A clinical study for the control of facial mucocutaneous herpes virus infections. I. Characterization of natural history in a professional school population

Antiviral Agents for the Prevention and Treatment of Herpes Simplex Virus Type-1 Infection in Clinical Oncology: A Network Meta-Analysis

Cancer therapy may be complicated and compromised by viral infections, including oral herpes simplex virus (HSV) infection. This network meta-analysis aimed to identify the best antiviral agent to prevent or treat oral HSV infection in patients being treated for cancer. A search was conducted for trials published since inception until the 10th of May 2020 in MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials. A network meta-analysis was performed on the data from randomized controlled trials that assessed antiviral agents for preventive or therapeutic activity vs. placebo, no treatment or any other active intervention in patients being treated for cancer. The agents were ranked according to their effectiveness in the prevention of oral HSV using surface under the cumulative ranking (SUCRA). Grading of Recommendations, Assessment, Development and Evaluations (GRADE) was used to assess the certainty of the evidence. In total, 16 articles were included. The pooled relative risk (RR) to develop oral HSV infection in the acyclovir group was 0.17 (95% CI: 0.10, 0.30), compared to 0.22 (95% CI: 0.06, 0.77) in the valacyclovir group. Acyclovir ranked highest for the prevention of oral HSV followed by valacyclovir. Subgroup analysis with different acyclovir regimens revealed that the best regimens in terms of HSV-1 prevention were 750 mg/m2 acyclovir administered intravenously followed by 1600 mg per day orally. Acyclovir (250 mg/m2 per day) administered intravenously was the least effective against the prevention of oral HSV.

Recurrent herpes labialis in the pediatric population: Prevalence, therapeutic studies, and associated complications

Recurrent herpes labialis (RHL) is an incredibly common condition, though the medical literature evaluating pediatric aspects is limited. This paper assesses prevalence and therapeutic studies of pediatric RHL as well as disease complications. A comprehensive literature search of English-language citations based on PubMed queries of selected terms was performed, with exclusion if methodology was not discussed, or if studies had 10 or fewer patients. RHL prevalence in pediatrics has been assessed by measures of point and periodic prevalence, though methodologic limitations may under- or over-estimate the true prevalence of RHL. Studies have been conducted to evaluate therapeutic safety, tolerability, and efficacy of antivirals in the pediatric population. Pediatric RHL point prevalence ranges from 0.72% to 5.2% depending on the population study and the methodologies used. Pediatric RHL carries a significant public health burden and is often implicated in patients with eczema herpeticum, erythema multiforme, reactive infectious mucositis eruptions, and hypersensitivity reactions. There are few studies that evaluate the rates of occurrence of these sequelae associated with pediatric RHL.

A series of in vitro and human studies of a novel lip cream formulation for protecting against environmental triggers of recurrent herpes labialis

Purpose

These studies describe the testing of a novel, daily-use lip cream designed for individuals with lips prone to recurrent herpes labialis (RHL) that protects against environmental triggers.

Subjects and methods

In vitro occlusive and in vitro and in vivo photoprotection analyses, a characterization of normal vs dry lips, and a randomized, evaluator-blinded, clinical trial that assessed the lip cream in healthy subjects with dry lips were conducted. In the clinical trial, subjects applied the lip cream or were untreated and evaluated using transepidermal water loss (TEWL), corneometry, visual assessments of lip dryness, expert photographic evaluations, and subject-rated outcomes.

Results

The lip cream’s in vitro water vapor transmission rate (84.1 g/(m² h)) indicated moderate occlusivity. The lip cream, but not placebo or control (water), reduced ultraviolet A (UVA)- and UVB-induced DNA damage, and tumor necrosis factor-α (EpiDerm^FT) and pros-taglandin E₂ release (EpiDerm^FT and EpiGingival™). The lip cream’s in vivo sun protection factor (SPF) was 12.2 (lower confidence limit, 11.3) and SPF/UVA protection factor ratio was 0.9. The characterization of dry vs normal lips identified differences in moisturization. In the clinical trial, the lip cream significantly decreased TEWL (difference: −7.19 [95% CI: −11.41, −2.98]; P<0.01), increased corneometry (difference: 4.62 [95% CI: 1.05, 8.19]; P<0.05), and reduced visual dryness (difference: −1.48 [95% CI: 2.24, −0.71]; P<0.001) compared to untreated subjects. Significant benefits were also observed on expert photographic assessments of scaling (difference: −0.89 [95% CI: −1.75, −0.03]; P< 0.05), cupping (difference: −1.50 [95% CI: −2.30, −0.70]; P<0.001), and healthy appearance (difference: −1.44 [95% CI: −2.29, −0.58]; P<0.01); differences in overall healthy appearance were not significant (P=0.51). Subject-rated assessments indicated improvements in cracking, dryness, and flaking in the lip cream group but worsening in untreated subjects.

