The natural history of ultraviolet radiation-induced herpes simplex labialis and response to therapy with peroral and topical formulations of acyclovir

COMPARATIVE EFFICACY OF ANTIVIRAL AGENTS FOR PREVENTION AND MANAGEMENT OF HERPES LABIALIS: A SYSTEMATIC REVIEW AND NETWORK META-ANALYSIS

OBJECTIVE

To compare the relative efficacy and safety of antiviral agents used in the prevention and management of herpes labialis through a network meta-analysis of clinical trials.

METHODS

A systematic search was performed in Ovid Medline PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Scopus and Clinicaltrials.gov for randomized controlled trials (RCTs) reporting a comparison of antiviral agents in the management and prevention of herpes labialis in healthy/immunocompetent adults. The data extracted from the selected RCTs were assessed and a network meta-analysis (NMA) was performed. The interventions were ranked according to the surface under the cumulative ranking (SUCRA).

RESULTS

A total of 52 articles were included for qualitative synthesis and for the quantitative part, 26 articles were analyzed for the primary treatment outcome and 7 studies were analyzed for the primary prevention outcome. The combination therapy of oral valacyclovir and topical clobetasol was the best ranked with a mean reduction in healing time of -3.50 (95% CI -5.22 to -1.78) followed by vidarabine monophosphate of -3.22 (95% CI -4.59 to -1.85). No significant inconsistencies, heterogeneity, and publication bias were reported for TTH outcome analysis. For primary prevention outcomes, only 7 RCTs fulfilled the inclusion criteria, and none of the interventions was shown to be superior to each other. The absence of adverse events was reported by 16 studies, whereas other studies reported mild side effects only.

CONCLUSION

NMA highlighted that several agents were effective in the management of herpes labialis among which the combination of oral valacyclovir with topical clobetasol therapy was the most effective in reducing the time to heal. However, further studies are required to determine which intervention is the most effective in preventing the recurrence of herpes labialis.

A Comprehensive Overview of Epidemiology, Pathogenesis and the Management of Herpes Labialis

Herpes labialis remains exceedingly prevalent and is one of the most common human viral infections throughout the world. Recurrent herpes labialis evolves from the initial viral infection by herpes simplex virus type 1 (HSV-1) which subsequently presents with or without symptoms. Reactivation of this virus is triggered by psychosocial factors such as stress, febrile environment, ultraviolet light susceptibility, or specific dietary inadequacy. This virus infection is also characterized by uninterrupted transitions between chronic-latent and acute-recurrent phases, allowing the virus to opportunistically avoid immunity and warrant the transmission to other vulnerable hosts simultaneously. This review comprehensively evaluates the current evidence on epidemiology, pathogenesis, transmission modes, clinical manifestations, and current management options of herpes labialis infections.

Interventions for prevention of herpes simplex labialis (cold sores on the lips)

BACKGROUND

Herpes simplex labialis (HSL), also known as cold sores, is a common disease of the lips caused by the herpes simplex virus, which is found throughout the world. It presents as a painful vesicular eruption, forming unsightly crusts, which cause cosmetic disfigurement and psychosocial distress. There is no cure available, and it recurs periodically.

OBJECTIVES

To assess the effects of interventions for the prevention of HSL in people of all ages.

SEARCH METHODS

We searched the following databases up to 19 May 2015: the Cochrane Skin Group Specialised Register, the Oral Health Group Specialised Register, CENTRAL in the Cochrane Library (Issue 4, 2015), MEDLINE (from 1946), EMBASE (from 1974), LILACS (from 1982), the China National Knowledge Infrastructure (CNKI) database, Airiti Library, and 5 trial registers. To identify further references to relevant randomised controlled trials, we scanned the bibliographies of included studies and published reviews, and we also contacted the original researchers of our included studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of interventions for preventing HSL in immunocompetent people.

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials, extracted data, and assessed the risk of bias. A third author was available for resolving differences of opinion.

