Penciclovir cream for herpes simplex labialis

Clinical question Is penciclovir cream effective for the treatment of recurrent herpes labialis?

Background Recurrent herpes labialis is a self-limiting problem in most cases, but may cause considerable pain, disfigurement, and embarrassment. Oral acyclovir has been shown to be an effective treatment in small clinical trials. Additionally, prophylactic therapy with oral acyclovir has been proven effective, but many episodes are mild or not frequent enough to warrant long-term suppressive therapy. A safe, topically administered, and effective therapy is desirable for recurrent infections, since results with topical acyclovir have been disappointing.

Population studied The authors studied immunocompetent men and women at least 18 years of age and in good health who had a history of at least three episodes of herpes labialis per year. Patients who typically ([is greater than] 50% of episodes) experienced classic lesions preceded by prodromal symptoms were included, and patients who frequently ([is greater than] 25% of episodes) experienced false prodromes or aborted lesions were excluded.

Study design and validity A total of 2209 patients were randomly assigned to receive either 1% penciclovir cream or vehicle control cream. Subjects were instructed to apply medication within 1 hour of the first sign or symptom of a cold sore recurrence and then every 2 hours while awake for 4 consecutive days. Patients returned for evaluation within 24 hours of initiation of therapy and continued daily clinic visits until all crusts were gone, then every other day until skin returned to normal. Swabs from lesions were collected to evaluate duration of viral shedding. Patients were trained to recognize stages of lesions and were asked to make diary entries four times daily to record pain level and stage at initiation of therapy and with each application. Initiation of therapy during the prodrome or erythema stage was considered early, while therapy begun during the papule stage or later was considered late.

Outcomes measured The primary outcome measured in the study was lesion healing determined by time to loss of lesion crust and the proportion of patients who had lost lesions by days 6, 7, and 8. Secondary outcomes measured included resolution of lesion pain and cessation of viral shedding. All outcomes were analyzed according to early or late initiation of therapy. An intent-to-treat analysis was performed on all patient groups who applied study medication at least once.

Results Of the 2209 randomized, 1573 patients initiated therapy for recurrence during the 15-month study period. Patient-reported healing was faster in the penciclovir group compared with placebo (4.8 vs 5.5 days, P [is less than] .001). Resolution occurred more rapidly in the penciclovir group regardless of whether medication was applied in the early or late stage. The proportion of patients who healed by days 6, 7, and 8 was significantly greater in the penciclovir group (P [is less than] .001). The penciclovir group reported relief of pain 0.6 days faster than placebo regardless of whether treatment was initiated early or late (P [is less than] .001). There was no overall difference in the isolation of virus from patients in either treatment group. If therapy was initiated early, however, penciclovir-treated patients ceased shedding virus faster than patients treated with placebo.

Recommendations for clinical practice Topical 1% penciclovir cream applied every 2 hours while awake reduced the time to healing of sores, relief of pain, and cessation of viral shedding in patients with an episode of recurrent herpes labialis. Benefit was also demonstrated in patients who applied the cream after sores were already clinically evident. Although these reductions were statistically significant, they may not remain clinically significant when cost and compliance issues are taken into account. Eighty-two percent of patients applied the medication at least six times daily in this study, a percentage unlikely to be attained in actual clinical practice. A 5-day course of generic oral acyclovir (400 mg three times a day) costs around $15, while a small 2-g tube of penciclovir (Denavir) costs approximately $27. It is unlikely that topical penciclovir offers any significant clinical advantages over currently accepted therapies for recurrent herpes labialis.

Herpes Simplex Virus Type 2 in Asymptomatic Persons

The seroprevalence of adults with herpes simplex virus type 2 (HSV-2) infection in the United States has been determined to be about 25 percent. However, only about 10 to 25 percent of these persons recall having symptoms of HSV infection. Consequently, it has been assumed that most persons with asymptomatic infections have less frequent or severe reactivation of this disease. Data that dispute this include the finding that after an educational session, asymptomatic persons often report that they did, indeed, have herpetic ulcerations. In addition, most persons infected with HSV-2 acquire the virus from a person who does not recall a history of HSV infection. Wald and colleagues performed a study to assess genital shedding of HSV-2 among a cohort of presumptively asymptomatic adults.