Conclusion

These studies indicate that this novel, daily-use lip cream protects against UV radiation, drying, and chapping, which are established environmental RHL triggers.

Central Cemento-Ossifying Fibroma: Primary Odontogenic or Osseous Neoplasm?

Currently, central cemento-ossifying fibroma is classified by the World Health Organization as a primary bone-forming tumor of the jaws. However, histopathologically, it is often indistinguishable from cemento-osseous dysplasias in that it forms osteoid and cementicles (cementum droplets) in varying proportions. It is believed that pluripotent cells within the periodontal membrane can be stimulated to produce either osteoid or woven bone and cementicles when stimulated. If this is true, cemento-ossifying fibroma would be better classified as a primary odontogenic neoplasm arising from the periodontal ligament. Cemento-ossifying fibromas also do not occur in the long bones. The present report compares several entities that fall within the diagnostic realm of benign fibro-osseous lesions and reviews the evidence for reclassifying central cemento-ossifying fibroma as a primary odontogenic neoplasm.

Acyclovir Lauriad(®): a muco-adhesive buccal tablet for the treatment of recurrent herpes labialis

The treatment of recurrent herpes labialis remains a challenge in the 21st century. The virus is ubiquitous and there is no vaccine against the disease. Although recurrence episodes are usually of shorter duration than the primary episode, they are debilitating to patients and there is significant stigma associated with the disease. Acyclovir Lauriad(®) is a new topical agent that was approved by the US FDA in 2013 for the treatment of recurrent herpes labialis, which affects approximately 20-40% of the population worldwide. The drug is a muco-adhesive tablet, applied to the upper gum at the onset of prodromal symptoms. Utilizing Lauriad(®) technology, a biologically active compound traverses the mucous membrane to deliver a high concentration of acyclovir directly to the site of the herpes simplex virus infection. Data from a Phase III clinical trial shows that this may be a promising therapy for patients with recurrent herpes labialis.

Herpes simplex virus reactivation and dental procedures

OBJECTIVES

Dental extraction is reported to trigger recurrent herpes labialis (RHL).

AIM

This aims to prospectively study the clinical occurrence of RHL and the oral herpes simplex virus type 1 (HSV-1) viral shedding before and 3 days after different dental procedures.

MATERIALS AND METHODS

Oral HSV-1 DNA was measured by real-time PCR before and 3 days after dental procedures of the inferior dentition in 57 immunocompetent patients (mean age 32.4 years) who were selected and divided into four distinct subgroups (dental inspection without anesthesia, n = 19; dental filling under local anesthesia, n = 14; molar extraction under local anesthesia, n = 15; and molar extraction under general anesthesia, n = 9) and compared to 32 healthy controls (mean age 33 years).

RESULTS

None of the patients suffered from RHL at day 3. Oral HSV-1 DNA was detected before and after procedure in 1.7 % (1/57) and 5.3 % (3/57), respectively [dental inspection without anesthesia, 5.3 % (1/19); molar extraction under local anesthesia, 6.7 % (1/15); and molar extraction under general anesthesia, 11 % (1/9)]. None of the controls presented RHL or detectable oral HSV-1 DNA. There was no statistically significant difference between the study groups and controls.

CONCLUSION

Molar extraction increases the risk of oral HSV-1 shedding but not of RHL. Procedure-related nerve damage probably accounts for HSV reactivation.

CLINICAL RELEVANCE

Antiviral prophylaxis for RHL is not routinely recommended for dental procedures, regardless of a prior history of RHL.

High-intensity laser and photodynamic therapy as a treatment for recurrent herpes labialis

OBJECTIVE

The aim of this study was to report the treatment of recurrent herpes labialis (RHL) using a high-intensity laser or methylene blue (MB)-mediated photodynamic therapy (PDT) in combination with low-level laser therapy (LLLT).

MATERIALS AND METHODS

Four clinical cases of patients diagnosed with RHL are described in this report. Two patients were subjected to high-intensity laser therapy (HILT) followed by LLLT, and two patients received MB-mediated PDT, again followed by LLLT. LLLT was conducted at 24, 48, 72 h, and 7 d after HILT or PDT. Patients were followed up after 6 mo.

RESULTS

Throughout the follow-up period, all patients reported pain relief and did not show any signs or symptoms of RHL. A favorable healing process was observed in all cases. None of the patients reported pain as a consequence of the treatment.

