reliance on primary care records, making the data susceptible to reporting bias. However, conducting a controlled trial on this topic would present ethical challenges.
A major limitation of the study is that NSAID exposure was identified through prescriptions. Since NSAIDs are widely available over the counter in the UK, cases of undocumented NSAID use and subsequent complications were likely missed, affecting data accuracy.
Despite this limitation, the study found a clear association between NSAID use and an increased risk of complications in chickenpox.
For a deeper dive into the data, take a look at this post from Alasdair Munro.
Be mindful that controversy exists around the use of this common drug in children with chickenpox.
Immunocompromised vs Immunocompetent
The varicella vaccine was originally developed to protect immunocompromised children from the complications of chickenpox, and evidence confirms that it has successfully achieved this goal.
Varicella vaccination policies vary internationally. In the UK, the vaccine is not included in routine childhood immunisations, whereas, as of 2021, 14 European countries have recommended its use. Decisions on vaccination policies are based on an assessment of disease burden, weighing both financial and medical considerations.
Since the introduction of the vaccine, the global mortality rate of varicella has significantly declined. Between 2012 and 2016, the World Health Organization reported a mortality rate of just 0.03 per million population due to varicella.
Certain groups remain at higher risk of severe disease and complications. Immunocompromised individuals are particularly vulnerable, but another key risk factor is infection in infancy. Neonates are at an increased risk of disseminated or haemorrhagic varicella, which should be considered in cases of maternal infection.
The highest risk for severe neonatal varicella occurs when maternal varicella-zoster virus (VZV) infection develops between five days before and two days after delivery, with a mortality rate of around 20% if infection occurs within this critical window.
Paramedics should have a lower threshold for hospital conveyance in this cohort.
How do you manage a simple case of Chickenpox?
The NICE guidelines recommend that children with chickenpox should be offered paracetamol for distress, along with topical calamine lotion and chlorphenamine (for children over one year old) to help relieve itching.
NSAIDs should be avoided, despite the evidence on their association with complications being inconclusive. The precaution is based on concerns about an increased risk of severe skin and soft tissue infections, including necrotising fasciitis.
There are resources available for paramedics to give advice to patients and their families, including those on the NHS Healthier Together website.
Why is this important?
Paramedics play a key role in assessing children with varicella-zoster virus (VZV), balancing risk stratification with effective decision-making to ensure the right care plan.
While chickenpox is common and usually self-limiting, inappropriate management can unnecessarily burden the NHS. Prehospital clinicians must stay alert to potential complications, which, although rare, can be serious and require urgent recognition.
Vignette 1: Reassurance and Self-Care Advice
The parents of a 2-year-old call 111, unsure whether they can give ibuprofen to help with their child’s chickenpox symptoms. An ambulance is dispatched for a face-to-face review, primarily to rule out a meningococcal septicaemia rash.
On arrival, the child’s observations are all within normal limits. There are no amber or red flags on the NICE traffic light system for febrile children, and the rash is typical of chickenpox, with no signs of secondary infection.
For paramedics, the focus here is on education and self-care support. Parents can be advised to avoid NSAIDs (such as ibuprofen) due to the potential risk of severe skin and soft tissue infections. Instead, they should use paracetamol for fever and distress, along with topical treatments like calamine lotion for itching.
Paramedics can use local referral pathways to notify the child’s GP if needed and should provide accessible safety-netting resources to empower self-care. The Healthier Together website is a great tool for this, offering trusted guidance for parents.
If ambulance trust policies do not allow on-scene discharge of children, paramedics can signpost to urgent care centres or primary care as appropriate. However, a transfer to the emergency department is not required in this case.
Vignette 2: A Life-Threatening Complication
The parents of a 3-year-old dial 999 in distress—their child won’t stop crying. On arrival, paramedics find a rapidly worsening rash, with areas of skin appearing swollen, red, and necrotic—a potential sign of necrotising fasciitis, a rare but life-threatening complication of chickenpox.
