Herpes simplex treatment: Difference between revisions
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*Symptomatic sex partners should be evaluated and treated in the same manner as patients who have genital lesions. | *Symptomatic sex partners should be evaluated and treated in the same manner as patients who have genital lesions. | ||
*Asymptomatic sex partners of patients who have genital herpes should be questioned concerning histories of genital lesions and offered type-specific serologic testing for HSV infection. | *Asymptomatic sex partners of patients who have genital herpes should be questioned concerning histories of genital lesions and offered type-specific serologic testing for HSV infection. | ||
==HIV Infection== | |||
*Immunocompromised patients can have prolonged or severe episodes of genital, perianal, or oral herpes. Lesions caused by HSV are common among HIV-infected patients and might be severe, painful, and atypical. | |||
*HSV shedding is increased in HIV-infected persons. Whereas antiretroviral therapy reduces the severity and frequency of symptomatic genital herpes, frequent subclinical shedding still occurs.<ref name="Posavad-2004">{{Cite journal | last1 = Posavad | first1 = CM. | last2 = Wald | first2 = A. | last3 = Kuntz | first3 = S. | last4 = Huang | first4 = ML. | last5 = Selke | first5 = S. | last6 = Krantz | first6 = E. | last7 = Corey | first7 = L. | title = Frequent reactivation of herpes simplex virus among HIV-1-infected patients treated with highly active antiretroviral therapy. | journal = J Infect Dis | volume = 190 | issue = 4 | pages = 693-6 | month = Aug | year = 2004 | doi = 10.1086/422755 | PMID = 15272395 }}</ref> | |||
*Clinical manifestations of genital herpes might worsen during immune reconstitution after initiation of antiretroviral therapy. | |||
*Suppressive or episodic therapy with oral antiviral agents is effective in decreasing the clinical manifestations of HSV among HIV-positive persons. <ref name="Conant-2002">{{Cite journal | last1 = Conant | first1 = MA. | last2 = Schacker | first2 = TW. | last3 = Murphy | first3 = RL. | last4 = Gold | first4 = J.| last5 = Crutchfield | first5 = LT. | last6 = Crooks | first6 = RJ. | title = Valaciclovir versus aciclovir for herpes simplex virus infection in HIV-infected individuals: two randomized trials. | journal = Int J STD AIDS | volume = 13 | issue = 1 | pages = 12-21 | month = Jan | year = 2002 | doi = | PMID = 11802924}}</ref><ref name="DeJesus-2003">{{Cite journal | last1 = DeJesus | first1 = E. | last2 = Wald | first2 = A. | last3 = Warren | first3 = T. | last4 = Schacker |first4 = TW. | last5 = Trottier | first5 = S. | last6 = Shahmanesh | first6 = M. | last7 = Hill | first7 = JL. | last8 = Brennan | first8 = CA. | title = Valacyclovir for the suppression of recurrent genital herpes in human immunodeficiency virus-infected subjects. | journal = J Infect Dis | volume = 188 | issue = 7 | pages = 1009-16 | month = Oct | year = 2003 | doi = 10.1086/378416 | PMID = 14513421 }}</ref> | |||
*The extent to which suppressive antiviral therapy will decrease HSV transmission from this population is unknown. HSV type-specific serologies can be offered to HIV-positive persons during their initial evaluation if infection status is unknown, and suppressive antiviral therapy can be considered in those who have HSV-2 infection. | |||
*Acyclovir, valacyclovir, and famciclovir are safe for use in immunocompromised patients in the doses recommended for treatment of genital herpes. For severe HSV disease, initiating therapy with acyclovir 5–10 mg/kg IV every 8 hours might be necessary. | |||
*If lesions persist or recur in a patient receiving antiviral treatment, HSV resistance should be suspected and a viral isolate should be obtained for sensitivity testing (184). Such persons should be managed in consultation with an HIV specialist, and alternate therapy should be administered. | |||
*All acyclovir-resistant strains are resistant to valacyclovir, and the majority are resistant to famciclovir. Foscarnet, 40 mg/kg IV every 8 hours until clinical resolution is attained, is frequently effective for treatment of acyclovir-resistant genital herpes. Intravenous cidofovir 5 mg/kg once weekly might also be effective. Imiquimod is a topical alternative, as is topical cidofovir gel 1%, which is not commercially available and must be compounded at a pharmacy. These topical preparations should be applied to the lesions once daily for 5 consecutive days. | |||
*Clinical management of antiviral resistance remains challenging among HIV-infected patients, and other preventative approaches might be necessary. However, experience with another group of immunocompromised persons (hematopoietic stem-cell recipients) demonstrated that persons receiving daily suppressive antiviral therapy were less likely to develop acyclovir-resistant HSV compared with those who received episodic therapy with outbreaks (185). | |||
==References== | ==References== | ||
Revision as of 17:14, 11 February 2014
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Lakshmi Gopalakrishnan, M.B.B.S.