CONCLUSION

These results suggest that HILT and MB-mediated PDT, in combination with LLLT, may constitute a benefit when treating vesicles in RHL.

Management of oral infections in cancer patients

The myelosuppressive and mucosal-damaging consequences of cancer and cancer therapies place patients at high risk for developing infectious complications. Bacterial, fungal, and viral infections are all commonly encountered in the oral cavity, contributing to both morbidity and mortality in this patient population. Prevention, early and definitive diagnosis, and appropriate management are critical to ensure optimal treatment outcomes. With the majority of cancer patients treated as outpatients in the community setting, oral health care professionals play an important role in managing such infectious complications of cancer therapy.

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.

Asymptomatic shedding of herpes simplex virus (HSV) in the oral cavity

OBJECTIVE

The aim of this study was to investigate the rate of herpes simplex virus (HSV) shedding from the oral cavity, because recent studies suggest that shedding is more frequent than originally reported. Factors that could influence the rate and duration of shedding from the oral cavity were examined.

METHODS

Existing epidemiologic data from 22 reports of HSV shedding from more than 3,500 individuals were analyzed with regard to demographics, frequency of sampling, and methodologic assays.

RESULTS

HSV-1 was more likely to be detected than HSV-2 in the oral cavity of asymptomatic persons (7.5 odds ratio, 95% confidence interval 4.4-12.8; P < .0001). The rate of shedding was highly variable among individuals, ranging from none to 92% of days tested, and occurred in seropositive and seronegative individuals. In cell culture studies, the rate of detection on a single day was 6.3%. Polymerase chain reaction studies provided a different picture. HSV-1 DNA was present in 97 of 180 patients (53.9%) at multiple visits, with a rate of daily detection of 33.3%. The mean duration of shedding was between 1 and 3 days, but more than 3 days in about 10% of patients.

CONCLUSIONS

At least 70% of the population shed HSV-1 asymptomatically at least once a month, and many individuals appear to shed HSV-1 more than 6 times per month. Shedding of HSV-1 is present at many intraoral sites, for brief periods, at copy numbers sufficient to be transmitted, and even in seronegative individuals. The dental implications of these findings are discussed.

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.

Herpes simplex virus type 1 and respiratory disease in critically-ill patients: real pathogen or innocent bystander?

Herpes simplex virus type 1 (HSV-1) has been associated with pulmonary disease, mostly in severely immunocompromised patients. After reactivation and shedding in the oropharynx, the virus may reach the lower respiratory tract by aspiration or by contiguous spread. HSV-1 can be detected in clinical specimens by virus culture or quantitatively by nucleic acid amplification techniques. With these techniques, HSV-1 is often detected in the respiratory secretions of critically-ill patients. However, a clear diagnosis of HSV-1 pneumonia is difficult to establish because clinical criteria, radiological features and laboratory findings all lack specificity. Lower respiratory tract HSV-1 infections have not been associated with specific risk-factors. There is also an absence of consistent data concerning the effect of antiviral treatment on the outcome of critically-ill patients. Further studies are needed to better define the pathogenic role of HSV-1 in the lower respiratory tract of these patients, to improve the diagnosis, and, especially, to assess the need for antiviral treatment in the individual patient.

The efficacy of valacyclovir in preventing recurrent herpes simplex virus infections associated with dental procedures

BACKGROUND

Oral herpes simplex virus, or HSV, infections recur after trauma and stress. The prevalence of these infections after dental procedures is not known. Also, it is unclear whether antiviral agents are effective in preventing dental procedure-induced HSV recurrences. This study determined the efficacy and safety of oral valacyclovir in suppressing dentally related cold sore outbreak and HSV shedding.

METHODS

The authors enrolled 125 otherwise healthy HSV-seropositive adults who reported having recurrent herpes labialis (more than one episode per year and at least one episode in the previous year) in a randomized, double-blind, placebo-controlled study and gave them valacyclovir prophylactically (2 grams taken twice on the day of dental treatment and 1 g taken twice the next day) or a matching placebo. To detect the presence of the virus, the authors used clinical examinations, viral cultures and real-time polymerase chain reaction analysis of saliva.

RESULTS

During the one-week observation period after treatment, there were more clinical lesions (20.6 percent versus 11.3 percent), more HSV-1-positive culture specimens (7.9 percent versus 1.6 percent) and more HSV-1-positive saliva specimens (7.9 percent versus 4.0 percent) in placebo than in valacyclovir-treated patients, respectively. The percentage of patients who developed recurrences and shed HSV-1 in saliva 72 hours after dental procedures was significantly smaller in the valacyclovir group than in the placebo group (11.3 percent versus 27 percent; P = .026). The mean time to pain cessation was significantly less in the valacyclovir group (3.2 days) than in the placebo group (6.2 days) (P = .006).

