shingles (zoster) and varicella (chickenpox) and use of NSAIDs

Last edited 12/2022 and last reviewed 02/2023

Nonsteroidal anti-inflammatory drugs (NSAIDs) use and the risk of severe skin and soft tissue complications in patients with varicella or zoster disease

• use of NSAIDs is associated with an increased risk of severe skin and soft tissue complication of varicella in children (1)
  • necrotizing fasciitis within 3 weeks of the onset of varicella
    • cases (previously healthy children hospitalized for a necrotizing fasciitis within 3 weeks of the onset of varicella)
      • were more likely than controls (previously healthy children hospitalized for another soft tissue infection within the same period of the onset of varicella) to have used ibuprofen in the time before the index date (OR 11.5, 95% CI 1.4, 96.9) (2)
  • cases of necrotizing soft tissue infections or other invasive group A streptococcal (GAS) infection within 2 weeks of onset of varicella
    • were more likely than controls (children with primary varicella infection who did not develop invasive GAS infection, recruited among primary care physicians) to have used ibuprofen (most frequently associated with acetaminophen (paracetamol) 7 days before the index date (OR 3.9, 95% CI 1.3, 12), compared with acetaminophen (paracetamol) alone (3)
  • ibuprofen is associated with severe necrotizing soft tissue infections (NSTI) during chickenpox course (4)
    • ibuprofen should not be recommended for chickenpox management
    • sufficient evidence to contraindicate ibuprofen for the management of chickenpox symptoms, due to the elevated risk of NSTI
      
      
• use of NSAIDs is also associated with a small increased risk of such complications in zoster disease in adults and the elderly (1)

Exposure to ibuprofen compromises the leukocytosis function, promotes an increase of inflammatory cytokine production, and creates a convenient environment for bacterial growth (5)

Reference:

• Mikaeloff Y, Kezouh A, Suissa S. Nonsteroidal anti-inflammatory drug use and the risk of severe skin and soft tissue complications in patients with varicella or zoster disease. Br J Clin Pharmacol. 2008 Feb;65(2):203-9.
• Zerr DM, Alexander ER, Duchin JS, Koutsky LA, Rubens CE. A case-control study of necrotizing fasciitis during primary varicella. Pediatrics. 1999;103:783-90.
• esko 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;107:110-15
• Quaglietta L, Martinelli M, Staiano A. Serious infectious events and ibuprofen administration in pediatrics: a narrative review in the era of COVID-19 pandemic. Ital J Pediatr. 2021 Jan 29;47(1):20.
• Antunes JJ, Dias SS, Monteiro RMPC, Martins AM. Cutaneous varicella zoster virus infection: an assocation with ibuprofen? Einstein (Sao Paulo). 2019 Oct 10;17(4):eAI4809.