From the Cochrane Library: Interventions for the Prevention of Herpes Simplex Labialis (Cold Sores on the Lips)

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Does bacillus Calmette-Guérin vaccine prevent herpes simplex virus recurrences? A systematic review

Recurrent infections with herpes simplex virus (HSV) in the orofacial (cold sores), ocular or genital region are common and sometimes disabling, calling for an effective preventive intervention. The bacillus Calmette-Guérin (BCG) vaccine has beneficial off-target effects that might impact recurrence of HSV infections. In this systematic review, Medline, EMBASE, and PubMed were searched in June 2020; 16 articles were deemed relevant comprising eight animal and eight human studies (301 patients). In animals, BCG administration led to a 1.9 to 5.5-fold increase in survival rate following HSV challenge (vaginal, corneal, or intraperitoneal inoculation). This beneficial effect was influenced by the dose of BCG (higher better), mode of administration (intradermal better than intraperitoneal), and the interval between vaccination and viral challenge (at least 6 days required). In nonrandomized human studies (that failed to control for a placebo effect), BCG vaccination appeared beneficial in 78% of adults with recurrent herpes genitalis or labialis, with 37% being recurrence-free for an extended period, 41% experiencing less frequent or severe episodes, and only 22% reporting no change. This clinical benefit is consistent with the findings of immunological sub-studies. In the two studies restricted to recurrent herpes labialis, 94% appeared to benefit from BCG. The one randomized controlled trial used an intervention in the control group that has immunomodulatory effects thus limiting interpretation. In conclusion, BCG vaccine is a potential, safe, affordable and readily available candidate intervention to decrease the high burden of disease associated with HSV infection and recurrences, but properly controlled randomized trials are required.

Resolution of Recurrent Oro-facial Herpes Simplex Using a Topical Botanical Gel: A Case Report

Oral herpes labialis, more commonly known as cold sores, are a common encountered viral infection involving herpes simplex virus-1 (HSV-1). Although relatively benign, these lesions can be both unsightly and clinically difficult to manage. Prescription standards of care and over-the-counter agents, such as docosonal, have often shown only limited efficacy in both decreasing lesional pain and reducing duration of lesional symptomology and are not without potential side effects. Despite some success with acute remediation, recurrent episodes often occur, with seemingly no imparted protection or suppression against future outbreaks. This case report involves the successful treatment of oro-facial herpes labialis with a synergistic botanical blend with marked reduction in symptoms, pain score, and lesion duration. Monitoring and evaluation post-treatment and application during future prodromal symptoms was also performed demonstrating additional reduction in the frequency of subsequent outbreaks. This case report supports the use of this treatment for prodromal and acute treatment of oro-facial herpes infection and appears to impart a reduction in the frequency of future outbreaks.

Kanuka honey versus aciclovir for the topical treatment of herpes simplex labialis: a randomised controlled trial

OBJECTIVE

To compare New Zealand medical grade kanuka honey with topical aciclovir for the treatment of herpes simplex labialis.

DESIGN

Prospective parallel randomised controlled open-label superiority trial.

SETTING

76 community pharmacies across New Zealand between 10 September 2015 and 13 December 2017.

PARTICIPANTS

952 adults randomised within the first 72 hours of a herpes simplex labialis episode.

INTERVENTIONS

Random assignment 1:1 to either 5% aciclovir cream or medical grade kanuka honey (90%)/glycerine (10%) cream, both applied five times daily.

OUTCOME MEASURES

The primary outcome was time from randomisation to return to normal skin (stage 7). Secondary outcomes included time from randomisation to stage 4 (open wound), time from stage 4 to 7, maximal pain, time to pain resolution and treatment acceptability.

RESULTS

Primary outcome variable: Kaplan-Meier-based estimates (95% CI) for the median time in days for return to normal skin were 8 (8 to 9) days for aciclovir and 9 (8 to 9) for honey; HR (95% CI) 1.06 (0.92 to 1.22), p=0.56. There were no statistically significant differences between treatments for all secondary outcome variables. No related serious adverse events were reported.

CONCLUSION

There was no evidence of a difference in efficacy between topical medical grade kanuka honey and 5% aciclovir in the pharmacy-based treatment of herpes simplex labialis.

TRIAL REGISTRATION NUMBER

ACTRN12615000648527;Post-results.

Protocol for a randomised controlled trial of 90% kanuka honey versus 5% aciclovir for the treatment of herpes simplex labialis in the community setting

INTRODUCTION

Worldwide, about 90% of people are infected with the herpes simplex virus, 30% of whom will experience recurrent herpes simplex labialis, commonly referred to as 'cold sores', which can last up to 10 days. The most common treatment is aciclovir cream which reduces healing time by just half a day compared with no specific treatment. This is a protocol for a randomised controlled trial (RCT) to determine the efficacy of medical grade kanuka honey-based topical treatment (Honevo) in reducing the healing time and pain of cold sores, compared with topical aciclovir treatment (Viraban).

METHODS AND ANALYSIS

This open-label, parallel-group, active comparator superiority RCT will compare the efficacy of medical grade kanuka honey with 5% aciclovir cream in the treatment of cold sores in the setting of a pharmacy research network of 60 sites throughout New Zealand. Adults presenting with a cold sore (N=950) will be randomised by pharmacy-based investigators. The pharmacy-based investigators will dispense the investigational product to randomised participants and both study groups apply the treatment five times daily until their skin returns to normal or for 14 days, whichever occurs first. In response to a daily SMS message, participants complete an assessment of their cold sore healing, with reference to a visual guide, and transmit it to the investigators by a smartphone eDiary in real time. The primary outcome variable is time (in days) from randomisation to return to normal skin. Secondary endpoints include total healing time stratified by stage of the lesion at onset of treatment, highest pain severity and time to pain resolution.

ETHICS AND DISSEMINATION

New Zealand Ethics Registration 15/NTB/93. Results will be published in a peer-reviewed medical journal, presented at academic meetings and reported to participants.

TRIAL REGISTRATION NUMBER

Australia New Zealand Clinical Trials Registry: ACTRN12615000648527, pre-results.SCOTT Registration: 15/SCOTT/14 PROTOCOL VERSION: 4.0 (12 June 2017).