наружная терапия в лечении herpes labialis

[DoctorElle]

здравствуйте, уважаемые коллеги!
есть еще один препарат- Феборцин, не так пачкает как Фукарцин, практически безцветный.
я его использую для подсушивания пустул, очень хороший эффект при герпесе, если наносить его через каждые 3 часа перед нанесением противовирусной мази, элементы быстро подсыхают и покрываются корочкой, достаточно 2 дней...
хотя у нас уже сняты с производства как Феборцин, так и фукорцин, не понятно почему.....

[nastassia]

а зачем вы наносите на элементы противовирусную мазь при герпесе. ее неэффективность по сравнению с плацебо доказана.
желательно лечить либо системными противовирусными препаратами в первые 2 дня, либо не лечить совсем, т.к. в таком случае, длительность высыпаний будет одна и та же

[DoctorElle]

[quote=nastassia;868595]а зачем вы наносите на элементы противовирусную мазь при герпесе. ее неэффективность по сравнению с плацебо доказана.
желательно лечить либо системными противовирусными препаратами в первые 2 дня, либо не лечить совсем, т.к. в таком случае, длительность высыпаний будет одна и та же[/QUOTE

к сожалению, не располагаю такими данными. при лечении сочетаю системные противовирусные препараты в течении 5 дней и наружное лечение, так как описано выше.
и еще , доктра, согласитесь,психологически нашим пациентам важно, не только провести осмотр и собрать анамнез, причем искренне сочуствуя пациенту, поскаблить, но и обязательно назначить что-нить помазать, дабы они могли активно поучаствовать в процессе своего выздоравления. были в моей практики случаи, когда не было необходимости проводить даже наружную терапию, достаточно было обычной беседы, но в течении всей этой беседы стоял вопрос,А ЧТО МНЕ ПОМАЗАТЬ? дабы не навредить использовала простую цинковую пасту, причем изготовленную по рецепту на заказ...

[nastassia]

не согласимся в английском языке есть чудесный термин reassurance.
если все пройдет само, зачем назначать ненужное?!
по поводу герпеса, судя по всему, ваши данные достаточно скудны. эта информация есть во всех современных гайдлайнах

[nastassia]

Treatment and prevention of herpes simplex virus type 1 infection

INTRODUCTION — The treatment and prevention of herpes simplex virus type 1 (HSV-1) infection depends upon a variety of considerations including:

The site of infection
The severity of symptoms
The frequency of recrudescence
The immunologic status of the patient
The standard treatments for HSV infections include various nucleoside derivatives that interfere with the synthesis of viral DNA. Acyclovir, an acyclic nucleoside analog, has become the cornerstone of treatment for most serious HSV infections and is the most widely prescribed antiviral medication. Alternative agents include valacyclovir, famciclovir, vidarabine, and foscarnet. (See "Acyclovir: An overview" and see "Valacyclovir: An overview" and see "Famciclovir: An overview" and see "Foscarnet: An overview").

Drugs are also in development that inhibit the helicase-primase enzyme of HSV-1 and -2 and represent a new target for antiviral activity [1,2]. Two of these agents, BILS 179 BS and BAY 57-1293, were effective in clearing both HSV-1 and -2 in murine models of infection following oral administration; BILS 179 BS appeared to be active even if administered as late as 65 hours after infection [1] and BAY 57-1293 may decrease the frequency and severity of recurrences [2]. Neither drug is active against latent virus, and neither has been subjected yet to clinical trials in humans.

Most drug development has been focused on inhibition of viral proteins. However, the extensive use of medications that target HSV proteins has led to the development of mutations and subsequent drug resistance. To address this problem, host cell proteins are being explored as potential targets for drug development [3].

The recommendations for treatment and prophylaxis of primary and recurrent HSV-1 infections in the normal and immunocompromised patient will be reviewed here. The epidemiology, clinical manifestations, and diagnosis of HSV-1 infections are discussed separately. (See "Epidemiology of herpes simplex virus type 1 infection" and see "Clinical manifestations and diagnosis of herpes simplex virus type 1 infection").

HERPES GINGIVOSTOMATITIS AND LABIALIS — Herpes gingivostomatitis is the principle manifestation of primary HSV-1 infection, and herpes labialis is the most common presentation of HSV-1 infection and generally represents HSV-1 reactivation. The treatment of herpes gingivostomatis and labialis have been subjects of far less study than therapy for genital HSV infection.

Primary infection — Gingivostomatitis is the principle manifestation of primary HSV-1 infection. Involvment of other organs can occur (see below).

