Interventions for prevention of herpes simplex labialis (cold sores on the lips)

Abstract

Background: Herpes simplex labialis (HSL), also known as cold sores, is a common disease of the lips caused by the herpes simplex virus, which is found throughout the world. It presents as a painful vesicular eruption, forming unsightly crusts, which cause cosmetic disfigurement and psychosocial distress. There is no cure available, and it recurs periodically.

Objectives: To assess the effects of interventions for the prevention of HSL in people of all ages.

Search methods: We searched the following databases up to 19 May 2015: the Cochrane Skin Group Specialised Register, the Oral Health Group Specialised Register, CENTRAL in the Cochrane Library (Issue 4, 2015), MEDLINE (from 1946), EMBASE (from 1974), LILACS (from 1982), the China National Knowledge Infrastructure (CNKI) database, Airiti Library, and 5 trial registers. To identify further references to relevant randomised controlled trials, we scanned the bibliographies of included studies and published reviews, and we also contacted the original researchers of our included studies.

Selection criteria: Randomised controlled trials (RCTs) of interventions for preventing HSL in immunocompetent people.

Data collection and analysis: Two authors independently selected trials, extracted data, and assessed the risk of bias. A third author was available for resolving differences of opinion.

Main results: This review included 32 RCTs, with a total of 2640 immunocompetent participants, covering 19 treatments. The quality of the body of evidence was low to moderate for most outcomes, but was very low for a few outcomes. Our primary outcomes were 'Incidence of HSL' and 'Adverse effects during use of the preventative intervention'.The evidence for short-term (≤ 1 month) use of oral aciclovir in preventing recurrent HSL was inconsistent across the doses used in the studies: 2 RCTs showed low quality evidence for a reduced recurrence of HSL with aciclovir 400 mg twice daily (risk ratio (RR) 0.26, 95% confidence interval (CI) 0.13 to 0.51; n = 177), while 1 RCT testing aciclovir 800 mg twice daily and 2 RCTs testing 200 mg 5 times daily found no similar preventive effects (RR 1.08, 95% CI 0.62 to 1.87; n = 237; moderate quality evidence and RR 0.46, 95% CI 0.20 to 1.07; n = 66; low quality evidence, respectively). The direction of intervention effect was unrelated to the risk of bias. The evidence from 1 RCT for the effect of short-term use of valaciclovir in reducing recurrence of HSL by clinical evaluation was uncertain (RR 0.55, 95% CI 0.23 to 1.28; n = 125; moderate quality evidence), as was the evidence from 1 RCT testing short-term use of famciclovir.Long-term (> 1 month) use of oral antiviral agents reduced the recurrence of HSL. There was low quality evidence from 1 RCT that long-term use of oral aciclovir reduced clinical recurrences (1.80 versus 0.85 episodes per participant per a 4-month period, P = 0.009) and virological recurrence (1.40 versus 0.40 episodes per participant per a 4-month period, P = 0.003). One RCT found long-term use of valaciclovir effective in reducing the incidence of HSL (with a decrease of 0.09 episodes per participant per month; n = 95). One RCT found that a long-term suppressive regimen of valaciclovir had a lower incidence of HSL than an episodic regimen of valciclovir (difference in means (MD) -0.10 episodes per participant per month, 95% CI -0.16 to -0.05; n = 120).These trials found no increase in adverse events associated with the use of oral antiviral agents (moderate quality evidence).There was no evidence to show that short-term use of topical antiviral agents prevented recurrent HSL. There was moderate quality evidence from 2 RCTs that topical aciclovir 5% cream probably has little effect on preventing recurrence of HSL (pooled RR 0.91, 95% CI 0.48 to 1.72; n = 271). There was moderate quality evidence from a single RCT that topical foscarnet 3% cream has little effect in preventing HSL (RR 1.08, 95% CI 0.82 to 1.40; n = 295).The efficacy of long-term use of topical aciclovir cream was uncertain. One RCT found significantly fewer research-diagnosed recurrences of HSL when on aciclovir cream treatment than on placebo (P < 0.05), but found no significant differences in the mean number of participant-reported recurrences between the 2 groups (P ≥ 0.05). One RCT found no preventive effect of topical application of 1,5-pentanediol gel for 26 weeks (P > 0.05). Another RCT found that the group who used 2-hydroxypropyl-β-cyclo dextrin 20% gel for 6 months had significantly more recurrences than the placebo group (P = 0.003).These studies found no increase in adverse events related to the use of topical antiviral agents.Two RCTs found that the application of sunscreen significantly prevented recurrent HSL induced by experimental ultraviolet light (pooled RR 0.07, 95% CI 0.01 to 0.33; n = 111), but another RCT found that sunscreen did not prevent HSL induced by sunlight (RR 1.13, 95% CI 0.25 to 5.06; n = 51). These RCTs did not report adverse events.There were very few data suggesting that thymopentin, low-level laser therapy, and hypnotherapy are effective in preventing recurrent HSL, with one to two RCTs for each intervention. We failed to find any evidence of efficacy for lysine, LongoVital® supplementation, gamma globulin, herpes simplex virus (HSV) type I subunit vaccine, and yellow fever vaccine in preventing HSL. There were no consistent data supporting the efficacy of levamisole and interferon, which were also associated with an increased risk of adverse effects such as fever.

