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Am Fam Physician. 2000;62(12):2672-2678

Topical corticosteroids are often recommended in addition to oral antiviral agents to help reduce the pain and inflammation of herpes zoster. Spruance and McKeough conducted a pilot study to assess the efficacy of combination therapy with oral famciclovir and a topical corticosteroid for sunlight-induced herpes simplex virus (HSV) labialis.

The 49 participants in the placebo-controlled study had a history of recurrent herpes labialis following sun exposure. HSV lesions were induced by means of exposure to ultraviolet radiation. Those with an outbreak of HSV were randomized to receive a five-day course of oral famciclovir, 500 mg three times daily, and 0.05 percent topical fluocinonide gel, applied three times daily, or oral famciclovir plus placebo gel. The participants were instructed to start therapy within one hour of the onset of any sign or symptom of HSV infection. Follow-up was daily for three days after the initiation of treatment and then three times weekly until the lesions healed. Efficacy was determined on the basis of the size and number of lesions, the degree of pain, the interval between the onset and healing and evidence of viral shedding.

HSV lesions developed within seven days of ultraviolet radiation exposure in 29 of the 49 subjects. The average time between the onset of symptoms and initiation of therapy was approximately 30 minutes. Treatment was started at the prodrome or erythema stage, when lesions would potentially be most susceptible to antiviral agents in five (29 percent) of the 17 participants in the famciclovir-topical steroid group and in seven (58 percent) of the 12 participants who received famciclovir alone. The lesions progressed to typical HSV lesions in 21 of the participants; in the remaining eight participants, the lesions did not progress beyond the papular stage. In the combination therapy group, seven (41 percent) of the 17 lesions were aborted, compared with one (8 percent) of the 12 lesions in the group who received famciclovir alone.

The size of the lesions was smaller in the famciclovir-corticosteroid group. The median maximal lesion area was 48 mm2 in the combination therapy group, compared with 162 mm2 in the control group. A trend toward more rapid healing occurred in participants who received topical steroids in addition to famciclovir. In the combination therapy group, the skin at the site of the lesion had returned to normal a median of 5.3 days after onset, compared with a median of 8.9 days in the control group. Combination therapy was associated with a reduction in pain, with 10 of 17 participants who received combination therapy reporting pain, compared with everyone in the control group. The two treatment groups did not differ in the frequency of HSV culture-positive cases; 44 percent (seven of 16) of those who received combination therapy and 45 percent (five of 11) of those who received the antiviral agent alone had positive cultures. There were no serious adverse reactions in either treatment group.

The authors conclude that topical fluocinonide in combination with oral famciclovir therapy produces significant clinical improvement in patients with herpes labialis, compared with patients who receive oral antiviral therapy alone. The addition of a topical corticosteroid also does not appear to increase viral shedding. However, the authors caution that larger controlled trials are required to confirm the findings of this pilot study before topical steroids are routinely used in the treatment of labial HSV infections.

editor's note: The results of this small, well-done study are not surprising, considering the anti-inflammatory effects of corticosteroids. However, applying this protocol to clinical practice may be difficult: the dose of oral famciclovir is high, treatment must be initiated very early to be effective and self-treatment could lead to injudicious use of high-potency topical steroids, which can cause significant problems when used on the face. Nonetheless, I suspect many clinicians are already prescribing topical steroid therapy for this common and bothersome skin problem.—j.t.k.

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