Ibuprofen is a common medication used in the management of pain, fever, and to reduce inflammation. Alongside paracetamol (Calpol) It is one of the first medicines considered by parents when a child is ill. However, ibuprofen may not be recommended as the drug of choice in a particular group of children or to treat specific conditions. What about chickenpox? Can you use ibuprofen for chickenpox?
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Can you use ibuprofen for chickenpox?
NHS recommends not to use ibuprofen for chickenpox unless advised to do so as it may increase the risk of severe skin infection called necrotising fasciitis (NF).
Necrotising fasciitis, also known as flesh-eating disease, is a severe bacterial infection, which happens beneath the skin. Skin infection is usually caused by a group of bacteria called group A streptococcus (GAS) and Staphylococcus aureus. During the infection, bacteria release toxins, which cause quick, severe damage and death of the skin. NF may lead to a life-threatening situation.
One UK review based on 630 patients admitted to the hospital found that 32% of children and 17% of adults admitted to the hospital with chickenpox had bacterial infections (NICE, 2018).
Paracetamol is recommended as medicine to help with fever (high temperature), and pain caused by chickenpox. Ibuprofen belongs to a group of drugs called Nonsteroidal Anti-Inflammatory Drugs (NSAIDs). Its mechanism of action (how it works) is different from paracetamol.
Why should you not give ibuprofen for chickenpox (evidence)?
NHS recommendation based on The National Institute for Health and Care Excellence (NICE) guide on the management of chickenpox in children and adults. NICE sets evidence-based guidelines for healthcare professionals (for example, doctors) on the management of conditions and diseases.
The evidence-based guide is constructed from different clinical studies. The evidence against the use of ibuprofen in children with chickenpox is taken from clinical trials, which took place in the USA. I will review a couple of relevant studies. To keep it simple, I will call both studies Study 1 and Study 2.
Study 1 – use of ibuprofen in children with chickenpox
Study 1 (Zerr et al., 1999) took place between December 1993 and June 1995. This study evaluated the risk of developing a severe bacterial skin infection called necrotising fasciitis (NF) in children who took ibuprofen for chickenpox. This was a small study involving just 42 participants. Children who end up with A streptococcus infection were more likely to have used ibuprofen before going to the hospital. However, in most cases, ibuprofen was started after children experienced symptoms of secondary infection.
The use of ibuprofen was associated with necrotising fasciitis (NF) during chickenpox infection. Additionally, it was suggested more research is needed to check the role of ibuprofen in getting NF.
Study 2 – do NSAIDs increase the risk of infections in children with chickenpox (Lesko et al., 2001)
The objective of this study was similar to the previously discussed research. The primary goal was to see if the use of nonsteroidal anti-inflammatory drugs (ibuprofen) increases the risk of A streptococcal (GAS) infections and necrotising fasciitis. Children with chickenpox who were hospitalised due to necrotising fasciitis or A streptococcal (GAS) infections were included in this study.
In this trial between June 1996 and September 1998, 52 cases of A streptococcal (GAS) infections were recorded including 21 necrotising fasciitis infections and compared to 172 other children who had uncomplicated chickenpox infection.
Interestingly necrotising soft tissue infection was not associated with the use of ibuprofen BEFORE the development of the symptoms of this infection. However, the risk of invasive GAS infection was associated with children who had ibuprofen.
It was concluded that there is no conclusive evidence to show that anti-inflammatory drugs like ibuprofen increase the risk of necrotising GAS infections but may increase the risk of invasive GAS infection. Furthermore, children who were treated with paracetamol and ibuprofen were at the highest risk of invasive GAS infection.
Based on both studies, there is some evidence which links ibuprofen use in chickenpox and the risk of serious infections.
A more recent meta-analysis (a study that looks at all available evidence) concluded that the majority of studies show an increased risk of secondary infections. However, it was noted that in many cases, ibuprofen was used after the onset of symptoms of secondary infection, and this creates some uncertainty (Stone et al., 2018).
Nevertheless, there is a broad agreement in line with the NHS recommendation not to use NSAIDs (ibuprofen) for the management of symptoms of chickenpox infections.
What are the alternative medicines for chickenpox?
Paracetamol is considered the first choice when it comes to the management of fever and associated symptoms in chickenpox. Paracetamol can be used in children aged two months and above. Calpol Infant, Six Plus or alternative brands of paracetamol solution are suitable for chickenpox infection.
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Management of skin itchiness in chickenpox
You can read in detail about the management of skin itchiness caused by chickenpox in a related post: Calamine lotion for chickenpox, which also lists calamine lotion alternative products.
Broadly speaking products and medicines which are used to reduce skin itchiness can be divided into:
- Topical products, which are applied directly to the skin such as calamine lotion & cream
- Oral medicines, such as antihistamines with chlorphenamine (Piriton) which is licensed for symptomatic relief of itch associated with chickenpox.
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Chlorphenamine, an antihistamine can be used alongside topical products.
References
Lesko SM, O’Brien KL, Schwartz B, Vezina R, Mitchell AA. Invasive group A streptococcal infection and nonsteroidal anti-inflammatory drug use among children with primary varicella. Pediatrics. 2001 May;107(5):1108-15. doi: 10.1542/peds.107.5.1108. PMID: 11331694. Available at: https://doi.org/10.1542/peds.107.5.1108 Accessed on 28/07/2023
NICE, (2018). Chickenpox: Scenario: Child or adult. Available at: https://cks.nice.org.uk/topics/chickenpox/management/child-or-adult/ Accessed on 28/07/2023
Stone K, Tackley E, Weir S. BET 2: NSAIDs and chickenpox. Emerg Med J. 2018 Jan;35(1):66-68. doi: 10.1136/emermed-2017-207366.2. PMID: 29247138. Available at https://doi.org/10.1136/emermed-2017-207366.2 Accessed on 28/07/2023
Zerr DM, Alexander ER, Duchin JS, Koutsky LA, Rubens CE. A case-control study of necrotising fasciitis during primary varicella. Pediatrics. 1999 Apr;103(4 Pt 1):783-90. doi: 10.1542/peds.103.4.783. PMID: 10103303. Available al: https://doi.org/10.1542/peds.103.4.783 Accessed on 28/07/2023