MAIN RESULTS

This review included 32 RCTs, with a total of 2640 immunocompetent participants, covering 19 treatments. The quality of the body of evidence was low to moderate for most outcomes, but was very low for a few outcomes. Our primary outcomes were 'Incidence of HSL' and 'Adverse effects during use of the preventative intervention'.The evidence for short-term (≤ 1 month) use of oral aciclovir in preventing recurrent HSL was inconsistent across the doses used in the studies: 2 RCTs showed low quality evidence for a reduced recurrence of HSL with aciclovir 400 mg twice daily (risk ratio (RR) 0.26, 95% confidence interval (CI) 0.13 to 0.51; n = 177), while 1 RCT testing aciclovir 800 mg twice daily and 2 RCTs testing 200 mg 5 times daily found no similar preventive effects (RR 1.08, 95% CI 0.62 to 1.87; n = 237; moderate quality evidence and RR 0.46, 95% CI 0.20 to 1.07; n = 66; low quality evidence, respectively). The direction of intervention effect was unrelated to the risk of bias. The evidence from 1 RCT for the effect of short-term use of valaciclovir in reducing recurrence of HSL by clinical evaluation was uncertain (RR 0.55, 95% CI 0.23 to 1.28; n = 125; moderate quality evidence), as was the evidence from 1 RCT testing short-term use of famciclovir.Long-term (> 1 month) use of oral antiviral agents reduced the recurrence of HSL. There was low quality evidence from 1 RCT that long-term use of oral aciclovir reduced clinical recurrences (1.80 versus 0.85 episodes per participant per a 4-month period, P = 0.009) and virological recurrence (1.40 versus 0.40 episodes per participant per a 4-month period, P = 0.003). One RCT found long-term use of valaciclovir effective in reducing the incidence of HSL (with a decrease of 0.09 episodes per participant per month; n = 95). One RCT found that a long-term suppressive regimen of valaciclovir had a lower incidence of HSL than an episodic regimen of valciclovir (difference in means (MD) -0.10 episodes per participant per month, 95% CI -0.16 to -0.05; n = 120).These trials found no increase in adverse events associated with the use of oral antiviral agents (moderate quality evidence).There was no evidence to show that short-term use of topical antiviral agents prevented recurrent HSL. There was moderate quality evidence from 2 RCTs that topical aciclovir 5% cream probably has little effect on preventing recurrence of HSL (pooled RR 0.91, 95% CI 0.48 to 1.72; n = 271). There was moderate quality evidence from a single RCT that topical foscarnet 3% cream has little effect in preventing HSL (RR 1.08, 95% CI 0.82 to 1.40; n = 295).The efficacy of long-term use of topical aciclovir cream was uncertain. One RCT found significantly fewer research-diagnosed recurrences of HSL when on aciclovir cream treatment than on placebo (P < 0.05), but found no significant differences in the mean number of participant-reported recurrences between the 2 groups (P ≥ 0.05). One RCT found no preventive effect of topical application of 1,5-pentanediol gel for 26 weeks (P > 0.05). Another RCT found that the group who used 2-hydroxypropyl-β-cyclo dextrin 20% gel for 6 months had significantly more recurrences than the placebo group (P = 0.003).These studies found no increase in adverse events related to the use of topical antiviral agents.Two RCTs found that the application of sunscreen significantly prevented recurrent HSL induced by experimental ultraviolet light (pooled RR 0.07, 95% CI 0.01 to 0.33; n = 111), but another RCT found that sunscreen did not prevent HSL induced by sunlight (RR 1.13, 95% CI 0.25 to 5.06; n = 51). These RCTs did not report adverse events.There were very few data suggesting that thymopentin, low-level laser therapy, and hypnotherapy are effective in preventing recurrent HSL, with one to two RCTs for each intervention. We failed to find any evidence of efficacy for lysine, LongoVital® supplementation, gamma globulin, herpes simplex virus (HSV) type I subunit vaccine, and yellow fever vaccine in preventing HSL. There were no consistent data supporting the efficacy of levamisole and interferon, which were also associated with an increased risk of adverse effects such as fever.

AUTHORS' CONCLUSIONS

The current evidence demonstrates that long-term use of oral antiviral agents can prevent HSL, but the clinical benefit is small. We did not find evidence of an increased risk of adverse events. On the other hand, the evidence on topical antiviral agents and other interventions either showed no efficacy or could not confirm their efficacy in preventing HSL.

Delayed type hypersensitivity in the pathogenesis of recurrent herpes stromal keratitis

Recurrent herpes stromal keratitis (HSK) is one of the leading causes of blindness in the developed world. Cyokines characteristic of Th1 cells (in particular IFN-γ and IL-2) have been shown to dominate in HSK in addition to mechanisms by nonspecific, antigen-independent effector cells such as neutrophils, basophils, and monocytes. More recently, the migration and maturation of dendritic cells (DC) within the corneal stroma of patients with HSK have been recognized as contributors to recurrent disease, suggesting a role for delayed type hypersensitivity (DTH) in the immunopathogenesis of HSK. The role of DC and DTH in recurrent HSK has not been studied extensively and experimental models of recurrent HSK focusing on DTH as the pathogenesis and viral particles as the triggering antigen may contribute to better understanding of the disease.

A case series: herpes simplex virus as an occupational hazard

Statement of the Problem

Herpes labialis infections are common and present a serious risk to the dental team.

Purpose of the Study

The purpose is to make dentists aware of the risks involved with treatment of patients with active herpes labialis. In addition, evidence-based risk-management strategies are presented.

Methods and Materials

The incidence and natural history of herpes simplex virus type 1 (HSV-1) are reviewed. Four previously unreported case histories are presented to illustrate the impact common sequelae of HSV-1 can have on the dental team. The differences between HSV-1 and the blood-borne diseases which are the focus of universal precautions are discussed. In particular, the highly contagious, highly transmissible nature of HSV-1 and its transmission through aerosols are highlighted. Finally, the need to include protection against aerosols in the profession's understanding of universal precautions is noted.

Results

The authors suggest limiting the treatment of patients with active lesions to urgent care only, and treating active HSV-1 lesions to reduce time of healing. For four common clinical situations involving HSV-1 infections, evidence-based methods for protecting the dental team and the patient from cross-contamination are also presented.

Conclusion

While it is clear that the treatment of patients with active herpes labialis lesions increases risk of cross-infection, there are good protocols for controlling this risk.

CLINICAL SIGNIFICANCE

By bringing common vectors of cross-infection to light and providing evidence-based protocols for preventing them, this article provides practitioners with positive steps that can be taken for controlling the risk of spreading herpes infections to the dental team.

(J Esthet Restor Dent 24:61–67, 2012)

Treatment of herpes labialis: comparison of two OTC drugs and untreated controls

STATEMENT OF THE PROBLEM

Rapid resolution of active herpes labialis lesions is of great benefit to the patient not only in terms of controlling pain and disfigurement, but in disruption of needed dental treatment.

PURPOSE OF THE STUDY

Using three groups, this retrospective study investigated the time required to complete healing and the loss of discomfort.