Overview
Antiviral chemotherapy offers clinical benefits to most symptomatic patients and is the mainstay of management. Counseling regarding the natural history of genital herpes, sexual and perinatal transmission, and methods to reduce transmission is an integral part of clinical management. Systemic antiviral drugs can partially control the signs and symptoms of herpes episodes when used to treat first clinical and recurrent episodes, or when used as daily suppressive therapy. However, these drugs neither eradicate latent virus nor affect the risk, frequency, or severity of recurrences after the drug is discontinued. Randomized trials have indicated that three antiviral medications such as acyclovir, valacyclovir, and famciclovir provide clinical benefit for genital herpes.[1][2][3][4][5][6][7][8][9] Valacyclovir is the valine ester of acyclovir and has enhanced absorption after oral administration. Famciclovir also has high oral bioavailability. Topical therapy with antiviral drugs offers minimal clinical benefit, and its use is discouraged.
Currently, there is no treatment that can eradicate any of the herpes viruses from the body. Non-prescription analgesics can reduce pain and fever during initial outbreaks. Topical anesthetic treatment (such as prilocaine, lidocaine or tetracaine) can relieve itching and pain.[10][11]
Treatment
Antiviral Therapy
Topical Treatments
Docosanol
- Docosanol prevents herpes simplex virus from fusing to cell membranes, thus barring the entry of the virus into the skin.
- It was approved for use after clinical trials by the FDA in July 2000.[12]
- It was the first over-the-counter antiviral drug approved for sale in the United States and Canada
Tromantadine
- Tromantadine is available as a gel that inhibits entry and spreading of the virus by altering the surface composition of skin cells and inhibiting release of viral genetic material.
Zilactin
- It is a topical analgesic barrier treatment, which forms a "shield" at the area of application to prevents a sore from increasing in size and decrease viral spreading during the healing process.
Other Drugs
Cimetidine
Cimetidine commonly used in heartburn, has been shown to lessen the severity of herpes zoster outbreaks in several different instances, and offered some relief from herpes simplex.
Vaseline
- Vaseline or any other type of fat prevents water, or saliva, from reaching the cold sore. Since, water helps in perpetuation of the cold sore, preventing water exposure will fasten the healing process.[13][14][15] This is an off-label use of the drug. It and probenecid have been shown to reduce the renal clearance of aciclovir.[16] These compounds also reduce the rate, but not the extent, at which valaciclovir is converted into aciclovir.
Aspirin
- Low doses aspirin (125 mg daily) have shown to be beneficial in patients with recurrent HSV infections. However, there are lack of sufficient supporting evidences.
- It reduces the level of the inflammatory mediators prostaglandins [17]
- A recent study in animals showed inhibition of thermal (heat) stress-induced viral shedding of HSV-1 in the eye by aspirin, and a possible benefit in reducing the frequency of recurrences.[18]
Management of Sex Partner
- The sex partners of patients who have genital herpes can benefit from evaluation and counseling.
- Symptomatic sex partners should be evaluated and treated in the same manner as patients who have genital lesions.
- Asymptomatic sex partners of patients who have genital herpes should be questioned concerning histories of genital lesions and offered type-specific serologic testing for HSV infection.
HIV Infection
- Immunocompromised patients can have prolonged or severe episodes of genital, perianal, or oral herpes. Lesions caused by HSV are common among HIV-infected patients and might be severe, painful, and atypical.