Persons enrolled were men and women who reported no history of genital herpes but were HSV-2 antibody-positive by serologic testing. The patients underwent a standard educational session on genital herpes that included photographs of lesions and discussion of symptoms. They were then asked to collect genital and perianal samples for viral culturing daily for three months. A symptom diary was maintained by each patient, and they were asked to come in for a clinic visit if they developed any lesions or symptoms.

Fifty-three HSV-2-seropositive adults without an apparent history of genital herpes enrolled in the study. Following the educational sessions, 62 percent of the women and 64 percent of the men reported having a genital ulcer, blisters or crusts during the follow-up period. The participants collected viral swabs for HSV culture for a median of 94 days, which produced more than 17,700 viral cultures. Positive HSV cultures were obtained on at least one occasion in 38 of the 53 persons. In 36 of these 38 persons, the virus was isolated on days in which there were no apparent genital lesions (asymptomatic shedding). Collectively, HSV was isolated in the absence of genital lesions on 3 percent of the total days. In nine patients for whom all cultures were negative, six had HSV DNA detected by polymerase-chain-reaction assay. The overall rate of HSV detection in persons without a history of clinical infection was 83 percent.

Among the comparison group of 90 persons who had a history of genital HSV, daily viral cultures were obtained. Positive results were obtained on 6.4 percent of all days tested, but in 36 percent of the cases, the participants had no apparent genital lesions. The overall rate of subclinical (asymptomatic) viral shedding was 2.7 percent. This was almost identical to the first cohort, who had initially reported not having a history of genital herpes.

The authors conclude from this study that a significant degree of asymptomatic shedding of HSV occurs among persons with this infection. Included are men in whom physicians have traditionally dismissed the notion of this occurring. The prior assumption has been that asymptomatic shedding occurred only in women who shed the virus from the cervix or vaginal mucosa. In addition, it is clear that patient counseling and education about HSV-2 allows most patients to recognize the typical lesions of HSV. Because most persons with HSV-2 infection are asymptomatic, episodic or chronic administration of oral antiviral therapy is not required. However, it is important to educate and counsel patients about the risk of HSV transmission to sexual partners.

JEFFREY T. KIRCHNER, D.O.
Wald A, et al. Reactivation of genital herpes simplex virus type 2
infection in asymptomatic seropositive persons.
N Engl J Med March 23, 2000;342:844-50.
EDITOR'S NOTE: This study presents two key points for practicing physicians. First, patient education about HSV infection is effective if done properly. Second, the risk of transmission, even in the absence of symptoms, should be explained to patients. The larger question that now remains is the role of antiviral therapy, which has historically been used only in patients with frequent outbreaks, with the intent of decreasing symptoms and viral transmission. This study makes me further question the efficacy of limiting this therapy to patients with frequent symptomatic recurrences.--J.T.K.
COPYRIGHT 2000 American Academy of Family Physicians
COPYRIGHT 2000 Gale Group

What you should know about herpes

There seem to be endless myths that swirl around the sexually transmitted disease herpes. Is it just cold sores? Can you get rid of it? Is your sex life ruined if you have it? I wanted to clear up some of the confusion.

There are two types of herpes, fueling much of the confusion right from the outset. Herpes simplex virus-1 is most often associated with oral herpes, while herpes simplex virus-2 is linked to genital herpes. It's true that Type 1 is more commonly spread via the mouth and Type 2 via the genitals. However, there is little difference between the two viruses, chemically speaking, and both can show up either place.

The real difference seems to be in the social stigma associated with the two. Oral herpes is often referred to as "cold sores" and written off as a common, benign condition. In sharp contrast, genital herpes is viewed as a chronic illness, which is unfair when you realize how similar the two types are, both in cause and treatment. It's important that we normalize both types of herpes to eliminate the shame that is arbitrarily associated with one of them.

Herpes results from oral or genital contact with the virus. Where you get a breakout is usually the result of which part of your body came into contact with the virus. A person with either type of herpes could transmit oral or genital herpes to their partner depending upon the type of sexual activity engaged in. Add to this that nearly two-thirds of the 45 million Americans with genital herpes and 100 million with oral herpes have no symptoms, and you can understand why the line between the two is fuzzy, at best.