CONCLUSION

HSV recrudescence after routine dental treatment is suppressed by valacyclovir prophylaxis.

CLINICAL IMPLICATIONS

HSV recrudescence is common after routine dental treatment. Clinicians should consider antiviral therapy for patients at risk of experiencing a recurrence, as well as to minimize transmission of the disease.

Herpes simplex virus: an occupational hazard in dentistry

Approximately 70% of the population in the western world become infected with the herpes simplex virus type 1 (HSV-1) by the second decade of life. This review discusses the role of the HSV-1 as a potential occupational hazard for dental workers, focusing on herpes labialis, herpetic whitlow and keratitis. The risks associated with the dental treatment of patients with HSV-1, both from the perspective of the clinician and the patient are presented. Procedures for minimising the impact of HSV-1 within the dental practice, in particular infection control, delivery of treatment and patient education, are addressed. The management options for recurrent herpes labialis are also reviewed.

High-dose, short-duration, early valacyclovir therapy for episodic treatment of cold sores: results of two randomized, placebo-controlled, multicenter studies

Oral valacyclovir is better absorbed than oral acyclovir, increasing acyclovir bioavailability three- to fivefold. This provides the opportunity to explore whether high systemic acyclovir concentrations are effective in the treatment of cold sores (herpes labialis). Two randomized, double-blind, placebo-controlled studies were conducted. Subjects were provided with 2 g of valacyclovir twice daily for 1 day (1-day treatment), 2 g of valacyclovir twice daily for 1 day and then 1 g of valacyclovir twice daily for 1 day (2-day treatment), or a matching placebo and instructed to initiate treatment upon the first symptoms of a cold sore. In study 1, the median duration of the episode (primary endpoint) was reduced by 1.0 day (P = 0.001) with 1-day treatment and 0.5 days (P = 0.009) with 2-day treatment compared to placebo. Similarly, the mean duration of the episode was statistically significantly reduced by 1.1 days with 1-day treatment and 0.7 days with 2-day treatment compared to placebo. The proportion of subjects in whom cold sore lesion development was prevented and/or blocked was increased by 6.4% (P = 0.096) with 1-day treatment and 8.5% (P = 0.061) with 2-day treatment compared to placebo. The time to lesion healing and time to cessation of pain and/or discomfort were statistically significantly reduced with valacyclovir compared to placebo. In study 2, results similar to those in study 1 were obtained. AEs were similar across treatment groups. These studies provide evidence supporting a simple, 1-day valacyclovir treatment regimen for cold sores that is safe and effective. The 1-day valacyclovir regimen offers patients a unique and convenient dosing alternative compared to available topical therapies.

Recrudescent herpes labialis during and prior to early pregnancy

OBJECTIVES

To assess the experience of recrudescent herpes labialis (RHL) before and during early pregnancy.

METHODS

History of RHL prior to and during the first trimester of pregnancy was obtained from 3738 women attending at 10-15 weeks' gestation. The influence of age, ethnicity, socioeconomic group, smoking behavior, and alcohol intake on RHL was assessed.

RESULTS

1066 women (28.5%) reported a history of RHL lesions, with reduced incidence of RHL during pregnancy (0.111 lesions/subject per month) compared with outside pregnancy (0.19 lesions/subject per month) (P<0.0001). Those who did report lesions during pregnancy (n=296) experienced them at a higher monthly rate (0.41 lesions/subject per month) than before pregnancy (0.25 lesions/subject per month) (P<0.0001). RHL rate in early pregnancy was related solely to the previous rate of lesion recrudescence (P<0.001).

CONCLUSION

Pregnant women with a history of RHL report reduced incidence of RHL during pregnancy.

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.

Comparative performance of herpes simplex virus type 1-specific serologic assays from MRL and Meridian Diagnostics

Two companies, MRL and Meridian Diagnostics, have developed Food and Drug Administration-approved herpes simplex virus type 1 type-specific enzyme immunoassays. The sensitivity, specificity, and overall testing efficiency of these assays were 98.2, 93.8, and 96.6% for MRL and 98.8, 99.0, and 98.1% for Meridian, making both of these kits suitable for use in the clinical lab.

