Oral acyclovir for the prevention of herpes-associated erythema multiforme

Current Perspectives on Erythema Multiforme

Recognition and timely adequate treatment of erythema multiforme remain a major challenge. In this review, current diagnostic guidelines, potential pitfalls, and modern/novel treatment options are summarized with the aim to help clinicians with diagnostic and therapeutic decision-making. The diagnosis of erythema multiforme, that has an acute, self-limiting course, is based on its typical clinical picture of targetoid erythematous lesions with predominant acral localization as well as histological findings. Clinically, erythema multiforme can be differentiated into isolated cutaneous and combined mucocutaneous forms. Atypical erythema multiforme manifestations include lichenoid or granulomatous lesions as well as lesional infiltrates of T cell lymphoma and histiocytes. Herpes simplex virus infection being the most common cause, other infectious agents like-especially in children-Mycoplasma pneumoniae, hepatitis C virus, Coxsackie virus, and Epstein Barr virus may also trigger erythema multiforme. The second most frequently identified cause of erythema multiforme is drugs. In different studies, e.g., allopurinol, phenobarbital, phenytoin, valproic acid, antibacterial sulfonamides, penicillins, erythromycin, nitrofurantoin, tetracyclines, chlormezanone, acetylsalicylic acid, statins, as well as different TNF-α inhibitors such as adalimumab, infliximab, and etanercept were reported as possible implicated drugs. Recently, cases of erythema multiforme associated with vaccination, immunotherapy for melanoma, and even with topical drugs like imiquimod have been described. In patients with recurrent herpes simplex virus-associated erythema multiforme, the topical prophylactic treatment with acyclovir does not seem to prevent further episodes of erythema multiforme. In case of resistance to one virostatic drug, the switch to an alternative drug, and in patients non-responsive to virostatic agents, the use of dapsone as well as new treatment options, e.g., JAK-inhibitors or apremilast, might be considered.

Erythema multiforme-oral variant: case report and review of literature

Erythema multiforme (EM) is an interesting dermatologic disease which has oral manifestations. EM is clinically characterized by a "minor" form and a "major" form. It presents a diagnostic dilemma because the oral cavity has the ability to produce varied manifestations. Infections (particularly herpes simplex and mycoplasma pneumonia) and drugs seem to predispose toward the development of EM. The range of possible etiologies for oral disease is immense. Therefore, an otolaryngologist or a dentist while treating such patients should have a differential diagnosis for all oral lesions. We report a case of erythema multiforme in which alcohol (ethanol) seems to be the precipitating factor and have also reviewed the English literature in the present context.

Herpes Simplex Virus Type 1 infection: overview on relevant clinico-pathological features

Herpes Simplex Virus Type 1 (HSV-1) is a nuclear replicating enveloped virus, usually acquired through direct contact with infected lesions or body fluids (typically saliva). The prevalence of HSV-1 infection increases progressively from childhood, the seroprevalence being inversely related to socioeconomic background. Primary HSV-1 infections in children are either asymptomatic or following an incubation period of about 1 week gives rise to mucocutaneous vesicular eruptions. Herpetic gingivostomatitis typically affects the tongue, lips, gingival, buccal mucosa and the hard and soft palate. Most primary oro-facial HSV infection is caused by HSV-1, infection by HSV-2 is increasingly common. Recurrent infections, which occur at variable intervals, typically give rise to vesiculo-ulcerative lesions at mucocutaneous junctions particularly the lips (herpes labialis). Recurrent HSV-1 infection within the mouth is uncommon in otherwise healthy patients, although in immunocompromised patients, recurrent infection can be more extensive and/or aggressive. The diagnosis of common herpetic infection can usually be based upon the clinical history and presenting features. Confirmatory laboratory diagnosis is, however, required when patients are, or may be, immunocompromised.

Human herpes simplex virus infections: epidemiology, pathogenesis, symptomatology, diagnosis, and management

Eight of the more than 80 known herpesviruses are human pathogens. Human herpes simplex virus (HSV) is a contagious infection with a large reservoir in the general population. It has a potential for significant complications in the immunocompromised host. In addition, psychological distress caused by the negative stigma associated with genital herpes and visible facial lesions in those experiencing frequent outbreaks renders it a challenging clinical dilemma. This article reviews the epidemiology, pathogenesis, and diagnostic features of HSV infections, providing the clinician with an up-to-date understanding of the available management strategies for mucocutaneous HSV-induced disease.