METHODS AND MATERIALS

Based on 180 completed surveys, responses were divided into three groups: One group used Abreva (GlaxoSmithKline, Parsippany, NJ, USA). The second used Viroxyn (Quadex Pharmaceuticals, West Jordan, UT, USA). The third group, the Control group, consisted of untreated lesions. All three groups were asked about past experiences with lesions treated using Abreva and/or Viroxyn, and lesions which were left untreated. In addition, 58 participants who had used Viroxyn only responded. Participants were provided standardized responses from which to choose.

RESULTS

For both the time to healing and time to loss of discomfort, participants in both the Abreva and Viroxyn groups experienced significant improvements. Relative to the Abreva, Viroxyn provided significant improvement in both outcomes (all t-tests; all p < 0.001). Relative to the Control group, Viroxyn and Abreva offered an 8.0 and 4.0 day reduction in time to healing, respectively. Loss of discomfort occurred within 3.0 days and 1 hour for Abreva and Viroxyn, respectively.

CONCLUSION

Relative to the untreated controls, both Abreva and Viroxyn offered a significant reduction in both the time to healing and time to loss of discomfort. Furthermore, Viroxyn offered a significant reduction relative to Abreva. .

Identifying potential pitfalls in conventional herpes simplex virus management

In recent years, it has become increasingly clear that genital ulcers from herpes simplex virus (HSV) are associated with HIV acquisition. In light of this evolving synergy in transmission and the availability of effective antiviral therapy, proper diagnosis and management of HSV becomes increasingly important. Unfortunately, conventional HSV management is founded on several popular misconceptions. Herein, we hope to dispel these common misconceptions and expand the current model of herpetic reactivation. By doing so, we aimed to unveil potential pitfalls in current herpetic management.

Spontaneous reactivation of herpes simplex virus type 1 in latently infected murine sensory ganglia

Careful studies of mouse trigeminal ganglia (TG) latently infected with herpes simplex virus type 1 (HSV-1) indicate the presence of productive cycle viral gene products and persistent immune response, suggesting ongoing spontaneous viral reactivation in these tissues. In the present study we set out to determine whether infectious virus is present in murine TG latently infected with HSV-1 (KOS). At 37 days after ocular inoculation we found a small amount of infectious virus in ca. 6% of latently infected murine TG. Furthermore, the amount of infectious virus that we detected (PFU per viral antigen-positive neuron) was similar to that detected in acutely infected ganglia. We conclude that spontaneous reactivation of infectious HSV-1 occurs in the mouse TG and is likely the principle cause of viral protein expression in these tissues. We next examined the role of latency-associated transcript (LAT) in spontaneous ganglionic reactivation by examining ganglia latently infected with KOS dlLAT1.8, a LAT deletion virus. Through the use of immunocytochemistry we found that KOS dlLAT1.8 had a rate of spontaneous ganglionic reactivation very similar to that of HSV-1 (KOS). Studying spontaneous ganglionic reactivation of HSV in the mouse TG allows a direct study of viral reactivation from latently infected neurons without the potential confounders and complicating downstream events that accompany the study of viral reactivation by explantation or peripheral viral shedding. Since most cases of human viral shedding and reactivation are not associated with a known trigger, spontaneous ganglionic reactivation of HSV-1 may be a better model of human disease than existing models.

Management of recurrent oral herpes simplex infections

The literature has been reviewed for evidence of the efficacy of antiviral agents in both the prophylaxis and treatment of recurrent oral herpes simplex virus (HSV) infections and discussed by a panel of experts. Emphasis was given to randomized controlled trials. Management of herpes-associated erythema multiforme and Bell palsy were also considered. The evidence suggests that 5% acyclovir (ACV) in the cream base may reduce the duration of lesions if applied early. Recurrent herpes labialis (RHL) and recurrent intraoral HSV infections can be effectively treated with systemic ACV 400 mg 3 times a day or systemic valacyclovir 500 to 1000 mg twice a day for 3 to 5 days (longer in the immunocompromised). RHL in the immunocompetent can be effectively prevented with (1) sunscreen alone (SPF 15 or above), (2) systemic ACV 400 mg 2 to 3 times a day, or (3) systemic valacyclovir 500 to 2000 mg twice a day. Valacyclovir 500 mg twice a day is also effective in suppressing erythema multiforme triggered by HSV. Further studies are needed to compare treatment efficacy between topical penciclovir, docosanol, and ACV cream for RHL.

A practical UV source to induce Herpes simplex labialis lesions in the clinic

BACKGROUND

Ultraviolet (UV) sources have been used to clinically induce herpes simplex lesions in the lips of susceptible individuals.

METHODS

This study reports the optimization of a UV source for studies involving multiple clinical laboratory sites and subsequent clinical UV induction of cold sore lesions. We describe novel adaptations of a commercially available broadband UV phototherapy lamp that facilitate determination of individual's minimal erythemal dose (MED) and expose the lips with minimal risk of viral transmission to or between the volunteers and technicians.

CLINICAL RESULTS

The source performed well in a clinical setting, with 171 of 386 subjects (44%) developing lesions, an induction rate similar to spectrally similar UV sources.

CONCLUSIONS

The advantages of consistent and reproducible exposure geometry, additional UV shielding and biological hygiene achieved by our method significantly enhance the execution of UV-induced herpes simplex labialis studies.

A randomised double-blind study comparing the effect of 1072-nm light against placebo for the treatment of herpes labialis

BACKGROUND

Previous research demonstrated that 1072-nm narrowband laser light is effective in the treatment of cold sores.

AIM

To evaluate the efficacy of an over-the-counter cold-sore treatment device (Virulite CS) incorporating 1072-nm light-emitting diodes.