The child’s observations are abnormal and concerning for sepsis, making early recognition and rapid escalation critical. This is a time-critical emergency.
Immediate Actions for Paramedics:
- Urgent transport to the local Emergency Department with a pre-alert to prepare the resuscitation team.
- Clear communication of the suspected necrotising fasciitis and sepsis to ensure early senior involvement.
- Notify the receiving team of the child’s infection status for appropriate infection control measures.
- Pain management as per local protocols, avoiding NSAIDs, and administering fluids if indicated.
- Continuous monitoring en route to detect deterioration.
Once at the Emergency Department, a structured handover should be given, ensuring a swift transition to resuscitation and definitive care. Early surgical and critical care involvement is essential, as necrotising fasciitis requires urgent surgical debridement and broad-spectrum antibiotics.
Bottom Line
Transmission Uncertainty: The scientific understanding of chickenpox transmission and communicability remains incomplete.
Vaccination: A varicella vaccine is available but is not currently funded by the NHS for immunocompetent children due to a cost-benefit analysis.
Complications: While rare, complications can be serious and should be identified early.
High-Risk Groups: Immunocompromised children and neonates are at higher risk of severe disease.
Medication Warning: NSAIDs should be avoided due to the risk of severe skin and soft tissue infections.
Home Management: Most cases of chickenpox can be managed at home with over-the-counter treatments
References
Health & Care Professions Council. The standards of proficiency for paramedics [Internet]. 2024 [cited 2024 Dec 8]. Available from: https://www.hcpcuk.org/standards/standards-of-proficiency/param
DFTB. Chicken pox – Skin Deep [Internet]. 2023 [cited 2024 Dec 8]. Available from: https://dftbskindeep.com/all-diagnoses/chicken-pox/
Marin M, Leung J, Lopez AS, Shepersky L, Schmid DS, Gershon AA. Communicability of varicella before rash onset: A literature review. Epidemiology and Infection. 2021;149. doi:10.1017/s0950268821001102
NICE. Chickenpox: Scenario: Child or adult [Internet]. 2023 [cited 2024 Dec 8]. Available from: https://cks.nice.org.uk/topics/chickenpox/management/child-or-adult/
Wang L, Zhu L, Zhu H. Efficacy of varicella (VZV) vaccination: An update for the clinician. Therapeutic Advances in Vaccines. 2016 Jan;4(1–2):20–31. doi:10.1177/2051013616655980
Lee YH, Choe YJ, Lee J, Kim E, Lee JY, Hong K, et al. Global varicella vaccination programs. Clinical and Experimental Pediatrics. 2022 Dec 15;65(12):555–62. doi:10.3345/cep.2021.01564
Leung J, Marin M. Update on trends in varicella mortality during the varicella vaccine era—United States, 1990–2016. Human Vaccines & Immunotherapeutics. 2018 Jul 16;14(10):2460–3. doi:10.1080/21645515.2018.1480283
Maheshwari A, Sharma A, Singh S, Rahman MM, Kasniya G, Boppana SB. Congenital and perinatal varicella infections. Newborn. 2022 Oct 7;1(3):278–86. doi:10.5005/jp-journals11002-0040
Munro A. Varicella and NSAIDs – are you too chicken to prescribe? [Internet]. 2024 [cited 2025 Jan 15]. Available from: https://dontforgetthebubbles.com/varicella-nsaidschicken-prescribe/
WY Healthier Together. Chickenpox [Internet]. NHS; [cited 2024 Dec 8]. Available from: https://wyhealthiertogether.nhs.uk/parentscarers/worried-your-child-unwell/chickenpox
NICE. NG143 traffic light tool [Internet]. 2019 [cited 2025 Jan 15]. Available from: https://www.nice.org.uk/guidance/ng143/resources/support-for-education-andlearning-educational-resource-traffic-light-table-pdf-696066433