Treatment — Children who present with gingivostomatitis often require either topical or oral administration of analgesics and, in severe cases, intravenous rehydration. Short-term relief (10 to 15 minutes) can be achieved via mouth rinses with viscous lidocaine. Zilactin, a nonprescription topical medication containing hydroxypropyl cellulose, adheres to mucosa and may be used to protect lesions from trauma and irritants [4]. Ziladent, a similar agent with the addition of benzocaine, a topical anesthetic, can provide pain relief for up to one to six hours. In more severe cases, oral opiates, usually in the form of elixirs, may be required for adequate pain relief. Adults may also benefit from topical analgesics but rarely require oral pain medications. In addition, antiseptics may hasten drying of lesions and decrease the risk of superinfection in both children and adults [5].

Compared to genital HSV infection, antiviral treatment of labial HSV disease is less well studied [6,7]. Studies suggest that acyclovir may be beneficial if begun early during primary (or recurrent) infections since the drug acts only during active viral replication, which generally precedes symptoms. In a randomized, double-blind, placebo-controlled trial, children with herpes gingivostomatitis treated early (<72 hours after the onset of lesions) with acyclovir (15 mg/kg up to a dose of 200 mg PO, with each dose taken five times daily for seven days) had the following results [8]:

Shorter duration of lesions (median 4 versus 10 days)
Earlier disappearance of fever (1 versus 3 days)
Earlier resolution of extraoral lesions (0 versus 5.5 days)
Decreased duration of eating difficulties (4 versus 7 days)
Reduced viral shedding (1 versus 5 days)
The conclusion of this trial was that oral acyclovir begun within the first three days of onset of lesions shortens the duration of all clinical manifestations and the infectivity of affected children. Topical acyclovir, which is available as a 5 percent polyethylene glycol ointment, has not been promising in the treatment of primary oral lesions since it has poor penetration to the sites of replication [9].
Most clinicians would treat primary herpes labialis with acyclovir (200 mg PO five times per day or 400 mg PO three times per day) for seven to ten days [10]. Intravenous acyclovir may be required in severe cases, such as ulcerative pharyngitis, and especially when herpes labialis is associated with other infections (eg, pneumococcal sepsis). There are no clinical trials on the use of valacyclovir or famciclovir for primary herpes labialis.

Prevention — There is currently no vaccine effective against HSV [11] and, because most adults have been exposed to HSV-1, there are no recommendations regarding postexposure prophylaxis with antiviral medications for immunocompetent individuals exposed to a patient with HSV-1. Children, however, have been shown to benefit from antiviral treatment during periods of known exposure to active HSV lesions. In one study, 45 children exposed to herpetic gingivostomatitis in a daycare center were randomized to treatment with acyclovir (30 to 50 mg/kg five times daily) or no treatment [12]. Among the 23 children randomized to treatment, none developed clinical HSV disease and only 8 seroconverted compared to 18 cases of clinical HSV infection and 20 seroconversions among the 22 untreated children.

Prevention of primary infections with HSV-1 and prophylaxis against recurrent attacks may be recommended in certain cases, depending upon the history of exposure, frequency of recrudescence, age, and immunologic status of the patient. Nonpharmacologic methods of prevention include the use of gloves and condoms to avoid direct contact with active lesions and the avoidance of excessive sun exposure in UV light-induced recurrent herpes labialis. However, when pharmacologic intervention is warranted, acyclovir is the drug of choice.

Recurrent infection

Treatment — Most immunocompetent individuals with recurrent herpes labialis do not require treatment other than the occasional use of local analgesics (see above).

Treatment trials have addressed a variety of strategies of managing HSV in patients with recurrent symptoms, including initiation of therapy before a stimulus well-known to trigger oral herpes [13,14]. For example, in a study of 237 skiers with a history of recurrent labial herpes triggered by sun exposure found no difference in the prevention of lesions or healing rate for acyclovir (800 mg BID PO initiated 12 to 24 hours before sun exposure and continued for three to seven days) compared with placebo [13].

Other trials have evaluated whether beginning therapy at the first sign of prodromal symptoms (eg, pain, tingling) has any significant benefit. Most have demonstrated that early initiation of therapy has a modest effect on time to healing and decreased pain. The following observations illustrate the range of findings:

The largest trial included 1573 patients who were randomly assigned to 1 percent penciclovir cream or a vehicle control cream [15]. The time to healing (4.8 versus 5.5 days) and days of pain (3.5 versus 4.1) were decreased in the group receiving penciclovir regardless of whether it was initiated early (prodrome or erythema stage) or late (papule or vesicle stage) [15]. Viral shedding was reduced significantly only in the group receiving penciclovir early.
In one trial, 174 immunocompetent patients were randomly assigned to oral acyclovir (400 mg taken five times daily) versus placebo within one hour of the first sign or symptom of recurrence [16]. The frequency of HSV culture positive lesions decreased by 48 percent, but the development of lesions and the maximum size of lesions was not altered by drug treatment. In the subgroup of patients able to start therapy in the prodromal stage or when the lesion was only erythematous, acyclovir decreased pain duration by 36 percent and the time to healing by 27 percent.