- HSV shedding is increased in HIV-infected persons. Whereas antiretroviral therapy reduces the severity and frequency of symptomatic genital herpes, frequent subclinical shedding still occurs.[19]
- Clinical manifestations of genital herpes might worsen during immune reconstitution after initiation of antiretroviral therapy.
- Suppressive or episodic therapy with oral antiviral agents is effective in decreasing the clinical manifestations of HSV among HIV-positive persons. [20][21]
- The extent to which suppressive antiviral therapy will decrease HSV transmission from this population is unknown. HSV type-specific serologies can be offered to HIV-positive persons during their initial evaluation if infection status is unknown, and suppressive antiviral therapy can be considered in those who have HSV-2 infection.
- Acyclovir, valacyclovir, and famciclovir are safe for use in immunocompromised patients in the doses recommended for treatment of genital herpes. For severe HSV disease, initiating therapy with acyclovir 5–10 mg/kg IV every 8 hours might be necessary.
- If lesions persist or recur in a patient receiving antiviral treatment, HSV resistance should be suspected and a viral isolate should be obtained for sensitivity testing (184). Such persons should be managed in consultation with an HIV specialist, and alternate therapy should be administered.
- All acyclovir-resistant strains are resistant to valacyclovir, and the majority are resistant to famciclovir. Foscarnet, 40 mg/kg IV every 8 hours until clinical resolution is attained, is frequently effective for treatment of acyclovir-resistant genital herpes. Intravenous cidofovir 5 mg/kg once weekly might also be effective. Imiquimod is a topical alternative, as is topical cidofovir gel 1%, which is not commercially available and must be compounded at a pharmacy. These topical preparations should be applied to the lesions once daily for 5 consecutive days.
- Clinical management of antiviral resistance remains challenging among HIV-infected patients, and other preventative approaches might be necessary. However, experience with another group of immunocompromised persons (hematopoietic stem-cell recipients) demonstrated that persons receiving daily suppressive antiviral therapy were less likely to develop acyclovir-resistant HSV compared with those who received episodic therapy with outbreaks (185).
References
- ↑ Leone PA, Trottier S, Miller JM (2002) Valacyclovir for episodic treatment of genital herpes: a shorter 3-day treatment course compared with 5-day treatment. Clin Infect Dis 34 (7):958-62. DOI:10.1086/339326 PMID: 11880962
- ↑ Wald A, Carrell D, Remington M, Kexel E, Zeh J, Corey L (2002) Two-day regimen of acyclovir for treatment of recurrent genital herpes simplex virus type 2 infection. Clin Infect Dis 34 (7):944-8. DOI:10.1086/339325 PMID: 11880960
- ↑ Aoki FY, Tyring S, Diaz-Mitoma F, Gross G, Gao J, Hamed K (2006) Single-day, patient-initiated famciclovir therapy for recurrent genital herpes: a randomized, double-blind, placebo-controlled trial. Clin Infect Dis 42 (1):8-13. DOI:10.1086/498521 PMID: 16323085
- ↑ Chosidow O, Drouault Y, Leconte-Veyriac F, Aymard M, Ortonne JP, Pouget F et al. (2001) Famciclovir vs. aciclovir in immunocompetent patients with recurrent genital herpes infections: a parallel-groups, randomized, double-blind clinical trial. Br J Dermatol 144 (4):818-24. PMID: 11298543
- ↑ Bodsworth NJ, Crooks RJ, Borelli S, Vejlsgaard G, Paavonen J, Worm AM et al. (1997) Valaciclovir versus aciclovir in patient initiated treatment of recurrent genital herpes: a randomised, double blind clinical trial. International Valaciclovir HSV Study Group. Genitourin Med 73 (2):110-6. PMID: 9215092
- ↑ Fife KH, Barbarash RA, Rudolph T, Degregorio B, Roth R (1997) Valaciclovir versus acyclovir in the treatment of first-episode genital herpes infection. Results of an international, multicenter, double-blind, randomized clinical trial. The Valaciclovir International Herpes Simplex Virus Study Group. Sex Transm Dis 24 (8):481-6. PMID: 9293612
- ↑ Diaz-Mitoma F, Sibbald RG, Shafran SD, Boon R, Saltzman RL (1998) Oral famciclovir for the suppression of recurrent genital herpes: a randomized controlled trial. Collaborative Famciclovir Genital Herpes Research Group. JAMA 280 (10):887-92. PMID: 9739972
- ↑ Mertz GJ, Loveless MO, Levin MJ, Kraus SJ, Fowler SL, Goade D et al. (1997) Oral famciclovir for suppression of recurrent genital herpes simplex virus infection in women. A multicenter, double-blind, placebo-controlled trial. Collaborative Famciclovir Genital Herpes Research Group. Arch Intern Med 157 (3):343-9. PMID: 9040303
- ↑ Reitano M, Tyring S, Lang W, Thoming C, Worm AM, Borelli S et al. (1998) Valaciclovir for the suppression of recurrent genital herpes simplex virus infection: a large-scale dose range-finding study. International Valaciclovir HSV Study Group. J Infect Dis 178 (3):603-10. PMID: 9728526
- ↑ "Local anesthetic creams". BMJ. 297 (6661): 1468. 1988. PMID 3147021.