Erythema multiforme and related disorders

Erythema multiforme (EM) and related disorders comprise a group of mucocutaneous disorders characterized by variable degrees of mucosal and cutaneous blistering and ulceration that occasionally can give rise to systemic upset and possibly compromise life. The clinical classification of these disorders has often been variable, thus making definitive diagnosis sometimes difficult. Despite being often caused by, or at least associated with, infection or drug therapy, the pathogenic mechanisms of these disorders remain unclear, and as a consequence, there are no evidence-based, reliably effective therapies. The present article reviews aspects of EM and related disorders of relevance to oral medicine clinical practice and highlights the associated potential etiologic agents, pathogenic mechanisms and therapies.

Oral and perioral herpes simplex virus type 1 (HSV-1) infection: review of its management

Herpes simplex virus type 1 (HSV-1) gives rise to a variety of clinical disorders and is a major cause of morbidity and mortality worldwide. HSV-1 infections are common in oral and perioral area. The aim of the present report was to critically examine the published literature to evaluate the advantages and limitations of therapy of HSV-1 infection in both immunocompetent and immunocompromised patients. Systemic antiviral therapy has been widely accepted as effective for primary herpetic gingivostomatitis. Aciclovir (ACV) 5% cream seems to be the accepted standard topical therapy for herpes labialis, being both effective and well tolerated, although penciclovir 1% cream has been proposed as a potentially useful treatment. Systemic ACV may be effective in reducing the duration of symptoms of recurrent HSV-1 infection, but the optimal timing and dose of the treatment are uncertain. Aciclovir and famciclovir may be of benefit in the acute treatment of severe HSV-1 disease in immunocompromised patients. There is also evidence that prophylactic oral ACV may reduce the frequency and severity of recurrent attack of herpetic infection in immunocompromised patients, but the optimal timing and duration of treatment is uncertain and can vary in different situations.

Erythema multiforme ID reaction in atypical dermatophytosis: a case report

BACKGROUND

Erythema multiforme (EM) is an uncommon mucocutaneous disorder, characterized by widespread erythematous-oedematous targetoid lesions, considered as a reaction pattern to many different stimuli.

OBSERVATION

Presentation is made of a classical EM eruption concomitant to an inflammatory, atypical dermatophytosis of the ala nasi, observed in a 37-year-old male at the Dermatology Department of Cagliari, Italy.

METHODS

Laboratory investigations revealed normal complete blood count and biochemistry profile. A direct microscopic examination with 20% potassium hydroxide of the nasal skin scales and of the vibrissae indicated the presence of dermatophyte hyphae and spores invading the rhinothrix. Culture confirmed a Trycophyton mentagrophytes infection. Specific determination of antiviral immunity in the blood (TORCH) was negative for recent infections, while the cell-mediated response, investigated with a delayed skin multitest, showed a marked positivity for the tricophyton antigen. Systemic therapy with terbinafine (250 mg/day) led to complete clinical and mycological recovery of the atypical ringworm in 30 days. Multiforme lesions rapidly improved and completely disappeared in 7 days.

CONCLUSIONS

ID reaction to a distant focus of dermatophyte infection very rarely presents as EM. The presented case fits all the essential criteria required for the diagnosis of an ID reaction. The atypical clinical presentation of the ringworm infection, with marked involvement of the intranasal hairs, seems to have induced an inflammatory allergic response, similar to that evoked by sycosis.