METHODS

A randomised, prospective, double-blind, self-reported study was performed to compare the efficacy of at least six 3-min treatments of 1072-nm narrowband light against placebo, in the treatment of herpes labialis.

RESULTS

The 1072-nm light-emitting diode device reduced cold-sore healing time to 6.3 days compared with 9.4 days for placebo (P=0.048). The time the cold sore took to form a crust was also reduced from 2.00 days for those treated with 1072-nm light, compared with 2.88 days for placebo (P=0.059)

CONCLUSIONS

The significant difference between the mean healing times in the two groups demonstrates that the Virulite CS device is an effective means of treating herpes labialis.

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.

Herpes Simplex Virus Infections in Neonates and Early Childhood

Of the commonly considered congenital infections, those caused by cytomegalovirus (CMV), syphilis, and herpes simplex virus (HSV) are frequently (CMV, HSV) or exclusively (syphilis) acquired sexually by the mother, with subsequent transmission to the developing fetus. Of the other commonly considered congenital infections, including rubella and toxoplasma infections, the mother is exposed to the infectious agent via interpersonal or environmental contacts. Unlike each of these other pathogens, which are transmitted transplacentally to the developing fetus following maternal infection though, HSV usually is transmitted perinatally as the neonate is exposed to the virus during passage through an infected birth canal. This difference in timing of acquisition of infection has had important consequence in the therapeutic advances achieved during the last 30 years in the management of neonatal HSV infections. Because the time period between the acquisition of infection and initiation of effective antiviral therapy is shorter in neonatal herpes than in congenital toxoplasmosis or CMV infections, the outcomes of therapy have the potential to be markedly different. This article will summarize the current state of neonatal HSV disease presentation, diagnosis, and management.

Antiviral therapies in children: has their time arrived?

The increase in the number and classes of antiviral agents that has occurred since the 1980s is remarkable. The rapid expansion in therapeutic options for previously untreatable illnesses challenges clinicians to gain familiarity and experience with these new drugs, especially with regard to their use in children. This article describes the clinical utilities, pharmacokinetics, and adverse effects of these new drugs to empower practitioners to use them appropriately.

Inhibition of Cyclooxygenase 2 Synthesis SuppressesHerpes simplexVirus Type 1 Reactivation

Recurrent herpes virus infection, in which the virus reactivates from the nervous system and causes painful lesions in peripheral tissues, is a significant clinical problem. Our recent studies showing that the amount of cyclooxygenase 2 (COX-2) in the trigeminal ganglia of heat-stressed untreated mice is higher than the amount in heat-stressed mice treated with the COX-2 inhibitor, celecoxib, have indicated that the prostaglandin synthesis pathway--and in particular COX-2--may be an intermediate in the pathway to herpes viral reactivation. To further study this process, we infected the corneas of mice using topical application to a lightly scratched epithelium and waited 30 days for Herpes simplex virus type 1 (HSV-1) latency to be established in the trigeminal ganglia. Prior to the induction of viral reactivation, the mice were treated orally with celecoxib. Treated and untreated mice were induced to undergo reactivation by immersion in 43 degrees C water for 10 min. The shedding of virus at the ocular surface was determined by culturing ocular swabs with indicator cells. The presence of infectious virus in the trigeminal ganglion was evaluated by incubating ganglion homogenates with indicator cells and observing for cytopathic effect. Celecoxib treatment significantly suppressed viral reactivation when given prophylactically by the gastrointestinal route. The numbers of corneas and ganglia containing infectious virus were significantly lower in the celecoxib-treated animals, compared to the placebo-treated mice. These experiments demonstrate that a selective COX-2 inhibitor can suppress hyperthermic stress-induced herpes viral reactivation in the nervous system. It may be possible to use COX-2 inhibitors to prevent viral reactivation in high-risk patients by drug prophylaxis.

Recurrent herpes labialis in US children and youth

OBJECTIVE

This study reports data from the Third National Health and Nutrition Examination Study, 1988-1994 (NHANES III).

METHODS

NHANES III was a complex, multistage sample of 33 994 civilian, non-institutional individuals from 19 528 households. Dentist examiners were trained to recognize, classify oral mucosal lesions to include recurrent herpes labialis (RHL). Subjects >or=8 years of age were asked if they had cold sores in the past year and serologic tests for herpes virus type 1 (HSV-1) and type 2 (HSV-2) were performed on blood of youth >12 years of age.

RESULTS

Examinations were performed on 10 032 individuals 2-17 years of age. Overall point prevalence was 1.42% (0.69-2.15); annual prevalence in individuals 8-17 years of age was 14.77% (12.74-16.80); and serologic prevalence of HSV-1 in youth 12-17 years of age was 43.18% (38.88-47.48). When the data were subset to youth 12-17, annual prevalence for seropositives was 24.13% (20.44-27.82) compared with 16.87 (14.16-19.57) for all subjects. Approximately 25% of the seropositive youth had at least one recurrence in the past year.

CONCLUSION

As RHL is a recurrent infection, prevalence in a population will be related to the proportion of the population that has been infected with herpes simplex virus. When lesion-specific prevalences are cited in the literature, they should be stratified by covariates known to be associated with them. Future studies should examine RHL prevalence in infected individuals.

Viral diseases of the oral mucosa

A wide variety of both DNA and RNA viruses affect the oral cavity. When considered in conjunction with cutaneous features, careful examination of the oral mucosa and oropharynx aids the clinician in making a diagnosis. Examination of the oral cavity should be incorporated as a regular component of the dermatologic examination because diagnostic clues are readily available to assist in the evaluation of infectious processes.

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.

