Evidence Corner: Topical Medications Improve Cold Sore Outcomes

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Laura Bolton, PhD, FAPWCA

Dear Readers:
  Recurrent orofacial herpes simplex virus (HSV) infection called herpes labialis (HSL), or cold sores, affects 1 in 3 persons in the western world. Most primary infections occur in childhood then recur as reactivated HSV, a DNA virus, migrates to the lips, face, or oral mucosa, usually from the sensory trigeminal ganglion.

  This recurrent infection creates a partial-thickness wound,2,3 that is usually shorter than the primary episode, progressing through 1 or more of the typical stages: prodrome, redness, papule, vesicle, ulcer, hard crust, and residual swelling/dry flaking before normal skin is restored. “False prodrome” can occur without progressing to the papule stage in up to one-third of episodes. Nonulcerative episodes stopped by the host’s immune response after the papule stage may last only 3 days. Classical ulcerative HSL lesions which progress through the vesicle, ulcer, crusting, and flaking stages last 7-10 days as compared to 5-6 days on average for ulcerative and nonulcerative lesions mixed.

  The 24-hour window of opportunity to initiate effective treatment plus variability in HSL lesion severity and related time to heal makes it difficult to study efficacy of the anti-viral agents most commonly used to prevent or treat HSV infection. The HSV lesion is a partial-thickness wound involving epidermis and dermis. Fear of preserving a moist HSL environment is unwarranted because viral replication occurs inside the already moist cell,2,3 so there appears no scientific reason to deny the HSL lesion the benefits of faster healing and lower complications experienced by similar depth wounds dressed with moisture-retentive or “occlusive” dressings.2,3,4 The 2 reports reviewed below summarize recent advances in managing HSL lesions and offer interesting hypotheses for further testing.

Laura Bolton, PhD, FAPWCA
Adjunct Associate Professor
Department of Surgery, UMDNJ
WOUNDS Editorial Advisory Board Member and Department Editor

Topical Medications Improve Cold Sore Outcomes

  Reference: Harmenberg J, Öberg B, Spruance S. Prevention of ulcerative lesions by episodic treatment of recurrent herpes labialis: A literature review. Acta Derm Venereol. 2010;90(2):122-130.

  Rationale: The rapid-onset and brief period of HSV replication that trigger recurrent HSL limit the opportunity for antiviral medications to reduce lesion severity. Recognized antiviral agents and their pro-drugs show only a 10% reduction in lesion healing time. New data suggests that episodic treatment may prevent outbreaks.

  Objective: Conduct a comprehensive critical review summarizing recent evidence of effects on recurrent HSL epidemiology, pathology, and development, and identify factors important in design of randomized controlled trials (RCTs) exploring agents affecting lesion progression.

  Methods: MEDLINE searches identified all clinical studies of episodic HSV treatment reporting epidemiology of herpes labialis excepting cases induced by ultraviolet light exposure. Epidemiology was summarized as number of episodes per individual per year. The authors developed a mathematical model to describe recurrent HSV epidemiology and to test treatment efficacy based on the assumption that each episode of HSL occurs independently of other episodes.

  Results: Seven qualifying studies, mostly retrospective surveys, reported that 30% to 45% experienced recurrent HSL among more than 36,000 subjects, including students, adults, blood donors, hospitalized patients, and hospital staff, from 21 countries, mainly Australia, Sweden, the United Kingdom, or the United States. Likelihood of HSL increased with age to 80% to 90% of subjects greater than 50 years of age.

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