Recent progress in herpes simplex virus immunobiology and vaccine research

Herpes simplex virus types 1 and 2 (HSV-1 and HSV-2) cause prevalent, chronic infections that have serious outcomes in some individuals. Neonatal herpes may occur when the infant traverses the cervix during maternal genital herpes. Genital herpes is a major risk factor for human immunodeficiency virus type 1 transmission. Considerable efforts have been made to design and test vaccines for HSV, focusing on genital infection with HSV-2. Several protein subunit vaccines based on HSV-2 envelope glycoproteins have reached advanced-phase clinical trials. These antigens were chosen because they are the targets of neutralizing-antibody responses and because they elicit cellular immunity. Encouraging results have been reported in studies of treatment of HSV-seronegative women with a vaccine consisting of truncated glycoprotein D of HSV-2 and a novel adjuvant. Because most sexual HSV transmission occurs during asymptomatic shedding, it is important to evaluate the impact of vaccination on HSV-2 infection, clinically apparent genital herpes, and HSV shedding among vaccine recipients who acquire infection. There are several other attractive formats, including subunit vaccines that target cellular immune responses, live attenuated virus strains, and mutant strains that undergo incomplete lytic replication. HSV vaccines have also been evaluated for the immunotherapy of established HSV infection.

Treatment of mucocutaneous presentations of herpes simplex virus infections

Infections by herpes simplex virus (HSV) types I and II are diverse and quite frequent. After primary infection, the virus establishes a life-long latency in the sensory ganglia and recrudescences may occur at an unpredictable rate. Recurrent labial and genital herpes infections represent the majority of clinical manifestations of HSV infections. Their management is currently well established using evidence-based medicine data. Primary labial herpes is generally not treated with antivirals in otherwise healthy children, although intravenous aciclovir may be offered in severe primary infections, particularly in the immunocompromised patient. The decision whether or not to treat recurrent labial herpes should be evaluated individually and depends on the frequency and severity of relapses, the impairment of the quality of life, and the cost of therapy. Patients with mild disease may benefit from topical therapy, and those with severe and frequent recurrences may be considered for intermittent or long-term oral antiviral therapy. Primary genital herpes is treated with oral or intravenous antivirals, depending on the severity of the infection and associated symptoms. Recurrent genital herpes can be managed with episodic short courses of oral antivirals in patients whose recurrences are moderate to severe and rare, and have a clear prodrome. Patients with >5 episodes/year, severe recurrences or unrecognisable prodromes may be best managed with long-term suppressive antiviral prophylaxis. HSV is also responsible for a variety of other clinical manifestations, including herpetic whitlow, neonatal infection, disseminated and atypical cutaneous infections, traumatic herpes, eczema herpeticum, and HSV-associated erythema multiforme. HSV infection may also represent a complication following cosmetic procedures of the oro-facial region, surgical and dental interventions, sun exposure and burns. Precise treatment guidelines for these HSV infections are not firmly established.

Long-term oral acyclovir therapy. Effect on recurrent infectious herpes simplex keratitis in patients with and without grafts

PURPOSE

To evaluate the efficacy of long-term oral acyclovir therapy in reducing recurrences of dendritic or geographic herpes simplex keratitis (HSK).

METHODS

Thirteen patients with a history of frequently recurring HSK were followed before (mean, 27 months) and during long-term systemic acyclovir, and eight were followed after the acyclovir was discontinued.

RESULTS

Treatment ranged from 8.5 to 62 months (mean, 34 months). During treatment, the number of recurrences per month decreased from 0.15 to 0.03, and the average duration of relapses decreased from 12.6 to 7.8 days. Recurrences correlated with daily doses of oral acyclovir of 800 mg or less, intraocular surgery within 6 weeks of initiating treatment, and discontinuation of therapy against medical advice.

CONCLUSION

The results of this small study appear to demonstrate the efficacy of long-term oral acyclovir in prophylaxis of recurrent epithelial herpes simplex infection: therapeutic doses of oral acyclovir reduce both the rate and duration of recurrences of infectious herpetic keratitis. A multicenter, double-masked, placebo-controlled study is indicated.

A double-blind, placebo-controlled trial of continuous acyclovir therapy in recurrent erythema multiforme

Twenty patients who suffered from more than four attacks of erythema multiforme (EM) per year were enrolled in a 6-month double-blind, placebo-controlled trial of acyclovir 400 mg twice daily. Fifteen patients had disease precipitated by recurrent herpes simplex. In the acyclovir-treated group the median number of EM attacks during the treatment period was zero, compared with three in the placebo-treated group (P < 0.0005, Wilcoxon rank sum test). Seven of the 11 patients treated with continuous acyclovir did not have any attacks of EM while taking the drug, and one showed almost complete disease suppression. Following treatment with acyclovir, two patients went into complete remission, whereas all individuals in the placebo group continued to have attacks. In the acyclovir-treated group nine of the 11 patients had herpes simplex-precipitated disease. One of the two patients with idiopathic disease showed complete disease suppression while on acyclovir, lending support to the view that idiopathic recurrent EM may be related to subclinical herpetic infection. In this study, we have shown that continuous acyclovir therapy can completely suppress attacks of recurrent EM and, in some cases, may induce disease remission.