Double-blind, randomized, placebo-controlled study of topical 5% acyclovir-1% hydrocortisone cream (ME-609) for treatment of UV radiation-induced herpes labialis

Immunopathology is recognized as an important component of infectious disease manifestations, and corticosteroids have been used as an adjunct to antimicrobial therapy for a variety of conditions. Antiviral therapy of herpes labialis has been shown to result in only a small reduction in the time to healing and the duration of pain. To determine if topical application of a combination product containing 5% acyclovir and 1% hydrocortisone (ME-609) could provide benefit to herpes labialis patients, 380 immunocompetent adults with a history of herpes labialis were exposed to experimental UV radiation (UVR) to induce a recurrence. On day 2, just before the appearance of the majority of lesions ("delayed" lesions), subjects were randomized to receive active medication or vehicle control six times per day for 5 days. Overall, 120 of 380 patients developed delayed classical lesions, of whom 50 of 190 (26%) had been treated with ME-609 and 70 of 190 (37%) had received placebo (a reduction of 29% [P = 0.02]). Healing time, measured as the time to normal skin, was reduced by treatment with ME-609 (9.0 days for treated patients versus 10.1 days for the controls [P = 0.04]). There was a trend toward a reduction in the maximum lesion size in the ME-609 recipients compared to that in the controls (43 versus 60 mm(2), respectively [P = 0.07]). The treatment had no effect on lesion pain, but ME-609 treatment reduced the number of patients with moderate or severe tenderness. Compared to treatment with a placebo, treatment with the combination antiviral-immunomodulatory cream provided benefit to patients with experimental UVR-induced herpes labialis, reducing classical lesion incidence, healing time, lesion size, and lesion tenderness. ME-609 is a novel product that merits further evaluation as a treatment for cold sores.

Ultraviolet light induces reactivation in a murine model of cutaneous herpes simplex virus-1 infection

We have developed a model of cutaneous herpes simplex virus-1 (HSV-1) reactivation in SKH-1 hairless mice which closely mimics the condition in humans. Sixty plaque-forming units of HSV-1 strain 17 syn+ were applied to a superficially abraded area on the lateral body wall. More than 85% of mice developed primary HSV-1 infection characterized by a zosteriform pattern of cutaneous vesiculation and ulceration. Approximately one-third of mice with primary skin lesions succumbed to neurologic disease and in the remaining mice cutaneous lesions healed completely. Subsequent exposure of healed areas to two minimal inflammatory doses of UV resulted in recrudescence of skin lesions in the irradiated areas in almost 60% of mice. Lesions appeared approximately 4 days after irradiation, persisted for 3-5 days and then resolved completely. Reactivation rarely resulted in death due to neurologic disease. Primary lesions had a histologic appearance typical of cutaneous HSV-1 infection with vesicles and focal epithelial necrosis accompanied by the formation of epithelial syncytial cells and the presence of herpetic intranuclear inclusion bodies. In primary lesions HSV-1 was demonstrated by immunohistochemistry, polymerase chain reaction and culture. In reactivated lesions epithelial syncytia and inclusion bodies were not seen; however, virus was demonstrable by polymerase chain reaction and culture. Exposure of the uninfected side to UV did not stimulate disease recurrence suggesting that local effects of UV rather than systemic immunosuppression were responsible for reactivation. Reactivation could also be obtained with two minimal inflammatory doses of UV from a UV-340 light source which emits light approximating the solar spectrum.

Fluconazole for the prevention and treatment of tinea gladiatorum

BACKGROUND

Tinea gladiatorum is a common problem in competitive wrestling. It impacts on a wrestler's ability to compete. Several methods have been advocated to prevent these infections; however, no well-designed study of pharmacologic prophylaxis has been conducted.

METHODS

In a double blind placebo-controlled trial during the 1998 to 1999 regular wrestling season, wrestlers were randomized to receive 100 mg of fluconazole once weekly or placebo once weekly. Those not involved in the study were treated as a second control group. The effects of prophylaxis were also examined by assessing treatment of clinical infections with fluconazole 200 mg weekly for 4 weeks.

RESULTS

There was a significantly smaller incidence of infection in those given fluconazole (6%) than in those receiving placebo (22%) and those not involved in the prophylaxis phase (18%) (P<0.05). There was also a significant reduction in the total number of infections in the fluconazole group (P<0.05). Prophylaxis with fluconazole did not impact on the severity of disease, if contracted, when compared with the placebo prophylaxis participants who contracted tinea corporis. Of 21 wrestlers with tinea infections and positive cultures, 14 were able to have their isolates identified as Trichophyton tonsurans.

CONCLUSIONS

Fluconazole is effective and safe for primary prevention of tinea gladiatorum. We must now define when and in what population prophylaxis would be warranted.

Advances in diagnosis and management of herpetic uveitis

Herpetic eye disease is common and is frequently associated with intraocular inflammation or uveitis. Despite recent advances in measuring anti-herpes virus antibodies and viral DNA in ocular fluids, diagnosis remains largely clinical. The two more common syndromes include anterior uveitis, often associated with keratitis, and the acute retinal necrosis (ARN) syndrome. Treatment is complex and requires careful monitoring to provide the appropriate balance of antiviral medication and corticosteroids. Long-term prophylaxis with oral antiviral agents may be required in selected patients to help prevent the vision-compromising complications associated with recurrences.

Penciclovir cream for the treatment of sunlight-induced herpes simplex labialis: a randomized, double-blind, placebo-controlled trial. Penciclovir Cream Herpes Labialis Study Group

OBJECTIVE

The purpose of this study was to further define the therapeutic value of penciclovir cream in the treatment of sunlight-induced herpes labialis by comparing its efficacy and tolerability with those of an inactive control (purified water).