The best way to protect yourself against herpes is by practicing good common sense and safer sexual practices. Outbreaks often appear as a red rash, sometimes progressing to blisters. Initial outbreaks are sometimes associated with fevers and flulike symptoms. If you see anything appearing like that, avoid sexual contact and see your doctor.

Once you transmit either kind of herpes virus, it remains permanently in your nervous system. There is a blood test that can test for herpes antibodies to check if you are a carrier, even if you have never had any symptoms.

Even if there are no visible lesions, herpes can be spread through a process known as shedding, in which the virus is active on the skin. While using a condom will protect against other STDs, it will not always protect against herpes since shedding can occur on areas not covered by the condom -- on both men and women. It happens far less often than when there is an active outbreak, but is still possible nonetheless.

The frequency of outbreaks and type of symptoms varies widely. Some people are symptom-free, others have just one breakout and still others have regular bouts of symptoms.

The good news: There are prescription medications to minimize outbreaks. Online resources and support groups offer places to share your experiences. There are even dating sites for people with herpes, which can be good for getting back out there when you discover you have it.

Most important is to remember that everyone has a part of their sexuality with which they struggle. And as Andy Warhol said -- the thing is not to make a problem about your problem. You can still have a great sex life, if you make the decision to do so.

Laura Berman, Ph.D., is a sex therapist, director of Chicago's Berman Center (www.bermancenter.com; 800-709-4709) and author of a new book, Secrets of the Sexually Satisfied Woman: 10 Keys to Unlocking Ultimate Pleasure. Have a topic you'd like to see addressed in a future column? E-mail drberman@suntimes.com
Copyright The Chicago Sun-Times, Inc.
Provided by ProQuest Information and Learning Company. All rights Reserved.

How To Find Correct Subwoofer Placement for Home Stereo

This is a really quick and simple guide to help those out there who have just got, are going to get or have a home theater system.

Have you ever noticed that some places speakers sound better than others in your car or other places? Sure you have, but the placement of your home theater subwoofer may be one of the biggest changes you can make to upgrade your sound without having to drop a dime!

O.K. .... O.K. ....how do we do it, well it is actually very simple. You just have to understand that sound is just a vibration, that travels though the air to your ear. So number one you want no obstructions between your sitting area and the sub.

Next connect your home stereo and sit your sub-woofer where you would sit. Sounds crazy, Just Do It.

Now heres the really fun part, you just move around the room crawling and jumping up and listening everywhere! For what you say, You are listening for the best sound of the subwoofer in the room...it just so happens since sound vibrates or bounces, you have just found the reflex area that will be the best area in the room to place the subwoofer.

Yes, once again just put the sub where it sounds best while its sitting in your seat and then switch places with it.

Trust me this works and it really can give any stereo a new PUNCH!!!


by: ns-technologies

Zalman HD160 HTPC Enclosure

A few years ago having a PC sat next to your TV recording programs, playing back movies or music was both uncommon and difficult to achieve. There never really was a specific software application for the job, so getting all your hardware to work properly together often was a nightmare. Microsoft helped Media PCs become mainstream with Windows Media Center Edition 2005, but with most computer cases looking completely out of place in your home entertainment system, companies started to design ones that would look as slick as the Home Cinema equipment they will reside next to.

We have looked at a few HTPC cases recently, the Silverstone LC16M and the Ahanix D.Vine D5 were other early examples and both had their strengths and weaknesses. A system designed to fit under your television, or incorporated in your Home Cinema, has the prerequisite for silent operation. There would be nothing worse than the whirring of a fan while you are trying to listen to the subtleties of Mozart or a rattling side panel during the few seconds of silence before Russell Crowe leads the Roman army into battle against the Germanics. Detracting from the Multimedia experience is probably the last thing you will want when you have invested a small fortune in your equipment, so when Zalman, the Korean kings of silence, offered us the Zalman HD160 HTPC Enclosure to look at we had great expectations.

http://www.bit-tech.net/modding/2006/04/18/Zalman_HD160_HTPC/1.html

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Asian Dinner Delights

We have traveled to the land of the Rising Sun and indulged in sushi; have visited the beautiful French coast and were treated to a mussel feast; and recently got stuffed with pasta from Italy. What could possibly be next? How about what most Americans refer to as "Chinese"? You see calling such food Chinese is doing it an injustice, as Oriental food is as diverse as it gets.
So break out the chopsticks, and let us indulge in different types of food you may have referred to as Chinese (up to now, of course). There are five main classifications, so let us begin with some appetizers.


