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EDMUND G. BROWN JR.
Governor

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


August 24, 2023


TO:
Health Care Providers

SUBJECT:
Supportive Care Suggestions for Patients with Mpox

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Information for Providers:   

The prognosis for mpox depends on multiple factors, such as mpox 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 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 ​control 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.
    • ​Inititiation 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:​

  • Avoid scratching lesions and keep lesions clean and dry.​
  • Patients with pruritis: Consider calamine lotion, petroleum jelly, colloidal oatmeal or cooling lotions (such as camphor or menthol lotion).
    • ​​Again, 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.​​​
  • 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 

  • General pain management strategies, as discussed above, should be considered for painful lesions to the anorectal or genital regions. ​
  • Warm ​sitz baths lasting 10 minutes several times a day. Disinfect bath in between uses.
    • ​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 anesthetics such as lidocaine gels or creams as described above under skin rash may provide symptomatic relief.
  • 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 (e.g., 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, or progressive erythema, pain, swelling or discharge suggestive of bacterial infection or abscess formation. ​

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 

  • Anti-motility agents NOT recommended as may cause ileus. 

  • Ensure adequate hydration and electrolyte replacement. 

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 ​patients 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 

  • Isolation can be associated with anxiety and depression. First line therapy is to connect the patient with a mental health counselor. Consider telehealth mental health services if available in your area.

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 Mpox Guidance for Health C​are Providers​, the Mpox 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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