METHODS

In this randomized, double-blind, placebo-controlled, parallel-group clinical trial, lesions were induced by exposure to sunlight. Treatment was self-initiated within 1 hour of development of the signs or symptoms of a recurrence.

RESULTS

Healthy male and female patients (mean age, 38.3 years; range, 18 to 81 years) who had a history of sunlight-induced herpes labialis (mean of 6 recurrences in previous 12 months) applied either penciclovir cream (n = 266) or purified water (n = 275). Penciclovir cream significantly decreased the time to lesion healing (P < 0.001), with a reduction in median time of up to 2 days. The efficacy of penciclovir cream was further supported by a significant reduction in maximum lesion area (P = 0.008), a faster loss of lesion-associated symptoms (P = 0.026), and significant reductions in daily assessments of pain (P < or = 0.040), itching (P < or = 0.032), burning (P < or = 0.028), and tenderness (P < or = 0.026) as moderate or severe. These effects were reinforced by the results of the daily self-assessment of lesion attributes, with significantly fewer severe/extreme assessments of lesion size (P < or = 0.003), noticeability (P < or = 0.003), amount of scab/crust (P < or = 0.003), raised/ swollen area (P < or = 0.040), soreness/tenderness (P < or = 0.043), and overall severity (P < or = 0.001) throughout the study period.

CONCLUSIONS

Penciclovir cream has demonstrated efficacy for a broad range of clinically important outcomes. Significant effects on lesion area, lesion symptoms, and other lesion attributes extend the clinical efficacy of penciclovir cream beyond lesion healing.

Herpes simplex virus type 1 infection has two separate modes of spread in three-dimensional keratinocyte culture

This study describes the outcome of herpes simplex virus type 1 (HSV-1) infection in an organotypic raft culture of spontaneously immortalized HaCat keratinocytes and human fibroblasts, as related to the virus load and epithelial stratification and differentiation. In this model, a confluent monolayer of HaCat keratinocytes was formed 60 h after seeding. Inoculation of HSV-1 before induction of differentiation by lifting of the culture to the air-liquid interface always resulted in a productive infection, but the virus yield was highest when the inoculation took place 72 h after seeding. Even at 0.1 p.f.u. per culture, the HaCat cultures became HSV positive. Infection of the full-thickness epithelium at 5 p.f.u. per culture resulted in a productive infection of the whole epithelium. The HaCat cells were about 10 times more sensitive to HSV-1 infection than the Vero cells in which the virus stocks were titrated. The raft cultures infected 30 min after lifting were negative by HSV-1 culture, and no HSV-1 antigen was detected by immunocytochemistry. PCR showed the presence of HSV-1 DNA and in situ hybridization showed reactivity with a latency-associated RNA probe, indicating the presence of a non-productive infection. Two different patterns of virus spread in epithelia were found: (i) lateral spread through the superficial layers of the epithelium and (ii) a demarcated infection throughout the whole thickness of the epithelium at the margins of the culture.

Herpes labialis in skiers: randomized clinical trial of acyclovir cream versus placebo

OBJECTIVE

A randomized, double-blind trial at seven ski sites in Canada and the United States was conducted to compare the effectiveness and the patient tolerance of topically applied 5% acyclovir cream (MAC III formulation) with those of a placebo cream in the prevention of sun-induced herpes labialis lesions.

STUDY DESIGN

All subjects had experienced more than three episodes of sun-induced herpes labialis during the previous year. There were 196 subjects enrolled; 5 did not receive medication, and 10 were excluded from the efficacy analysis for protocol violations. There were 191 subjects in the intent-to-treat analysis, and a separate efficacy analysis was done on 181 subjects. Log rank and Fisher exact tests were used in the analysis.

RESULTS

There was no difference between the two groups at baseline with respect to any clinical or demographic factor. There was no substantial difference between the groups with respect to adverse experiences (15 for acyclovir; 13 for the placebo). The acyclovir group had significantly fewer lesions (p < 0.01) than the placebo group (21% vs. 40%) during the 4-day follow-up period.

CONCLUSION

The acyclovir group was significantly better than the placebo group during the follow-up period. The safety record of the drug was satisfactory; there was no difference between acyclovir and the placebo in side effects or pain. Topically applied 5% acyclovir cream is an effective preventive step for those who are active and exposed to the sun.

Pinning down skin infections: diagnosis, treatment, and prevention in wrestlers

Wrestling fosters skin infections such as herpes simplex, tinea corporis, and impetigo. Visual examination often suggests the diagnosis, but some lesions, like late-stage herpes, can mimic other conditions, like impetigo; laboratory studies therefore may be required. Drug therapy can mitigate an infection and help prevent recurrence. In addition, physicians must know when to disqualify a wrestler and how to prevent an outbreak through measures like good hygiene and immediate diagnosis.

