Treatment Guidance

Supportive care includes maintenance of fluid balance, pain management (pain management strategies should be tailored to the needs and context of an individual patient), treatment of bacterial superinfections or co-occurring sexually transmitted infections. Providers should give detailed guidance on supportive care and address these symptoms early to prevent hospitalizations. 

Over-the-counter medications (e.g., acetaminophen, NSAIDs) are recommended for general pain control for patients with monkeypox. Topical steroids and anesthetics such as lidocaine could also be considered for local pain relief. Topical lidocaine or other topical anesthetics should be used with caution on broken skin or on open or draining wounds. To minimize the risk of transferring virus from a lesion to another site on the body, persons with monkeypox or their caregivers should use disposable gloves when applying topical medications to lesions, then dispose of the gloves and practice hand hygiene. In some circumstances, prescription pain medications such as gabapentin and opioids have been used for short-term management of severe pain not controlled with other treatments including acetaminophen, NSAIDs, and/or topical medications. See CDC’s Opioid Prescribing Guideline Resources and CDC's Clinical Considerations for Pain Management of Monkeypox

Data from biomedical research involving burns, superficial wounds, herpes, eczema vaccinatum, and so forth—suggest that MPX patients could benefit from clinical support to lessen the consequences of compromised skin and mucosa. This should include prevention and treatment of secondary bacterial infections (and other complications), ensuring hydration and nutrition, and protecting vulnerable anatomical locations such as the eyes and genitals. 

• Skin lesions should be kept clean and dry when not showering or bathing to prevent bacterial superinfection. Warm oatmeal baths can also reduce itching and pain.
• For oral lesions, patients can rinse their mouths with salt water at least four times per day. Alcohol-free oral antiseptics (such as Listerine Zero Alcohol and chlorhexidine mouthwash) can be used to keep lesions clean. For pain, patients can suck on ice chips or ice pops, or use compounds such as “magic” or “miracle” mouthwashes (prescription solutions used to treat mucositis). Topical treatments such as patches (for example, Dentemp Canker Covers) and benzocaine or lidocaine gels can be used for temporary relief, especially to facilitate eating and drinking, but should be limited to recommended doses.
• For painful genital and anorectal lesions, warm sitz baths lasting at least 10 minutes several times per day may be helpful. Topical benzocaine or lidocaine gels or creams at the recommended doses may provide temporary relief. 
• Proctitis can occur with or without internal or external lesions and, though often manageable with appropriate supportive care, can progress to become severe and debilitating. Stool softeners such as docusate should be initiated early. Sitz baths, as described above, are also useful for proctitis and may calm inflammation.
• For itching, oral antihistamines may provide some relief of pruritus associated with monkeypox lesions. Topical agents such as calamine lotion, petroleum jelly, or colloidal oatmeal may also improve symptoms. Patients who use topical steroids for pre-existing skin conditions should avoid applying steroids to active lesions of monkeypox, unless directed to do so by their treating clinician.

Please refer to NYC Health’s Interim Guidance for Treatment of Monkeypox and CDC’s Clinical Considerations for Pain Management of Monkeypox for specific treatment steps and tools, including detailed information on pain management for lesions in various locations.

Many people infected with monkeypox virus have a mild, self-limiting disease course in the absence of specific therapy. However, the prognosis for monkeypox depends on multiple factors, such as previous vaccination status, initial health status, concurrent illnesses, and comorbidities among others. More information can be found on the CDC’s Interim Clinical Guidance for the Treatment of Monkeypox.

For information regarding who is eligible for tecovirimat (TPOXX) treatment, see the CDC Guidance for Tecovirimat.

For information about Monkeypox Treatment in patients with HIV, see the CDC Clinical Considerations for Treatment and Prophylaxis of Monkeypox Virus Infection in People with HIV.

TPOXX is available through the CDC’s Strategic National Stockpile (SNS). To request TPOXX, clinicians must complete the TPOXX Provider Treatment Initiation Interest Form. Providers requesting TPOXX for an identified patient will have the following choices for medication distribution:

1. VDH dispenses the medication and ships the medication directly to the patient
2. VDH dispenses the medication and ships the medication to the provider for the provider to give to the patient

VDH distributes the medication to the provider and the provider dispenses (i.e. labels the medication). The provider may then give the medication to the patient. *Please note this option is only for providers that can dispense medication consistent with the Virginia Board of Pharmacy regulations. 

Prescribers must complete the TPOXX Inventory & Patient Initiation Survey for all patients who are started on TPOXX.

Local health departments, infectious disease providers and health systems may also request additional TPOXX supply to have prepositioned for expedited time to treatment. Prepositioned inventory requests will be fulfilled based on TPOXX inventory and disease burden.

Providers who redistribute TPOXX must complete the Monkeypox Vaccine and Medication Redistribution Survey. If TPOXX is wasted for any reason, providers should complete the Monkeypox Vaccine and Medication Wastage Survey.

Optional documentation: 

• Clinical Outcome Form. Provides clinical progress of patients during TPOXX therapy (e.g., at Day 7). If the patient’s clinical condition necessitates performing clinical labs, please include a copy of the results. 
• Photos of lesions. Ideally, a photograph of at least 1 lesion prior to tecovirimat treatment and then the same lesion photographed again during treatment between days 7 and 14 (indicated dates on photos). Provide photo(s) of any new lesions that develop during or up to 7 days after completion of TPOXX treatment.
• Samples of lesions for molecular testing. Ideally, a sample from at least 1 lesion prior to tecovirimat treatment but only if baseline diagnostic testing wasn’t performed, as well as samples from any new lesions that develop during TPOXX treatment or up to 7 days afterwards to assess for development antiviral resistance mutations. Submit samples to CDC with CDC Form 50.34, and indicate Poxvirus Molecular Detection (CDC-10515) as the test order (code). Lesions should not be deroofed (scab removed) to obtain a sample. Vigorous swabbing on the scab is sufficient as the crust has ample viral DNA.

Providers who agree to complete the above documentation and submit documentation to the CDC may obtain TPOXX by completing the TPOXX Provider Treatment Initiation Interest Form. Prescribers must complete the TPOXX Inventory & Patient Initiation Survey for all patients who are started on TPOXX.

Adverse reactions and drug interactions, as well as special population considerations (pregnancy/lactation and pediatrics) can be found on the CDC’s Interim Clinical Guidance for the Treatment of Monkeypox.

No, the drug should be provided at no cost. There is no funding available to assist with laboratory testing. Testing plasma PK samples collected and sent by the hospital to the lab contracted to test PK samples and/or blood or specimens sent via the health department to CDC for serology or virologic testing would not have a cost to the patient.