[nastassia]

Two randomized controlled trials reported together compared a one-day (2 g twice) or two-day (2 g twice on the first day and 1 g twice on the second day) regimen of valacyclovir to placebo taken at the first sign of symptoms [17,18]. Valacyclovir therapy was associated with reductions in the duration of the episode, the time to healing of lesions, and the duration of pain. Treatment for one day was as effective as two days.
In a randomized, double-blind, placebo-controlled trial, 701 patients with recurrent oral herpes were randomly assigned to famciclovir at 1500 mg as a single dose, 750 mg twice a day for a single day, or placebo within one hour of onset of prodromal symptoms [19]. Time to healing was significantly shorter in the treatment groups compared to placebo (4.4, 4.0, 6.2 days, respectively).
While the benefit is modest, it may be reasonable to treat the small subset of patients with an identifiable prodrome with oral acyclovir, valacyclovir, famciclovir, or penciclovir cream. No studies have been performed comparing one antiviral agent to another in the treatment of this infection [20]. Chronic suppressive therapy is another approach discussed below.

Docosanol cream, which appears to block viral entry, has also been approved by the FDA [21-23]. This topical therapy in unpublished data from the manufacturer shortened the course of recurrent herpes labialis compared to placebo when given at the time of prodromal symptoms but has not been compared to other antiviral treatments. Thus, like all other antivirals, this compound may only have some benefit if used extremely early in the process, ie, prior to the development of symptoms, and, therefore, is of dubious utility in the treatment of herpes labialis.

Imiquimod, which has been approved for the treatment of genital warts, was evaluated in 47 subjects with recurrent herpes labialis episodes [24]. Application of imiquimod led to severe local inflammation in several subjects and study enrollment was stopped early.

Suppressive therapy to prevent recurrences — As discussed above, intermittent treatment of HSV-1 recurrences has not resulted in either adequate amelioration of an attack that is already underway or the prevention of further recurrences. However, chronic suppression has proven helpful in preventing HSV recrudescence in individuals with frequently recurrent lesions. Controlled trials show a decrease in occurrence of new lesions from 50 to 78 percent in immunocompetent patients on prophylactic regimens of oral acyclovir (600 to 1000 mg daily). A daily suppressive regimen (200 mg three to five times daily) has been shown to be safe and effective when used continuously for up to one year [25]. In a crossover trial of 22 patients with frequently recurrent herpes labialis (≥6 episodes per year), the number of recurrences over four months was lower with daily suppressive acyclovir (400 mg twice daily) than with placebo (0.85 versus 1.80) [26].

Valacyclovir also appears to suppress recurrences of herpes labialis. Two small randomized double-blind trials evaluated oral valacyclovir (500 mg once daily) versus placebo for 16 weeks in patients with a history of four or more attacks during the previous year [27]. Patients receiving valacyclovir were more likely to remain free of recurrences during the four month period than those receiving placebo (60 versus 38 percent) and the time to first recurrence was significantly longer (13 versus 9.6 weeks).

Chronic suppressive therapy for virologically confirmed recurrent HSV in immunocompetent patients is indicated when:

Recurrences are very frequent, more than two every four months.
Recurrences are associated with serious systemic complications, eg, erythema multiforme, eczema herpeticum or recurrent aseptic meningitis [5].
Recurrences interrupt job performance or present increased risk of infection for others, eg, medical and dental personnel with herpetic whitlow.
If prophylaxis is successful in suppressing recrudescence in immunocompetent patients, the dose of acyclovir can be reduced slowly after two to three months until a breakthrough occurs [5]. Prophylaxis can then continue at a slightly higher dose for 6 to 12 months, at which point a "drug holiday" is recommended.

Short-term antiviral prophylaxis can also be considered in cases of UV light-induced HSV recurrences [28]. Other immunocompetent patients who may consider short-term prophylaxis include those undergoing procedures that increase the risk of an outbreak such as dermabrasion [29,30] or trigeminal ganglion or lumbar disc surgery [9].