Effect of foscarnet cream on experimental UV radiation-induced herpes labialis

A topical 3% foscarnet cream formulation was evaluated for its ability to treat experimental UV radiation (UVR)-induced herpes labialis in a double-blind study. Healthy adult volunteers with a history of sunlight-induced herpes labialis were randomly assigned at four centers to receive either foscarnet cream (n = 152) or a vehicle control (n = 150). Following measurement of the minimal erythematous dose (MED), the subjects' lips were exposed to 4 MEDs of UV light. Subjects applied the cream on the UVR-exposed area approximately eight times daily beginning immediately after UVR exposure and continuing for 7 days, or until all lesions had a minimum of 4 days of treatment. There were no significant differences between groups in the percentages of subjects that developed any lesion, aborted lesions (did not progress beyond a papule), immediate lesions (developed within 48 h of UVR), or delayed classic lesions (developed 48 h to 7 days after UVR). Treatment with foscarnet significantly reduced the mean lesion area (49 versus 81 mm2; P = 0.01), the maximum lesion area (80 versus 141 mm2; P = 0.01), and the time to healing (P = 0.03) of the delayed classic lesions (n = 78). There was also a trend for a decrease in the mean duration of these lesions (156 versus 191 h; P = 0.08) and the duration of pain (3.9 versus 4.3 days; P = 0.06) in foscarnet-treated subjects. There were no clinically significant adverse reactions. These data suggest that topical foscarnet can be efficacious and deserves further evaluation for the treatment of herpes labialis.

Propranolol suppression of ocular HSV-1 recurrence and associated corneal lesions following spontaneous reactivation in the rabbit

PURPOSE

Hyperthermia has been shown to induce HSV-1 ocular shedding in mice. Systemic administration of propranolol significantly reduced the recovery of infectious virus in the tears, cornea, and trigeminal ganglia of mice subjected to hyperthermia. The present study was performed to determine the effects of systemic propranolol on ocular shedding and recurrent corneal epithelial lesions in the rabbit model.

METHODS

New Zealand white rabbits were infected with HSV-1 strain McKrae or 17Syn+. After latency was established, the animals were treated with systemic propranolol or saline (control) and examined by slit lamp biomicroscopy for corneal lesion. Tear film swabs were cultured to determine the frequency and duration of viral shedding.

RESULTS

Propranolol caused a significant reduction in the frequency and duration of ocular HSV-1 shedding and a reduction in the frequency of recurrent corneal epithelia disease, compared with saline treatment.

CONCLUSIONS

These results suggest that beta-adrenergic receptor blockers such as propranolol could be useful in suppressing HSV-1 ocular recurrences and corneal disease.

Viral infections in the immunocompetent patient

Human herpesviruses and human papillomaviruses are ubiquitous and may cause an array of oral disease. Herpesviruses are unique because recurrent localized disease occurs after the primary infection. Human papillomaviruses are known for their ability to produce benign epithelial proliferations and increasingly are implicated in the development of oral cancer. This article reviews the pathogenesis of common oral lesions induced by these viruses.

Th1/Th2-like immunity and resistance to herpes simplex labialis

To investigate potential immunologic mechanisms of resistance to recurrent herpes simplex labialis, we assayed serum antibody titers and cultured peripheral blood mononuclear cell (PBMC) cytokine production among patients with a history of frequent episodes (H+S+), herpes simplex virus (HSV)-seropositive individuals without a history of herpes labialis (H-S+) and HSV-seronegative persons (H-S-). In addition, H+S+ patients were exposed to experimental ultraviolet radiation (UVR) on the lips and the immunologic assay results compared among those who developed experimental lesions and those who did not. H+S+ patients were found to have higher median serum titers of HSV antibody and trends to lower levels of HSV-specific PBMC IFN-gamma and IL-2 than H-S+ control patients (123 vs 66, P = 0.04; 424 vs 548 pg/ml, P = 0.08; 14 vs 26 pg/ml, P = 0.14, respectively). Correlation of the results with the occurrence of experimental lesions showed the inverse: the subgroup of H+S+ patients with UVR-induced lesions had lower titers of antibody and trends to higher levels of IFN-gamma and IL-2 than H+S+ patients who could not be induced (93 vs 149, P = 0.02; 501 vs 347 pg/ml, P = NS; 26 vs 11 pg/ml, P = NS, respectively). The size and duration of UVR-induced lesions showed positive correlations with IFN-gamma and IL-2 levels (r = 0.60-0.67, P = 0.02-0.04). Although the small number of patients limited the power of this study, the overall pattern of the findings suggests that a Th1-like cytokine response (IFN-gamma and IL-2 production) may be associated with resistance to naturally occurring episodes of herpes labialis. The development and severity of experimental UVR-induced herpes labialis appears to be regulated differently and may involve an immunopathologic mechanism.

Susceptibility to herpes labialis following multiple experimental exposures to ultraviolet radiation

We studied susceptibility to herpes labialis by exposing 20 volunteers to experimental ultraviolet radiation (UVR) on three occasions at 3- to 4-month intervals. The number of patients who developed lesions after each session was 9/20 (45%), 9/20 (45%) and 14/20 (70%). Herpes simplex virus (HSV) was isolated from 21/29 (72%) of lesions sampled. Three patients never developed a lesion, 13 developed lesions on one or two of the three occasions, and 4 patients had a lesion following all three sessions. Seven of 33 (21%) lesions were 'immediate' lesions (developed within 48 h) and the others developed 3-7 days after UVR exposure (delayed lesions). Development of lesions correlated with historical susceptibility to sun-induced herpes labialis, but not with age, sex, years with herpes labialis, frequency of herpes labialis from all causes, or concurrent serum levels of cortisol, dehydroepiandrosterone, estradiol, progesterone or alpha 1-antitrypsin. Among normally menstruating females, a significant association was identified between the development of herpes labialis and the luteal phase of the menstrual cycle (8 cases of herpes labialis/11 attempts, RR = 14, P = 0.005). The lack of correlation between episodes of natural herpes labialis and susceptibility to experimental UVR-induced disease suggests that these events are controlled differently. The results of serial attempts to induce experimental herpes in each patient was most commonly inconsistent, indicating that individual patient susceptibility to UVR varies over time. While the explanation for this variation remains unclear, stages of the menstrual cycle may be important among women.