Prospects for control of herpes simplex virus disease through immunization

Herpes simplex viruses (HSVs) can cause a variety of infections, including genital herpes. Despite effective antiviral therapy, HSV infections remain a significant worldwide public health problem. Vaccines offer the best hope for controlling spread and limiting HSV disease. This article discusses the pathogenesis and immunobiology of mucocutaneous HSV infections, summarizes the spectrum of diseases caused by HSV, and provides a review of the field of HSV vaccine research. This article also discusses what might be realistically expected of a vaccine intended for control of genital herpes and explores the question of whether a vaccine that is effective in controlling genital HSV disease might also be effective in controlling nongenital HSV disease. The efficacy of such vaccines for the full spectrum of HSV disease will eventually determine the timing and targeting of immunization, ranging from selective immunization in preadolescence to universal childhood immunization as part of the routine childhood regimen.

Molecular aspects of herpes simplex virus I latency, reactivation, and recurrence

The application of molecular biology in the study of the pathogenesis of herpes simplex virus type 1 (HSV-1) has led to significant advances in our understanding of mechanisms that regulate virus behavior in sensory neurons and epithelial tissue. Such study has provided insight into the relationship of host and viral factors that regulate latency, reactivation, and recurrent disease. This review attempts to distill decades of information involving human, animal, and cell culture studies of HSV-1 with the goal of correlating molecular events with the clinical and laboratory behavior of the virus during latency, reactivation, and recurrent disease. The purpose of such an attempt is to acquaint the clinician/scientist with the current thinking in the field, and to provide key references upon which current opinions rest.

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.

Evaluation of antioxidant healing formulations in topical therapy of experimental cutaneous and genital herpes simplex virus infections

A genital HSV-2 infection of guinea pigs and a cutaneous HSV-1 infection in mice were used to examine the ability of antioxidant components CRT1 to reduce lesion development, duration, and severity. CRT is a patented antioxidant formulation developed by Warner-Lambert Worldwide Consumer Healthcare R. and D. CRT contains three components that work synergistically: vitamin E, sodium pyruvate and membrane stabilizing fatty acids. The MS strain of HSV-2 was utilized for intravaginal inoculation of guinea pigs with approximately 1.2 x 10(5) plaque forming units. The guinea pigs were treated on the external genital skin four times daily for 10 days beginning 48 h post viral inoculation. This study was designed to optimize the CRT formulations that would be used to quantify the synergistic effect of the CRT components. SKH-1 male hairless mice were inoculated with 1 x 10(7) HSV-1 (McIntyre strain) on the dorsal surface of the mouse and treated with CRT formulations starting on the afternoon of the day of infection, and treated for the following 14 days. In the guinea pig model, the CRT formula that contained all three CRT components, worked synergistically to reduce lesion development, duration and severity scores significantly compared to vehicle control or acyclovir. Acyclovir was the only compound that reduced viral titers, but in contrast to CRT, acyclovir did not reduce lesion development, duration or severity. The quantitative effect of the three CRT components was demonstrated in the mouse model.

Patient recognition of recrudescent herpes labialis: a clinical and virological assessment

OBJECTIVES

The purpose of this study was to ascertain how accurate the general public was at diagnosing the condition of recrudescent herpes labialis.

METHODS

An advertisement was placed in a local newspaper inviting patients to attend the Oral Medicine Clinic as soon as they thought they developed the clinically evident stage of herpes labialis. At the clinic, patients were examined to confirm the clinical presence of herpes labialis and also had a swab of the lesion(s) taken for virus culture. Virus culture was by the HEP-2 culture technique capable of detecting both herpes simplex Type 1 and herpes simplex Type 2. Patients also completed a detailed questionnaire concerning their knowledge of herpes labialis.

RESULTS

In total, 41 patients attended for screening. The findings were that all patients had clinical herpes labialis, and herpes simplex virus was isolated in 96% of cases. In contrast, in only about 50% of cases were patients aware that their herpes labialis was caused by a virus.

CONCLUSIONS

The general public are very good at recognizing herpes labialis lesions but need to be given more information about their infectivity.

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.

Toward assessing trends in oral mucosal lesions: lessons learned from oral cancer

Trend data on oral mucosal lesions are limited. The literature is comprised of a large number of studies documenting the prevalence of various lesions in different populations. Trend data on cancers of the oral cavity and pharynx are the exception. An overview of the international epidemiologic studies of these cancers is provided. General conclusions across studies and countries for trend data of these cancers cannot easily be drawn, since variations exist in data collection methods, risk factors, and other characteristics of the study populations. This paper also reviewed the available prevalence data for oral mucosal lesions in general as well as data on leukoplakia, recurrent herpes labialis, and recurrent aphthous ulcers. A few studies of the incidence of leukoplakia are described. In order to explore the potential for future trend data on oral mucosal lesions, this paper discusses issues related to the feasibility and structure of monitoring these lesions. Criteria that could be used to identify which conditions should be monitored in the future were discussed, such as, those that present a public health problem, those that are sentinel events for serious conditions, and infectious lesions. Once lesions are identified, it is clear that international consensus for diagnostic criteria of these lesions is needed in order to permit comparisons to be made among studies. Finally, strategies for monitoring these conditions and factors that may affect future trends are reviewed.

