āInformation for Providers:
The prognosis for mpox depends on multiple factors, such as mpox vaccination status, initial health status, concurrent illnesses, and comorbidities among others.āÆSupportive care and treatment of symptoms should be initiated for all patients who have mpox 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.
Pain:
- Mpox lesions can be painful, especially when they involve mucosal sites such as the oropharynx, rectum, or urogenital region.
- Pain ācontrol should be individualized and include the use of a multimodal approach, including pharmacologic and nonpharmacologic methods.
- General mild to moderate pain: over-the-counter (OTC) ibuprofen and/or acetaminophen.
- Targeted pain relief associated with skin lesions: topical steroids or anesthetics like lidocaine can be considered.
- To prevent autoinoculation and infection of caregivers, disposable gloves should be worn when applying topical agents, disposed after use, and persons should practice hand hygeine.
- Avoid applying topical agents to broken skin or open lesions.
- In cases of severe pain not improved by NSAIDs and/or topical agents: consider a short course of gabapentin or opiates.
- āInititiation of opiate therapy should be done cautiously, with consideration of risks including constipation, dependence and overdose. If prescribing opiates, use immediate-release medications at the lowest effective dose for no longer than needed for the severe acute pain episode. A bowel regimen should accompany opiate prescription to prevent constipation.
Skin rash:ā
- Avoid scratching lesions and keep lesions clean and dry.ā
- Patients with pruritis: Consider calamine lotion, petroleum jelly, colloidal oatmeal or cooling lotions (such as camphor or menthol lotion).
- āāAgain, to prevent autoinoculation and infection of care givers, disposable gloves should be worn when applying topical agents disposed after use, and persons should practice hand hygeine.
- Avoid applying topical agents to broken skin or open lesions.āāā
- If uncontrolled pruritis despite topical therapy: Consider oral 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 if any redness, swelling, or cloudy fluid develops at the site of the rash.
Oral lesions
- Consider saltwater rinses 4 times daily.
- Consider oral antiseptic (e.g., chlorhexidine mouthwash) to keep the lesions clean.
- Prescription analgesic mouthwashes (e.g., magic mouthwash) can be prescribed if significant oral pain. Such mouthwashes commonly include local anesthetics or antihistamines (e.g., viscous lidocaine). Local pharmasists can assist in formulating such medications.
Genital lesions, anorectal lesions, and proctitis
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General pain management strategies, as discussed above, should be considered for painful lesions to the anorectal or genital regions. ā
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Warm āsitz baths lasting 10 minutes several times a day. Disinfect bath in between uses.
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āSitz ābaths: 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.
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Topical anesthetics such as lidocaine gels or creams as described above under skin rash may provide symptomatic relief.
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For Proctitis:
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āStool softeners should be prescribed early.
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āIf āpain is not improving with OTC medications (e.g., acetaminophen and ibuprofen) and with topical remedies mentioned above, consider prescription medications (e.g., gabapentin or opioids.) If prescribing opioid medications, note the possibility of side effects such as constipation.
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Consider corticosteroid/local anesthetic (e.g., hydrocortisone/lidocaine) gels/creams.
- āAnticipatory guidance for patients
- āSeek ācare if blood in the urine, difficult urinating, inability to retract foreskin or foreskin cannot return to normal position after retracting, rectal bleeding, or progressive erythema, pain, swelling or discharge suggestive of bacterial infection or abscess formation. ā
Nausea, vomiting, or dyspepsia
Consider antiemetics (e.g., ondansetron, promethazine) and ensure adequate hydration.
Consider temporary antacid therapy (e.g., proton-pump inhibitors) for dyspepsia.
Diarrhea
Ocular Involvement
Trifluridine is a topical antiviral medication that can be used for ocular complications of mpox in consultation with an opthalmologist.
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.
In āpatients with corneal disease, consider topical lubricants/antibiotics to prevent bacterial superinfection.
Nutrition and Hydration
Ensure adequate hydration and nutrition. If it is not adequate, evaluate whether therapies for pain/nausea are needed.
Vitamin A supplementation may aid in wound healing.
Mental Health Considerations