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EDMUND G. BROWN JR.
Governor

State of California—Health and Human Services Agency
California Department of Public Health


September 26, 2022


TO:
Health Care Providers

SUBJECT:
Supportive Care Suggestions for Patients with Monkeypox (MPX)


Information for Providers:   

The prognosis for MPX depends on multiple factors, such as MPX vaccination status, initial health status, concurrent illnesses, and comorbidities among others. Supportive care and treatment of symptoms should be initiated for all patients who have MPX infection. This may include different topical, systemic medications, or other clinical interventions to control pain, itching, nausea and vomiting. Proctitis can occur and progress to become severe and debilitating, that may require prescription medication. 

Skin rash: 

  • Patients with pruritis, consider: Calamine lotion, petroleum jelly, menthol lotion, or camphor lotion. 
  • If uncontrolled pruritis despite topical therapy: Consider antihistamines (e.g. loratadine). 
  • Anticipatory guidance for patients: 
    • Keep the area clean and dry when not bathing to prevent bacterial infections.  
    • Seek care if pain increases or they observe any pain, redness, swelling, or cloudy fluid at the site of the rash.  

Oral lesions 

  • Saltwater rinses 4 times daily. 
  • Consider chlorhexidine mouthwash to keep the lesions clean. Alcohol-free mouthwash (e.g. Listerine Zero Alcohol) can also be used to keep the lesions clean.  
  • Magic/Miracle Mouthwash can be prescribed if significant oral pain.  
  • Consider oral lidocaine gels if significant pain that makes eating difficult. These should be limited to recommended dosages.

Painful genital and anorectal lesions, proctitis 

  • Warm sitz baths lasting 10 minutes several times a day. 

    • Sitz baths: Warm bath made up of water and baking soda or Epsom salt to help reduce inflammation and cleanse area. Patients can buy sitz baths online or at a pharmacy, or can sit in a bathtub with shallow water.  

  • Topical lidocaine gels or creams (at recommended dosages) 

  • For proctitis:  

    • Stool softeners should be prescribed early 

    • If pain is not improving with OTC medications (e.g. acetaminophen and ibuprofen) and with topical remedies mentioned above, consider prescription medications (such as gabapentin or opioids.) If prescribing opioid medications, note the possibility of side effects such as constipation. Consider corticosteroid/local anesthetic (e.g. hydrocortisone/lidocaine) gels/creams 

  • Anticipatory guidance for patients: 

    • Seek care if blood in the urine, difficult urinating, inability to retract foreskin (or foreskin cannot return to normal position after retracting), rectal bleeding.  

Nausea and Vomiting, dyspepsia 

  • Consider antiemetics and ensure adequate hydration. 

  • Consider temporary PPI therapy for dyspepsia. 

Diarrhea 

  • Anti-motility agents NOT recommended (given potential for ileus). 

  • Ensure adequate hydration and electrolyte replacement. 

Ocular Involvement 

  • Trifluridine is a topical antiviral medication that can be used for ocular complications of MPX.  

  • For lesions near the eye or eyelid lesions, there is still a risk for autoinoculation, prophylactic Trifluridine drops along with Tecovirimat therapy should be considered.  

Nutrition and Hydration 

  • Ensure adequate hydration and nutrition. If it is not adequate, evaluate whether therapies for pain/nausea are needed. 

Mental Health Considerations 

  • Isolation can be associated with anxiety. First line therapy is to connect the patient with a mental health counselor. 

In addition to the above supportive therapies, tecovirimat therapy should be considered for patients with severe disease, for patients at high risk for severe disease, or patients with lesions in anatomic areas that may be at high risk for complication such as scarring or stricture. Please see CDPH Healthcare Providers page, the MPX Tecovirimat Treatment Information for Providers and the CDC guidance for tecovirimat use for more details.  

 

For Patients: Please see the CDC website linked here for suggestions on how to best care for yourself 

 

References: 

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