The prevalence of recurrent herpes labialis during an army hot weather exercise

A survey was performed on 1,062 of 2,500 (42%) Army personnel participating in a desert training exercise at Fort Irwin, California, in September 1983. The prevalence of recurrent herpes labialis (RHL) and chapped lips was observed during the third week of a four-week training period. Complexion, sex, lip protectant use, age, and time spent outdoors were obtained by observation and interview. Recurrent herpes labialis was found in 46 subjects (4%). Stratified analysis and stepwise logistic regression were used to identify risk factors associated with RHL and to determine the prevalence odds ratios (POR). Risk factors with statistically significant associations with RHL were lip protectant use (POR = 0.19), chapped lips (POR = 2.87), being female (POR = 5.00), and light complexion (POR = 2.48). These findings strongly support the use of lip protectants during prolonged exposure to hot, dry climates as a prophylaxis against recurrent herpes labialis. Additional studies should focus on excitatory factors of RHL; and clinical trials of the efficacy of the lip protectants to protect against RHL and chapped lips should be undertaken.

Prevention of ultraviolet-light-induced herpes labialis by sunscreen

Sunlight exposure is reported by some patients to precede onset of recurrent herpes labialis. Ultraviolet (UV) B light is known to be a stimulus for the reactivation of herpes simplex virus (HSV) infections. We assessed the effect of a sunblocking agent on UV-light-induced reactivation of recurrent herpes labialis in a double-blind, placebo-controlled crossover trial. 38 patients were exposed on two separate occasions to four minimum erythema doses of UV light at an area of previous labial herpes recurrence. A solution containing sunscreen was applied to the lips before one exposure and a matched placebo before the other. After placebo and UV exposure, herpes labialis developed in 27 (71%) of the 38 patients, with a mean time to recurrence of 2.9 (SEM 0.2) days. In contrast, when sunscreen was applied before UV exposure, no lesions developed, but 1 of the 35 patients shed virus at the exposure site. We conclude that UV light is a potent stimulus for inducing reactivation of herpes labialis, and that application of sunscreen may be effective in the prevention of sunlight-induced recurrent infection.

Determining therapeutic efficacy in recurrent herpes labialis by lesion size analysis

We devised an experimental model for the analysis of therapeutic efficacy of topical medications for recurrent herpes labialis with a double-blind, placebo-controlled format. Rigid prestudy screening evaluations allowed the enrollment of a homogeneous starting population with characteristic herpetic reactivation in an early stage. Using precise measurements of lesion area for a 5-day period, we evaluated the effects of a novel medication containing tannic acid, which has demonstrated impressive inhibitory effects on herpes simplex virus in many recent studies, and salicylic acid, which has rapid absorption kinetics and substantial topical anti-inflammatory and keratin-disrupting properties. Using parametric and nonparametric tests, we studied differences in mean lesion size and used these measurements to evaluate objective and clinically applicable improvement criteria. Although there were no significant differences in mean lesion size at presentation (day 1) between the active medication and placebo groups, the former demonstrated significantly smaller lesions at days 2 through 5 (p less than 0.05). By day 5, 10 of 14 treated subjects showed improvement as defined by a 25% reduction in lesion size compared with day 1, in contrast to only 2 of 12 subjects in the placebo group (p = 0.0079, Fisher's Exact Test). This model can be employed in the evaluation of topical antiviral agents for herpes labialis in a healthy population, because it standardizes criteria for subject enrollment and provides objective and reproducible measurements of therapeutic efficacy.

Epidemiologic studies of oral mucosal conditions--methodologic issues

The methods used in the international English-language literature of epidemiologic investigations of oral mucosal conditions were reviewed. Methods used to study leukoplakia, lichen planus, recurrent herpes labialis, recurrent aphthous ulcers, geographic tongue and candidiasis are highlighted. In addition, studies of the full range of pathologies documented in a population were reviewed. The methodologic issues raised by the epidemiologic literature as well as those to be considered for future studies of oral mucosal conditions are presented. Emphasis is placed on study population selection, diagnostic criteria development, type and training of examiners, risk factor assessment and issues related to data collection, analysis and reporting.