entrée


Sweet and sour soup
Won ton soup
Egg roll
Imperial roll
Spring roll

vietnamese style

The most memorable Vietnamese style dish is actually a soup, or Pho. I spent almost half my salary at my previous job on the most succulent broth-like soups you will ever have at a local Vietnamese joint. A popular way of preparing Pho is to have a boiling vegetable water base, and add some meat (either chicken or strips of beef -- not ground), green onions and noodles. This soup is best served by adding a couple of dashes of spicy sauce; soya (who could get enough of that?); limejuice; srpouts; and you are on your way. Carry a napkin or two, as the heat and spice will have you sweating like a madman.

thai style

I was not a big fan of Thai at first because I dislike satay sauce (a peanut butter base sauce). Now, despite the many peanut butter and jelly sandwiches I have had, they were consumed in the morning, not after drinking binges when you want something sour, salty or spicy. Nonetheless, if you like peanut butter sauces, then this is for you. I am sure you will enjoy it.
That was then and this is now. A very special woman re-introduced me to Thai not too long ago: grilled vegetables and (sometimes fried) meat, always reinforced with a hint of ginger.


cantonese & hong kong style

I have a bias. I grew up on rice, so rice is very non-exotic to me. Whenever I have the choice, I go with noodles. Not soft noodles (or Low Mein ), but rather the crispy fried ones (or Chow Mein ). Chow Mein has a greasy taste (in a great way) and fried texture that is rather irresistible.
Several variations come with vegetables, and various meat and seafood. A popular dish is Cantonese style Chow Mein (fried noodles, vegetables, chicken, beef, shrimp, and a great 'creamy' sauce). There are two points that I must elaborate on however:

First; the vegetables. Some restaurants impose red and green peppers, onions, and Chinese broccoli. I can live with the Chinese broccoli, but please, spice that baby up. I recommend baby corns, mushrooms, regular broccoli, and even eggplant.

By Gregory Cartier

The Strait of Hommus

DUBAI, United Arab Emirates--The shipping agent from Bombay lowers his teacup and whispers. "I know a vessel that leaves the Gulf tonight," he says. "From the Dubai Creek at three. If there is no Iranian trouble, you will reach the Strait of Hormuz after dawn."

Outside his office, along the creek that winds through Dubai and into the Persian Gulf, Iranian traders are unloading pistachios and Persian carpets, ferried illicitly from Bandar Abbas. Outgoing sailors pile their teakwood dhows with Marlboros, Levis, and Panasonic boom boxes for the 12-hour return to Iran.

"You have never met me and do not know my name," says the agent, who traffics this night in contraband reporter. "I do this for you only, as a favor." He nods his head toward the door.

I have come to Dubai like a thousand other journalists to see the war firsthand. It is here, in an oil-rich port 50 miles from Iranian territory, where shellshocked supertankers limp in for repairs. It is in Dubai, too, that television networks rent helicopters for $2,000 an hour, to hover above the water for shots of Iranian speedboats and burning oil rigs.

But at the creek in Dubai, there is another Persian Gulf, one that doesn't often appear in nightly newscasts or geopolitical thinking. Each night, a workday fleet of fishing trawlers, traders, and supply boats jostle for moorings between shifts on the open water. Every war has them, little people, caught in the crossfire. I joined a supply boat carrying dried goods to ships off the coast of Fujairah. Through the eyes of the crew the conflict looks completely different.

The dockside customs official weighs my passpor and visa in his hand, barely glancing at their contents. "Your papers, I think maybe they are not in order," he says, looking as if he might bite one corner to test for counterfeit.

I force a smile. "Perhaps I have cause some inconvenience by arriving at this late hour." Flowery language is the Muzak of Arab officialdom. "Gertain arrangements of a financial kind can...."

"...Please, no," the man says, his face wrinkling in disgust. Here in the world's wealthiest nation, even to offer a bribe is insulting. He waves toward the water.

by Tony Horwitz