Propranolol suppresses reactivation of herpesvirus

Herpes simplex virus type 1 (HSV-1) reactivates from the nervous system and causes recurrent disease in end organs such as the eye and the lips. We found that the beta-adrenergic receptor blocker, propranolol, reduces HSV-1 reactivation in an animal model. Mice latent for McKrae strain HSV-1 were injected with propranolol or saline once a day for 3 successive days, and subjected to a brief period of hyperthermia on the second day to induce reactivation. Twenty-four hours after the third injection, swabs of the ocular surface and homogenates of the corneas and trigeminal ganglia were analyzed for the presence of infectious virus and viral DNA. Treatment with propranolol significantly decreased the appearance of infectious virus in the tear film, cornea, and trigeminal ganglia (P < 0.05, chi 2-test). The results suggest a possible new pharmacologic approach to suppressing herpesvirus reactivation in the nervous system and thereby preventing recurrent disease.

Correlation between detection of herpes simplex virus in oral secretions by PCR and susceptibility to experimental UV radiation-induced herpes labialis

We examined the oral secretions of 25 patients for herpes simplex virus (HSV) at the time of and following experimental UV radiation (UVR). HSV was detected in one or more oral secretion specimens in 5 of 12 (42%) cases by cell culture and in 8 of 12 (67%) cases by PCR. On the day of UVR, HSV was detected in 1 of 12 (8%) patients who developed a lip lesion and 2 of 16 (13%) patients who did not (the difference is not significant). We conclude that PCR is more sensitive than culture in the detection of HSV and that HSV is not shed with increased frequency from the oral cavity before the development of UVR-induced herpes labialis.

Solar simulator-induced herpes simplex labialis: use in evaluating treatment with acyclovir plus 348U87

Models of UV radiation induced herpes labialis utilizing crude light sources have previously been used to examine the efficacy of antivirals. We sought to improve upon this model by using a solar simulator. Initial studies revealed that 13 of 34 (38%) subjects with a history of recurrent HSV labialis receiving three minimal erythema doses (MED's) of UV light developed herpes labialis. We next evaluated the effects of combined therapy with topical ACV and 348U87, a ribonucleotide reductase inhibitor, begun immediately after UV exposure for the prevention and treatment of herpes labialis. No significant reduction in the incidence or severity of herpes labialis was detected although the study was terminated after the interim analysis revealed no benefit, thus reducing the power to detect a difference. This lack of effect may be explained by the general poor efficacy of topical treatment for recurrent HSV infection. Further studies of ACV + 348U87 in vehicles that should increase the penetration and stability of the drugs are planned.

Acyclovir: is it an effective virostatic agent for orofacial infections?

Oral and intravenous acyclovir formulations provide effective virostasis against many herpes viruses infections, especially severe herpes simplex or varicella-zoster infections in ambulatory and immunocompromised patients. The therapeutic virostatic efficacy of topical acyclovir formulations requires further development, however, especially for orolabial herpetic infections.

The effect of UV therapy on immune function in patients with psoriasis

Ultraviolet radiation (UVR) is known to suppress some cell-mediated immune responses to antigens encountered during or soon after exposure. Phototherapy is widely used in psoriasis, and this study was undertaken to monitor changes in a range of immunological parameters during standard courses of treatment, with the aim of ascertaining whether such modulations contribute to the effectiveness of therapy. The responses of 17 patients with psoriasis undergoing UVB therapy, and four receiving PUVA therapy, were compared with 15 patients receiving coal tar treatment and four normal subjects undergoing UVB irradiation. In each case, samples were taken before starting therapy, after 4 weeks of therapy, and 4 weeks after completion of treatment. Serum immunoglobulin isotypes and complement components were within normal ranges in most of the psoriasis patients, and remained unchanged throughout therapy. Similarly, percentages of subsets of peripheral blood mononuclear cells (PBMC) were normal, and were unaltered by treatment. Patients who were already infected with herpes simplex virus (HSV), as demonstrated by a positive lymphoproliferation test in vitro, were monitored for asymptomatic HSV shedding and HSV recrudescences during therapy. There was little evidence that phototherapy caused reactivation of the virus. No significant alteration in lymphoproliferative response to HSV and to the mitogen concanavalin A was observed during therapy. Epidermal cells and blood adherent cells were used to present HSV to PBMC, depleted of adherent cells and enriched for T cells, in a lymphoproliferative assay. The functional antigen-presenting ability of adherent cells remained unchanged throughout therapy, whereas that of epidermal cells was suppressed during UVB irradiation and recovered, in most instances, after UVB therapy had been completed. The epidermis of patients with psoriasis contained about three times the quantity of urocanic acid (UCA) of normal subjects, whereas the UCA concentration in suction blister fluid did not differ between the two groups. During UVB irradiation, the percentage of cis-UCA rose in both the epidermis and suction blister fluid of all subjects, and it remained elevated in the blister fluid after therapy had finished. Tumour necrosis factor-alpha was measured in suction blister fluid, and its concentration did not alter consistently as a result of therapy. Whether any of the immunological parameters measured, and the changes noted, contribute to the effectiveness of phototherapy in the treatment of psoriasis remains uncertain.

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.

Stopping the Spread of Herpes Simplex

In brief Herpes simplex is readily spread through contact sports like wrestling, and sun exposure, emotional stress, and fever can trigger a recurrence. Ruling out other skin disorders is an important part of the diagnosis. Although acyclovir helps reduce recurrent episodes, physicians need to identify infected athletes early and remove them from sports when contagion is likely.