Treatment Guidance

Supportive care for mpox includes pain management (pain management strategies should be tailored to the needs and context of an individual patient), maintenance of fluid balance, and 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.

Additional supportive care considerations:

• Use of over-the-counter medications for general pain management
• Prescription pain medications for short-term management of severe pain, not otherwise controlled
• Topical steroids and anesthetics for local pain relief – use with caution on open skin or draining wounds
• Use of appropriate personal protective equipment when touching lesions, followed by good hand hygiene

See CDC’s Opioid Prescribing Guideline Resources and CDC's Clinical Considerations for Pain Management of Mpox for further guidance.

Data from biomedical research involving burns, superficial wounds, herpes, eczema vaccinatum, and so forth—suggest that mpox 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 mpox 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 mpox, unless directed to do so by their treating clinician.

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

Severe manifestations of mpox can occur in both immunocompetent and immunocompromised people; however, most people diagnosed with mpox have had mild-to-moderate clinical courses. As the mpox outbreak has progressed, 38 percent of people diagnosed with mpox were coinfected with HIV1 and most reported cases of mpox with severe manifestations have been among people living with untreated HIV. An increasing proportion of cases have been identified among Black and Hispanic/Latino people. See CDC’s Health Advisory Severe Manifestations of Monkeypox among People who are Immunocompromised Due to HIV or Other Conditions. Strongly consider conducting HIV testing for people with confirmed or suspected mpox and remain aware of risk factors for severe manifestations of mpox.

In immunocompromised people, mpox treatment should include:

• Optimizing immune function by limiting the use of immunosuppressive medications if not otherwise clinically indicated
• Providing antiretroviral therapy for those with HIV

Consider medical countermeasures that may have a role in treating severe illness, including oral and intravenous tecovirimat (TPOXX), cidofovir or brincidofovir, and vaccinia immune globulin intravenous (VIGIV). Although there is no data on effectiveness in treating human mpox with these medical countermeasures, CDC currently recommends them for those at risk or experiencing severe illness. Decisions on whether and when to use these medical countermeasures must be made individually for each person and can depend on a variety of clinical and other parameters.

TEMBEXA (brincidofovir) is an oral antiviral medication approved by the U.S. Food and Drug Administration (FDA) in tablet and oral suspension formulation for the treatment of human smallpox disease in adult and pediatric patients, which is currently being used to treat mpox. The Strategic National Stockpile (SNS) released a TEMBEXA (brincidofovir) fact sheet that includes background information, how to access the product, and SNS supply. Please note there are multiple methods for requesting this product, listed in the access portion of the document.

Clinicians with mpox patients necessitating brincidofovir treatment need to submit an e-IND request to FDA by email (DDI.EIND@fda.hhs.gov) or phone 301-796-3400 or 1-855-543-3784 during normal business hours (8 am-4:30 pm ET M-F). During after hours, call the FDA Emergency Coordinator at 1-866-300-4374 or 301-796-8240 or email CDER-EIND@fda.hhs.gov and call the CDER Emergency Coordinator at 301-796-9900. 

Initial Presentation

• Upon initial presentation of signs and symptoms consistent with mpox, in addition to testing for mpox, test all sexually active adults and adolescents for HIV (including acute infection) and other sexually transmitted infections (such as syphilis, herpes, gonorrhea, and chlamydia); assess for other immunocompromising conditions, severe manifestations of mpox, and risk factors for severe disease.
• Discuss HIV pre-exposure prophylaxis (PrEP) with those who are HIV negative and at risk for HIV.
• Contact local and state health departments early when there is concern for severe manifestations of mpox for guidance on management and securing necessary resources for treatment.

TPOXX Therapy

• Consider tecovirimat (TPOXX) as first-line therapy for eligible patients with monkeypox. To order TPOXX, please review the “TPOXX Prescribing Requirements” and “Requesting TPOXX Treatment” sections.
• If you are a provider prescribing tecovirimat, consider first seeking access through enrollment in the AIDS Clinical Trials Group (ACTG) Study of Tecovirimat for Human Mpox Virus (STOMP) trial, which is evaluating the efficacy of tecovirimat. In this study, all adults with severe mpox, severe immunodeficiency, or other noted criteria will be enrolled in the open-label arm to receive oral tecovirimat. Virginia Commonwealth University (VCU) is a participant in this trial and it is open to all residents of Virginia. For patients not eligible for the STOMP trial or who decline to participate, contact your local health department to receive tecovirimat through the CDC’s Expanded Access-IND.