Characteristics of the oral lesions in patients with cutaneous recurrent erythema multiforme

Erythema multiforme may be recurrent and the oral cavity is often affected. A series of 82 patients with unequivocal recurrent cutaneous erythema multiforme were examined to determine the incidence and nature of oral lesions. Seventy per cent of patients had oral lesions, comprising multiple, large, shallow, extremely painful and debilitating ulcers, which affected the entire oral mucosa in over 20%. The buccal mucosa and tongue were the most frequently affected sites in the remainder and the lips were affected in 13% of patients. Lesions generally lasted for 1-3 weeks. In over 60% of cases these attacks followed an episode of herpes simplex virus infection during the preceding fortnight. Recurrent attacks showed a different site distribution from the initial attacks, with a greater proportion having genital as well as skin and oral mucosal involvement. Detailed case histories of five patients are presented to illustrate the role of azathioprine in treating oral lesions and to document a familial case of recurrent erythema multiforme, with severe mucosal involvement.

Are viruses associated with aphthae and oral vesiculo-erosive disorders?

Oral and maxillofacial surgeons in District General Hospitals in UK often carry the major workload of patients with chronic oral ulcerative conditions. Although the immunopathogenic basis of many of these is being unravelled, the aetiology is often unclear, though a role for viruses is increasingly suspected. This paper reviews the current evidence.

Recurrent erythema multiforme: clinical features and treatment in a large series of patients

Recurrent erythema multiforme is an uncommon disorder. We have reviewed the clinical features and treatment of 65 patients with this condition. The mean number of attacks per year was six (range 2-24), and the mean duration of the disease was 9.5 years (range 2-36) reflecting its chronicity. The majority of patients had oral mucous membrane involvement (69%). In 46 patients (71%) the condition was precipitated by a preceding herpes simplex virus infection. Acyclovir was found to be the most useful first-line treatment, with 55% of patients deriving benefit from either continuous oral acyclovir or a patient-initiated 5-day oral course at the onset of herpes simplex virus infection. Of those failing to respond to acyclovir, a small proportion responded to dapsone. The most resistant patients (11) were treated with azathioprine, with complete disease suppression in all cases.

Prophylactic chemotherapy with acyclovir for recurrent herpes simplex labialis

The medical literature was reviewed and 11 clinical trials of prophylactic topical or peroral acyclovir for the suppression of recurrent herpes simplex labialis were identified. The results of these trials showed that prophylactic topical acyclovir was mostly ineffective, but that prophylactic peroral acyclovir, in doses ranging from 400 to 1,000 mg/day, reduced the frequency of herpes labialis during treatment by 50-78%. The reduction in the frequency of episodes of herpes labialis with acyclovir prophylaxis is less than the suppressive effect that has been reported for herpes genitalis (50-78% vs. 80-90%). In trials of prophylactic acyclovir for herpes labialis induced by experimental ultraviolet radiation, 26% of induced lesions developed within 48 hours of radiation exposure ("immediate" lesions) and, in contrast to "delayed" lesions that developed 2-7 days post-irradiation, were not suppressed by the antiviral compound. It is proposed that these treatment-unresponsive immediate lesions have an atypical pathogenesis, possibly involving latency of herpes simplex virus in the labial epithelium, and that these may be responsible for the apparent difference between herpes labialis and genitalis in the degree of benefit from prophylactic acyclovir therapy.

Erythema multiforme: a literature review and case report

Erythema multiforme is a florid mucocutaneous disease characterized by oral, cutaneous, and ocular manifestations. The cutaneous lesions are pathognomonic because of their unique "target-like" appearance. A severe form of EM has been termed "Stevens-Johnson Syndrome". Although the etiology of EM is unknown, much of the research suggests an immunological association with HSV. The diagnosis of EM is based on signs and symptoms, and a differential diagnosis should include other ulcerative, mucocutaneous diseases, such as erosive lichen planus, pemphigus, varicella zoster, ANUG, TEN, aphthous stomatitis, and primary HSV. Therapeutic measures are palliative, including a soft bland diet, topical anesthetics, and corticosteroids. A case of EM is described which underscores the appearance of the disease and its clinical course.