Prevalence of oral soft tissue lesions in out-patients at two Malaysian and Thai dental schools

At the Faculties of Dentistry in Chiang Mai, Thailand (CM), and Kuala Lumpur, Malaysia (KL), 234 and 233 consecutive out-patients of mean ages 33.8 and 31.0 yr, respectively, were examined for the presence of oral mucosal lesions. Tobacco in some form was regularly used by 31.7% and 27.5% of the study populations in CM and KL, respectively. Cigarette smoking was the predominant habit. In CM three persons chewed betel quids and nine smoked banana leaf cigars daily. In addition, there were 24 habitual chewers of tea leaves (miang). In KL six persons chewed betel quids daily. In CM and KL three cases each (1.3%) of tobacco-associated leukoplakias were found. In KL an additional idiopathic leukoplakia was registered. One and three cases of betel related lesions were found in CM and KL, respectively. One case of a squamous cell carcinoma was found in a 45-yr-old Indian woman in KL who had been chewing betel with tobacco daily for many years. High prevalence figures were found for lichen planus, 3.8% in CM and 2.1% in KL, and an extremely high one, 48.3%, in CM for episodes of aphthous ulcers experienced during the last 2 yr. Comparatively low prevalence figures were found for herpes labialis. As could be expected melanin pigmentation was prevalent while only low figures were encountered for denture-related lesions and amalgam tattoos.

Occurrence of recurrent herpes labialis in an adult Swedish population

In a general adult Swedish population recurrent herpes labialis (RHL) was found in 3.1% of 20,333 people aged 15 years and more. When a 2-year history of RHL was considered, the total prevalence was 17.4%. There was a slight predominance among women. Only slight differences were found between various age groups. In a fraction of the population studied, constituting 2771 people, interviews concerning cases of RHL were carried out. Thus, for example, most individuals referred to only one herpes episode a year; the most prevalent site of eruption was an area comprising both the vermilion border and the skin, and most of the lesions showed healing times of 5-8 days. The prevalence of RHL was influenced by some tobacco habits. Thus, the prevalence was significantly lower among smokers, and especially among pipe smokers, than among people with no tobacco habit at all. Snuff dipping did not seem to influence the prevalence values.

Natural history of frequent recurrences of herpes simplex labialis

We prospectively studied all herpes simplex labialis (HSL) episodes in a group of 84 (age, 6 to 71 years) persons who previously had frequent recurrences of HSL to determine whether their recurrences of HSL were different from those of the general population. The mean +/- standard error for number of HSL outbreaks for 6 months was 2.7 +/- 0.3. Age, gender, or season did not influence the recurrence rate. The mean time to vesicle healing of 214 outbreaks was 6.4 +/- 0.2 days. Again, age or gender did not influence healing time. An episode of HSL did not elicit a refractory period to the next attack of HSL. Furthermore, the severity of the previous HSL lesion did not influence the interval to next recurrence or the location of the next lesion. In 47%, the next recurrence of HSL crossed the midline of the face, and in 45%, it moved from one lip to the other. The high recurrence frequency and multiple facial locations of HSL lesions seen in these persons differed from the general population, who report infrequent lesions of HSL at the same facial location.

Oncogenic potential of sexually transmitted viruses with special reference to oral cancer

Recent changes in social mores have been accompanied by a noted increase in the frequency of sexually transmitted diseases. Viruses that have been identified as causative agents for a large proportion of these diseases have also been associated with various malignant states. Concomitantly, the number of cases of oral cancer (considered to occur usually around or after the fifth decade of life) reportedly has been increasing among young adults. The oncogenic potential of several sexually transmitted viruses (HSV, HPV, CMV, and LAV/HTLV III) and their possible role in the development of malignant conditions, in particular oral cancer, are discussed in this review.

Recurrent herpes labialis in skiers. Clinical observations and effect of sunscreen

Recurrent orofacial herpes infection may be triggered by high altitude skiing, presumably because of solar ultraviolet radiation exposure. Six (12%) of a group of 51 subjects with a history of skiing-triggered herpes observed during 1 week of high altitude skiing experienced reactivations of orofacial herpes a median of 3 1/2 days after exposure. Within this group, application of a sunscreen with a sun protection factor (SPF) of 15 failed to influence the reactivation rate as compared with a placebo. Reactivation of herpes triggered by skiing is common. As application of a sunscreen with an SPF of 15 did not appear to influence the reactivation rate, alternate approaches to the control of recurrent orofacial herpes are needed.