Immunocompromising Conditions

• Recognize that patients with severe immunocompromise may require longer courses of tecovirimat, as well as additional therapies, until their immune systems can effectively clear the virus. Tecovirimat can be extended on a day-by-day basis beyond its standard 14-day course based on clinical course.
• Have a low threshold to use multiple medical countermeasures, including tecovirimat, cidofovir or brincidofovir, and VIGIV in immunocompromised people who present with severe manifestations of mpox or are at high risk of progression to severe manifestations. These include patients with HIV and CD4 counts <350 cells/mm3 and patients with other severely immunocompromising conditions. 
• Concurrent with tecovirimat therapy, for immunocompromised patients, make efforts to facilitate competent native immunity (e.g., ensure persons with HIV are receiving effective antiretroviral therapy) and limit the use of immunocompromising therapies (e.g., chemotherapy, TNF inhibitors), if feasible. Restoring immune function is an important strategy to minimize morbidity and mortality associated with mpox and may decrease the duration of tecovirimat therapy for these patients.
• Consider consultation with CDC mpox Response Clinical Escalations Team (email eocevent482@cdc.gov or healthcare providers may contact the CDC EOC at (770) 488-7100), and multidisciplinary consultation with specialists such as infectious disease, ophthalmology, dermatology, urology, or critical care medicine. Consultation is encouraged for any patient who may benefit from receiving multiple therapeutics.

TPOXX Resistance

• Viral resistance to tecovirimat has been rare, and when documented has occurred with prolonged administration and severe clinical outcomes.
• Consider testing lesion swab specimens for tecovirimat resistance and plasma pharmacokinetic sample collection for any patient who, after completing 14 days of tecovirimat treatment, experiences persistent or newly emergent mpox lesions. CDC provides detailed instructions for collecting and submitting specimens for resistance testing and pharmacokinetic testing. Pharmacokinetic testing is performed by a designated lab, not at CDC. 
  • Two cases of laboratory-confirmed tecovirimat resistance have been reported nationally. The patients in both cases had immunocompromising conditions and progressive, severe manifestations of mpox, and both patients received prolonged courses (>14 days) of tecovirimat.
  • Note that no transmission of tecovirimat-resistant mpox virus has been documented so far.
  • Counsel patients about the critical importance of taking oral tecovirimat with fatty meals to ensure adequate gastrointestinal absorption and maximize serum levels of the drug. Inadequate serum levels could promote resistance as described above.

Many people infected with mpox 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 Mpox and the CDC Health Advisory: Update on Managing Mpox in Patients Receiving Therapeutics.

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

TPOXX is available through the CDC’s Strategic National Stockpile (SNS). Providers must request TPOXX through the TPOXX Treatment Initiation Interest Form. Providers have the following choices for medication distribution if they have identified a patient who needs TPOXX:

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 can also distribute TPOXX to health systems and independent, outpatient infectious disease providers for prepositioning. 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. 

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.

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

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

TPOXX is available for the treatment of mpox under an expanded access investigational new drug (EA-IND) protocol through the CDC. A condensed version of the protocol for providers may be found here.

On October 24, 2022, CDC amended and approved the EA-IND protocol (version 6.2). On October 28, 2022, the updated protocol information was added to the CDC website to include the amended protocol, an Online Registry for providers and facilities, and transition to electronic IND forms. Providers who have returned required IND forms prior to the online registry transition are grandfathered in as participating providers under the EA-IND. Providers may refer to the CDC website for more details. 

Under this protocol, providers who wish to initiate treatment must complete a set of required documents. This documentation is not mandatory prior to initiating treatment, with the exception of informed consent, however, providers should submit required documentation for every patient receiving TPOXX to the CDC at regaffairs@cdc.gov or uploading to ShareFile. More information can be found at the CDC’s Information for Healthcare Providers Obtaining and Using TPOXX for the Treatment of Mpox site.

Step 1: Informed Consent: Providers must obtain informed consent prior to obtaining treatment. Completed forms must be submitted to the CDC at regaffairs@cdc.gov, or uploaded to ShareFile, no later than 7 days after treatment initiation.

Step 2: Tecovirimat IND Online Registry

The following forms are required to be submitted, within 7 days of starting treatment, through the Tecovirimat IND Online Registry:

• Patient Intake Form
• FDA Form 1572: One form per facility for all TPOXX treatments administered at the same facility

Step 3: Serious Adverse Events

Report life-threatening or serious adverse events associated with TPOXX by completing a PDF MedWatch Form and returning it to CDC within 72 hours of awareness or sooner, if possible. 

Step 4: Optional Documentation

The following documentation is optional to submit to the CDC at regaffairs@cdc.gov:

• Clinical Outcome Form: Healthcare providers are strongly encouraged to complete and submit to CDC progress information during and post treatment – optional submission 3 -14 days after last patient follow-up 
• Lesion samples for resistance testing
• Pharmacokinetic samples for testing

For more information or if you have questions, providers are advised to contact the CDC IMS TPOXX IND mailbox.

For information about Mpox Treatment in patients with HIV, see

• CDC Clinical Considerations for Treatment and Prophylaxis of Mpox Virus Infection in People with HIV 
• CDC Health Advisory (Sep 29, 2022): Severe Manifestations of Mpox among People who are Immunocompromised Due to HIV or Other Conditions.

For information about Mpox Therapeutics, including TPOXX, see

• CDC Health Advisory (Nov 17, 2022): Update on Managing Mpox in Patients Receiving Therapeutics
• The TPOXX Information Sheet for Virginia Providers  provides guidance for referring patients, ordering, dispensing, and reporting TPOXX and required CDC documentation.