- ↑ Kaminester LH, Pariser RJ, Pariser DM; et al. (1999). "A double-blind, placebo-controlled study of topical tetracaine in the treatment of herpes labialis". J. Am. Acad. Dermatol. 41 (6): 996–1001. PMID 10570387.
- ↑ "Drug Name: ABREVA (docosanol) - approval". centerwatch.com. July 2000. Retrieved 2007-10-17.
- ↑ Kapińska-Mrowiecka M, Turowski G (1996) [Efficacy of cimetidine in treatment of Herpes zoster in the first 5 days from the moment of disease manifestation.] Pol Tyg Lek 51 (23-26):338-9. PMID: 9273526
- ↑ Hayne ST, Mercer JB (1983) Herpes zoster: treatment with cimetidine. Can Med Assoc J 129 (12):1284-5. PMID: 6652595
- ↑ Komlos L, Notmann J, Arieli J, Hart J, Levinsky H, Halbrecht I et al. (1994) IN vitro cell-mediated immune reactions in herpes zoster patients treated with cimetidine. Asian Pac J Allergy Immunol 12 (1):51-8. PMID: 7872992
- ↑ De Bony F, Tod M, Bidault R, On NT, Posner J, Rolan P (2002) Multiple interactions of cimetidine and probenecid with valaciclovir and its metabolite acyclovir. Antimicrob Agents Chemother 46 (2):458-63. PMID: 11796358
- ↑ Karadi I, Karpati S, Romics L. (1998). "Aspirin in the management of recurrent herpes simplex virus infection". Ann. Intern. Med. 128 (8): 696–697. PMID 9537952.
- ↑ Gebhardt BM, Varnell ED, Kaufman HE. (2004). "Acetylsalicylic acid reduces viral shedding induced by thermal stress". Curr. Eye Res. 29 (2–3): 119–125. PMID 15512958.
- ↑ Posavad, CM.; Wald, A.; Kuntz, S.; Huang, ML.; Selke, S.; Krantz, E.; Corey, L. (2004). "Frequent reactivation of herpes simplex virus among HIV-1-infected patients treated with highly active antiretroviral therapy". J Infect Dis. 190 (4): 693–6. doi:10.1086/422755. PMID 15272395. Unknown parameter
|month=ignored (help) - ↑ Conant, MA.; Schacker, TW.; Murphy, RL.; Gold, J.; Crutchfield, LT.; Crooks, RJ. (2002). "Valaciclovir versus aciclovir for herpes simplex virus infection in HIV-infected individuals: two randomized trials". Int J STD AIDS. 13 (1): 12–21. PMID 11802924. Unknown parameter
|month=ignored (help) - ↑ DeJesus, E.; Wald, A.; Warren, T.; Schacker, TW.; Trottier, S.; Shahmanesh, M.; Hill, JL.; Brennan, CA. (2003). "Valacyclovir for the suppression of recurrent genital herpes in human immunodeficiency virus-infected subjects". J Infect Dis. 188 (7): 1009–16. doi:10.1086/378416. PMID 14513421. Unknown parameter
|month=ignored (help)