Authors' conclusions: The current evidence demonstrates that long-term use of oral antiviral agents can prevent HSL, but the clinical benefit is small. We did not find evidence of an increased risk of adverse events. On the other hand, the evidence on topical antiviral agents and other interventions either showed no efficacy or could not confirm their efficacy in preventing HSL.

1

Study flow diagram.

2

'Risk of bias' graph: review authors' judgements about each 'Risk of bias' item presented as percentages across all included studies.

3

'Risk of bias' summary: review authors' judgements about each 'Risk of bias' item for each included study.

1.1. Analysis

Comparison 1 Oral aciclovir (short‐term) versus placebo, Outcome 1 Incidence of HSL during use of the preventative intervention (by clinical evaluation).

1.2. Analysis

Comparison 1 Oral aciclovir (short‐term) versus placebo, Outcome 2 Incidence of HSL during use of the preventative intervention (by culture).

1.3. Analysis

Comparison 1 Oral aciclovir (short‐term) versus placebo, Outcome 3 Adverse effects during use of the preventative intervention.

1.4. Analysis

Comparison 1 Oral aciclovir (short‐term) versus placebo, Outcome 4 Severity (lesion size) of attack of herpes labialis during use of the preventative intervention.

1.5. Analysis

Comparison 1 Oral aciclovir (short‐term) versus placebo, Outcome 5 Severity (stage) of attack of recurrent HSL during use of the preventative intervention.

1.6. Analysis

Comparison 1 Oral aciclovir (short‐term) versus placebo, Outcome 6 Severity (pain) of attack of recurrent HSL during use of the preventative intervention.

1.7. Analysis

Comparison 1 Oral aciclovir (short‐term) versus placebo, Outcome 7 Incidence of HSL after use of the preventative intervention.

2.1. Analysis

Comparison 2 Oral aciclovir (long‐term) versus placebo, Outcome 1 Duration of attack of herpes labialis during use of the preventative intervention.

3.1. Analysis

Comparison 3 Valaciclovir (short‐term) versus placebo, Outcome 1 Incidence of herpes labialis during use of the preventative intervention (by clinical evaluation).

3.2. Analysis

Comparison 3 Valaciclovir (short‐term) versus placebo, Outcome 2 Incidence of herpes labialis during use of the preventative intervention (by culture).

3.3. Analysis

Comparison 3 Valaciclovir (short‐term) versus placebo, Outcome 3 Adverse effects during use of the preventative intervention.

3.4. Analysis

Comparison 3 Valaciclovir (short‐term) versus placebo, Outcome 4 Viral load (shedding) in saliva.

4.1. Analysis

Comparison 4 Valaciclovir (long‐term) versus placebo, Outcome 1 Adverse effects during use of the preventative intervention.

5.1. Analysis

Comparison 5 Valaciclovir (suppressive regimen versus episodic regimen), Outcome 1 Incidence of herpes labialis during use of the preventative intervention (number of recurrences per participant per month).

5.2. Analysis

Comparison 5 Valaciclovir (suppressive regimen versus episodic regimen), Outcome 2 Adverse effects during use of the preventative intervention.

5.3. Analysis

Comparison 5 Valaciclovir (suppressive regimen versus episodic regimen), Outcome 3 Duration of attack of recurrent HSL during use of the preventative intervention.

5.4. Analysis

Comparison 5 Valaciclovir (suppressive regimen versus episodic regimen), Outcome 4 Severity (pain) of attack of recurrent HSL during use of the preventative intervention.

5.5. Analysis

Comparison 5 Valaciclovir (suppressive regimen versus episodic regimen), Outcome 5 Severity (maximum total lesion area) of attack of recurrent HSL during use of the preventative intervention.

6.1. Analysis

Comparison 6 Famciclovir versus placebo, Outcome 1 Incidence of HSL during use of the preventative intervention (by clinical evaluation).

6.2. Analysis

Comparison 6 Famciclovir versus placebo, Outcome 2 Duration of attack of recurrent HSL during use of the preventative intervention.

6.3. Analysis

Comparison 6 Famciclovir versus placebo, Outcome 3 Severity (pain) of attack of recurrent HSL during use of the preventative intervention.

7.1. Analysis

Comparison 7 Levamisole versus placebo, Outcome 1 Incidence of HSL during use of the preventative intervention.

7.2. Analysis

Comparison 7 Levamisole versus placebo, Outcome 2 Adverse effects during use of the preventative intervention (leading to withdrawal).