Autoinoculation herpes of the hand in a child with recurrent herpes labialis

Herpes simplex virus infections involving the fingers and hands have been reported primarily in medical and dental personnel. A 10-year-old boy is described who presented with herpes simplex virus infection of his left hand two weeks after resolution of an episode of recurrent herpes labialis. Since herpes simplex infections of the fingers and hands may be confused with a variety of other more common conditions, clinicians should be alert to this possibility when diagnosing vesiculopustular lesions of the hands, particularly in medical and dental personnel and in patients with histories of recurrent herpes simplex infections elsewhere. A need for greater patient awareness of the potential for herpes simplex virus autoinoculation is also stressed.

Lack of oral HSV-2 in a college student population

A population of individuals with a high incidence of genital herpes simplex virus type 1 (HSV-1), due most likely to oro-genital contact, was examined to determine the incidence of oral herpes simplex virus type 2 (HSV-2) infection. Herpes simplex virus was isolated from the oral cavity of 43 college students whose symptoms ranged from singular lesions of the lips with minimal discomfort to severe oral disease with systemic involvement resulting in lymphadenopathy, chills, sweat, myalgia, and fever. The virus isolated from each case was identified by serum neutralization and typed as HSV-1 or HSV-2 using (E)-5-(2-bromovinyl)-2'-deoxyuridine (BVDU) sensitivity, monoclonal antibody immunofluorescence, and restriction endonuclease EcoRI digestion of viral DNA. In every instance the isolate was HSV-1. Additional identification and typing of head and neck isolates as well as oral samples from non-university patients demonstrated that all were also HSV-1. Therefore, while HSV-1 appears to be readily transmitted to the genitalia in this group of individuals, the transmission of HSV-2 to the oral cavity may not be as common, even though clinical histories revealed that several of these patients were engaging in oro-genital contact.

Successful treatment of herpes labialis with topical acyclovir

A double blind, placebo controlled trial of 5% acyclovir cream, applied topically five times a day for five days, was carried out in 49 patients with recurrent herpes labialis. These patients had a total of 74 episodes, 34 of which were treated with the 5% acyclovir cream and 40 with matching placebo. First episodes and all episodes treated with acyclovir cream had significantly shorter times to formation of ulcer or crust and to complete healing (p less than 0.05 for all variables). The duration of all symptoms and proportion of patients developing itching was also reduced by acyclovir cream in first episodes, though the difference was not significant. When the patient started treatment early in the course of a first episode acyclovir cream significantly reduced the percentage of lesions progressing beyond the papular stage (p less than 0.05). Acyclovir cream is well tolerated and effective for the treatment of recurrent herpes labialis.

Treatment of herpes labialis

Untreated herpes labialis may take up to 10 days or more to heal and antiviral therapy must be initiated early if it is to be effective. Acyclovir ointment has been reported to have an antiviral effect but no clinical benefit and a newer formulation, acyclovir cream, has been developed in an attempt to enhance skin penetration. In placebo-controlled trials, acyclovir cream shortened the duration of lesions significantly and when therapy was started before vesicles developed, the number of lesions aborting was increased significantly. This therapy was well tolerated by most patients. Topical acyclovir offers hope for the successful management of herpes labialis where systemic therapy is considered inappropriate.

Herpetic whitlow: an occupational disease of practicing dentists

Recurrent herpes simplex virus lesions of fingers, hand, or eyes are suspected to be encountered in health practitioners in greater frequency than in the general population. To determine whether an increased risk of disease contraction coincident to practicing dentistry exists and to determine the magnitude of risk, a survey of dentists practicing in the state of Michigan was conducted. An age and sex matched nondentist patient from each respondent's practice provided a control population. Frequency of herpes labialis and herpes infection of the eye were found be lower in dentists than in the control population. Conversely, herpetic whitlow was found to be more frequent in practicing dentists than in the control population. If the occurrence of herpes labialis in each of the two groups is taken as the reference point, the frequency of herpetic whitlow is significantly higher among practicing dentists than among the control population (P less than .01).

Mucocutaneous herpes simplex virus infections in immunocompromised patients. A model for evaluation of topical antiviral agents

Forty-three immunocompromised patients with progressive cutaneous herpes simplex virus infections were studied in a double-blind, placebo-controlled evaluation of topically applied acyclovir. Patients were randomized and 22 received acyclovir and 21 placebo; medications were applied four times daily for 10 days. Both study populations were balanced for all demographic characteristics. Acyclovir therapy resulted in no median differences in time to total healing compared with placebo responses, p = 0.13. However, those patients who received the acyclovir ceased shedding virus more rapidly, p less than 0.001, and lost pain more readily, p = 0.04, than placebo counterparts. Neither group experienced adverse effects. Because of the protracted nature of mucocutaneous herpes simplex infections in these patients, the immunocompromised host provides a good model for evaluation of topical antiviral therapy.