Supportive Care Management Recommendations for Mucocutaneous Manifestations of Monkeypox Infection

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TL;DR

This paper provides a consensus-based protocol for supportive care of mucocutaneous monkeypox lesions, drawing from management of similar conditions like herpes and aphthous stomatitis. The main finding is that standardized supportive care—including topical anesthetics, antihistamines, and wound care—can reduce hospital admissions for pain control, which accounted for 30% of hospitalizations in a recent case series. The clinical significance is that these strategies offer a practical framework for outpatient management, especially when antiviral treatments are limited.

Full summary

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**Background** The 2022 monkeypox outbreak spread to over 50 countries, presenting unique clinical challenges. While antiviral treatments like tecovirimat exist, access is limited and adverse effects may preclude use. Most cases are self-limited and managed with supportive care, but clear guidance on what supportive care entails is lacking. Pain management often relies on systemic analgesics, and specialty care (dermatology, ophthalmology, infectious diseases) may not be readily accessible. This report aims to provide supportive care strategies for mucocutaneous manifestations of monkeypox, drawing from management of similar conditions.

**Methods** The authors reviewed literature on supportive care for mucocutaneous infectious and inflammatory disorders with similar lesional morphology and symptoms to monkeypox, including herpetic lesions, Mycoplasma pneumoniae–induced rash and mucositis, cutaneous chronic graft-vs-host disease, recurrent aphthous stomatitis, and acute genital ulcerations. They developed a consensus opinion–based protocol for supportive care management of mucocutaneous lesions during monkeypox infection, organized by anatomical site (ocular, oropharyngeal, nongenital skin, genital/anorectal, proctitis) and symptom severity. The protocol includes behavioral, topical, and systemic strategies.

**Key Results** The paper presents a detailed table of supportive care recommendations. For ocular involvement, they recommend ophthalmology consultation, avoidance of contact lenses, and lubricants for minimal pain; for increasing pain or purulent discharge, topical antibiotics or antivirals (e.g., trifluridine) under ophthalmology guidance. For oropharyngeal lesions, they suggest a soft diet, adequate hydration, oral antiseptic washes, and topical anesthetics (lidocaine gel, benzocaine gel, or 'magic mouthwash' up to three times daily). For nongenital skin, they recommend washing lesions with soapy water, keeping fingernails trimmed, loose-fitting clothing, and for pain: 2.5% lidocaine–2.5% prilocaine cream or amitriptyline 2%–ketamine 0.5% cream for small areas (<30%), or systemic pain medications and lidocaine 4%-5% patches for large areas (≥30%). For pruritus, they suggest cooling lotions (menthol, camphor) for mild cases, and tap water wet wraps with moisturizers or topical corticosteroids for severe pruritus. For genital and anorectal skin, they recommend sitz baths, topical benzocaine or lidocaine gels, and barrier cream (zinc oxide) for mild pain (≤4/10), and amitriptyline 2%–ketamine 0.5% cream for severe pain (≥5/10). For proctitis, they advise adequate fluid and food intake, warm sitz baths, and consideration of gastroenterology consultation. The paper cites data from the SHARE-net Clinical Group report of 528 cases: 95% presented with rash, 73% had anogenital lesions, 41% had mucosal lesions, and the most common reasons for admission were pain management (30% of hospitalized cases) and infection control (19%). Additionally, 41% had a history of HIV infection, and 29% had a concomitant sexually transmitted infection.

**Clinical Implications** The proposed supportive care protocol aims to optimize and standardize outpatient management, potentially reducing hospital admissions for pain control—one of the most common causes of admission in monkeypox cases. This could also reduce nosocomial spread and challenges to infection prevention and control. For patients requiring admission, these strategies may minimize the amount of systemic analgesia needed. The authors emphasize the importance of comprehensive evaluation, testing, and treatment of coexisting sexually transmitted infections and secondary bacterial infections, as well as patient education on contagiousness and infection prevention. They note that treatment with systemic antivirals like tecovirimat should be considered when available per CDC guidance. The protocol provides a framework for developing supportive care strategies for related mucocutaneous manifestations of infectious and inflammatory disorders, with the understanding that management will evolve with more experience and access to antiviral treatments.