Recommendations

Painful oral and labial lesions of primary HSV-1 infection can be treated with viscous lidocaine, zilactin, or ziladent. Oral opiates or intravenous hydration are generally reserved for severe cases.
Primary herpes labialis is usually treated with acyclovir (400 mg PO three times per day or 200 mg PO five times per day) for seven to ten days.
Recurrent herpes labialis is usually not treated with antivirals unless a prodromal stage before the appearance of lesions can be identified. In these cases oral acyclovir or penciclovir cream can be prescribed for four days duration [31,32].
Intermittent therapy does not prevent recurrences but chronic suppressive therapy can be useful in immunocompetent patients with recurrences more than every two to four months, recurrences associated with systemic complications, or recurrences that affect job performance. Acyclovir (200 mg PO three to five times a day) is generally used, but valacyclovir (500 mg once daily) is also effective.

[DoctorElle]

что ж спасибо, буду расширять свои познания..

[Pecatum]

Topical acyclovir, which is available as a 5 percent polyethylene glycol ointment, has not been promising in the treatment of primary oral lesions since it has poor penetration to the sites of replication [9].

[Ссылки доступны только зарегистрированным пользователям ]
Healing

Topical antiviral agents compared with placebo Topical aciclovir or topical penciclovir seem to be more effective at marginally reducing healing time (moderate-quality evidence).

Topical antiviral agents versus placebo:

Seven RCTs found that aciclovir reduced healing time compared with placebo. [8] [23] [26] [27] [28] [29]

И это не где-то там, а на сайте BMJ. Последние рекомендации CDC датируются, если не ошибаюсь, 2006 годом. За три года вполне могли бы и измениться. Доказательная медицина - не панацея, и если Вы наблюдаете эффективность конкретного препарата у конкретного человека (а эффективность ацикловира местного я наблюдал не раз), "как бы ДМ" в виде одного прочитанного гайда - еще не повод отменять лечение. Необходимо еще и учитывать комплаентность пациента, который не всегда готов жрать таблетки, а воспользоваться мазью - не против.

[Pecatum]

Сообщение от nastassia

желательно лечить либо системными противовирусными препаратами в первые 2 дня, либо не лечить совсем, т.к. в таком случае, длительность высыпаний будет одна и та же

И оттуда же:
We found no RCTs comparing early versus delayed intervention, therefore no firm conclusions about timing of treatment can be drawn.

[Dr.Anisimova]

- да, но есть и мнение, что при использовании топических противовирусных препаратов при герпесе увеличивает риск устойчивости на будущее, поэтому пока классика рекомендаций-противовирусные препараты системно
- наружно допускаются всякие обезболивающие средства, противовирусные как минимум уступают системному использованию

[Dr.Anisimova]

- наружное, как пишется, обладает минимальной эффективностью
"Topical Antiviral Therapy Approved for herpes labialis; minimal efficacy."
- т.е применение конечно допустимо:
"Acyclovir 5% ointment Apply q3h, 6 times daily for 7 days. Approved for initial genital herpes and
limited mucocutaneous HSV infections in immunocompromised individuals.
Penciclovir 1% cream Apply q2h while awake for recurrent orolabial infection in immunocompetent
individuals."

[nastassia]

Сообщение от Pecatum

Topical antiviral agents compared with placebo Topical aciclovir or topical penciclovir seem to be more effective at marginally reducing healing time (moderate-quality evidence).

.

т.е. сравнивали только наружные методы лечения между собой, а не применение топических и системных препаратов...

[Pecatum]

И тем не менее, эффективность по сравнению с плацебо была. Вы же утверждаете обратное.
Неужели какой-то умник бы додумался, что я якобы говорю о большей эффективности местных, чем системных?

[Timazov]

И тем не менее, эффективность по сравнению с плацебо была.

Конечно была. Только вот эффективность эта заключается в ускорении регресса высыпаний аж на целых 0.5 дня. Затраты на препарат , пятикратное его нанесение ради 12 часов

[Ссылки доступны только зарегистрированным пользователям ]

Topical treatments speed healing, reduce pain

Topical penciclovir 1% cream decreases the duration of lesion healing and pain compared with a vehicle control, as shown by 2 RCTs (n=3057, 1573). Patients initiated self-treatment every 2 hours during waking hours for 4 days. In one RCT, the treatment patients lost classic lesions 31% faster than the placebo group. In another trial, healing of classical lesions was faster by 0.7 days (4.8 vs 5.5). Benefits were achieved in both the early (P=.001) and later stages (P=.0055) of recurrence. Two RCTs of topical acyclovir 5% cream, 5 times a day for 4 days (n=689, 699) showed that topical acyclovir, compared with placebo, shortened the duration of an outbreak by 0.5 day (4.3 vs 4.8) and 0.6 day (4.6 vs 5.2), respectively.

[Pecatum]

Еще раз повторю, НЕэффективность не доказана. Зачем вводить людей в заблуждение?
А в остальных статьях не читали?