7.3. Analysis

Comparison 7 Levamisole versus placebo, Outcome 3 Duration of attack of recurrent HSL during use of the preventative intervention.

8.1. Analysis

Comparison 8 Lysine versus placebo, Outcome 1 Incidence of HSL during use of the preventative intervention (number of recurrences per participant per month).

9.1. Analysis

Comparison 9 Topical aciclovir (short‐term) versus placebo, Outcome 1 Incidence of HSL during use of the preventative intervention.

9.2. Analysis

Comparison 9 Topical aciclovir (short‐term) versus placebo, Outcome 2 Adverse effects during use of the preventative intervention.

9.3. Analysis

Comparison 9 Topical aciclovir (short‐term) versus placebo, Outcome 3 Severity (aborted lesions) of attack of recurrent HSL during use of the preventative intervention.

9.4. Analysis

Comparison 9 Topical aciclovir (short‐term) versus placebo, Outcome 4 Incidence of HSL after use of the preventative intervention.

10.1. Analysis

Comparison 10 Topical aciclovir and 348U87 cream (short‐term) versus placebo, Outcome 1 Incidence of HSL during use of the preventative intervention (by culture).

10.2. Analysis

Comparison 10 Topical aciclovir and 348U87 cream (short‐term) versus placebo, Outcome 2 Incidence of HSL during use of the preventative intervention (by clinical evaluation).

10.3. Analysis

Comparison 10 Topical aciclovir and 348U87 cream (short‐term) versus placebo, Outcome 3 Duration of attack of recurrent HSL during use of the preventative intervention.

10.4. Analysis

Comparison 10 Topical aciclovir and 348U87 cream (short‐term) versus placebo, Outcome 4 Severity of attack of recurrent HSL during use of the preventative intervention (maximum lesion area).

11.1. Analysis

Comparison 11 Topical foscarnet versus placebo, Outcome 1 Incidence of HSL during use of the preventative intervention.

11.2. Analysis

Comparison 11 Topical foscarnet versus placebo, Outcome 2 Adverse effects during use of the preventative intervention (leading to discontinuation).

11.3. Analysis

Comparison 11 Topical foscarnet versus placebo, Outcome 3 Adverse effects during use of the preventative intervention (application site reactions).

11.4. Analysis

Comparison 11 Topical foscarnet versus placebo, Outcome 4 Duration of attack of recurrent HSL during use of the preventative intervention (healing time).

11.5. Analysis

Comparison 11 Topical foscarnet versus placebo, Outcome 5 Severity of attack of recurrent HSL during use of the preventative intervention (mean lesion area).

11.6. Analysis

Comparison 11 Topical foscarnet versus placebo, Outcome 6 Severity of attack of recurrent HSL during use of the preventative intervention (maximum lesion area).

11.7. Analysis

Comparison 11 Topical foscarnet versus placebo, Outcome 7 Severity of attack of recurrent HSL during use of the preventative intervention (duration of pain).

12.1. Analysis

Comparison 12 Topical 1,5‐pentanediol versus placebo, Outcome 1 Severity (blistering, swelling, or pain) of recurrence.

13.1. Analysis

Comparison 13 Sunscreen versus placebo, Outcome 1 Incidence of HSL during use of the preventative intervention (by clinical evaluation).

13.2. Analysis

Comparison 13 Sunscreen versus placebo, Outcome 2 Incidence of HSL during use of the preventative intervention (by culture).

14.1. Analysis

Comparison 14 Interferon versus placebo, Outcome 1 Incidence of HSL during use of the preventative intervention.

14.2. Analysis

Comparison 14 Interferon versus placebo, Outcome 2 Adverse effects during use of the preventative intervention (fever).

14.3. Analysis

Comparison 14 Interferon versus placebo, Outcome 3 Adverse effects during use of the preventative intervention (other).

15.1. Analysis

Comparison 15 Gamma globulin versus histamine (control), Outcome 1 Duration of attack of recurrent HSL during use of the preventative intervention.

15.2. Analysis

Comparison 15 Gamma globulin versus histamine (control), Outcome 2 Severity of attack of recurrent HSL during use of the preventative intervention (less severe recurrences than usual).

16.1. Analysis

Comparison 16 Thymopentin versus placebo, Outcome 1 Adverse effects during use of the preventative intervention.

17.1. Analysis

Comparison 17 Yellow fever vaccination versus placebo, Outcome 1 Adverse effects during use of the preventative intervention.

18.1. Analysis

Comparison 18 Laser versus no interventions, Outcome 1 Time to first recurrence.

19.1. Analysis

Comparison 19 Hypnotherapy versus control, Outcome 1 Incidence of HSL during use of the preventative intervention (change in frequency of recurrence).

19.2. Analysis

Comparison 19 Hypnotherapy versus control, Outcome 2 Severity of attack of recurrent HSL during use of the preventative intervention.