Blistering disorders in childhood

Many conditions present in childhood with vesicles and bullae, ranging from benign conditions to life-threatening diseases. This article reviews selected blistering disorders, with emphasis on new information that is helpful to the practicing physician. Entities that are discussed in this article include childhood zoster and fetal varicella syndrome, urticaria pigmentosa, scabies, bullous bug bites, lichen sclerosus et atrophicus, epidermolysis bullosa, and erythema multiforme.

Topical treatment of cutaneous herpes simplex virus infections

Topical antiviral chemotherapy has a number of potential advantages over systemic drug delivery for the treatment of cutaneous herpes simplex virus infections, including convenience; higher target tissue drug levels and greater efficacy; and specific targeting of the drug to the site of infection, with reduced cost and reduced exposure of the remainder of the body to drug side effects. Realization of these possibilities has been slow in part because of the paucity of 'active' topical drug formulations with effective penetration-enhancing agents and a technical barrier-our failure as yet to measure drug levels in the epidermis, which could guide formulation development. Recent success with a topical treatment for herpes simplex labialis should stimulate continued laboratory and clinical research in this field.

Common nonvenereal genital lesions

There are a wide variety of local and systemic skin diseases that produce lesions in the genitoanal region. These lesions may resemble those produced by sexually transmitted microorganisms. The purpose of this article is to make physicians aware of the common skin diseases that produce lesions on the genitalia to avoid the inappropriate diagnosis of a sexually transmitted disease.

Detection of herpes simplex virus DNA in cutaneous lesions of erythema multiforme

The association between erythema multiforme (EM) and herpes simplex virus (HSV) infection has long been appreciated, although the exact role which HSV may play in the pathogenesis of this herpes-associated EM (HAEM), is unknown. Previous studies have suggested, but not definitively demonstrated, the presence of HSV in lesions of HAEM. The presence of HSV would support the hypothesis that an immune-mediated response directed against HSV-specific antigens in the skin is central to lesion development in HAEM. The purpose of this study was to examine lesions of EM for the presence of HSV DNA by using the polymerase chain reaction (PCR). In addition, in situ hybridization using an HSV-specific RNA probe was performed to further localize the HSV nucleic acids within the skin. DNA was extracted from formalin-fixed, paraffin-embedded specimens of cutaneous lesions of HAEM and also from EM for which no precipitating factor could be documented, otherwise known as idiopathic EM (IPEM). DNA from lesions of bullous pemphigoid served as a negative control. Using PCR to specifically amplify HSV sequences which might be present, and then performing Southern analysis, we demonstrated HSV DNA in 9/13 HAEM and 6/9 IPEM biopsies. No HSV was detected in six lesions of bullous pemphigoid. In situ hybridization of three cutaneous HAEM lesions using an 35S-labeled HSV-specific RNA probe localized the HSV nucleic acids predominantly to the epidermis. Three biopsies of chronic dermatitis, used as negative controls, did not demonstrate this specific hybridization. These findings confirm the presence of HSV in lesions of HAEM and are consistent with the concept of an HSV-specific immune-mediated pathogenesis for this disease. In addition, most cases of IPEM appear to be herpes associated despite the absence of clinically apparent HSV infection.

Controversy: are systemic steroids indicated in the treatment of erythema multiforme?

The treatment of erythema multiforme major with systemic steroids became established during the 1950s. Recently, two retrospective case reviews comparing steroid-treated and nonsteroid-treated groups of patients with erythema multiforme found that these agents may be associated with complications. As a result, many clinicians have become uncertain as to the appropriate therapy of this disease entity. We successfully treated the condition with steroids in two children and one adolescent. The controversy over the potential efficacy of such therapy for erythema multiforme persists, however.

Dermatologic therapy: December 1985 to December 1986

I have reviewed the significant therapeutic changes reported in the English literature between December 1985 and December 1986. Readers should review the original articles in toto before attempting any new experimental or controversial therapy summarized.