#94 Simplicity for simplex (cold sores): a pill in the pocket takes the tingling away

CLINICAL QUESTION

QUESTION CLINIQUE

Do antivirals (oral or topical) or docosanol (Abreva®) improve healing time for patients with recurrent herpes labialis (cold sores)?

BOTTOM LINE

RÉSULTAT FINAL

One or two doses of famciclovir may improve cold sore healing by about 2 days, while valacyclovir and longer courses of topical acyclovir or docosanol (Abreva®) may improve healing by 0.5-1 day.

Reading Tools for Practice Article can earn you MainPro+ Credits

La lecture d'articles d'outils de pratique peut vous permettre de gagner des crédits MainPro+

Join Now S’inscrire maintenant

Already a CFPCLearn Member? Log in

Déjà abonné à CMFCApprendre? Ouvrir une session

EVIDENCE

DONNÉES PROBANTES

Placebo-controlled randomized controlled trials (RCT) of:

Immunocompetent patients with recurrent cold sores (most ≥3 episodes/year).
Starting treatment ≤1 hour of prodrome symptoms (unless specified).

Oral antivirals:

Three larger RCTs:
- Famciclovir: 1500mg x1 or 750mg BID x1 day (477 patients).¹
- Valacyclovir: 1 day (2g BID) or 2 day (2g BID then 1g BID) (1856 patients).²
- Acyclovir: 400mg 5 times/day x5 days (174 patients).³
Healing time improvement:
- Famciclovir: 2-2.5 days.
- Valacyclovir: 0.5~1 day.
- Acyclovir: not significant.

Topical acyclovir:

RCT: acyclovir 5% cream 5 times/day x4 days (1341 patients).⁴
- Healing time improved ~0.5 day.

Docosanol 10% (Abreva®):

RCT: docosanol 5 times/day started <12 hours of symptoms until healing occurred (743 patients).⁵
- Healing time improved ~0.75 day.

Limitations:

No direct comparisons of different oral agents.^1,2
Many studies industry-supported1-4,5 and by same author.^1-4

Context:

Antivirals generally help cold sores heal in 4-5 days versus 5-6 days.^1-4
35% of patients experience >4 recurrences per year.⁶
Cost for treating one recurrence (using study dose regimens):
- Oral antivirals: ~$20 (valacyclovir 1 day) to $44 (acyclovir 5 days).
- Topical acyclovir (4g) ~$40 or docosanol (2g) ~$25.
Health Canada has approved only valacyclovir for treating cold sores,⁷ while FDA has approved valacyclovir,⁸ famciclovir⁹ and acyclovir^9,11(oral and topical).

updated jan 29, 2018

Latest Tools for Practice

Derniers outils pour la pratique

Émélie Braschi MD PhD CCFP

#378 Tony Romo-sozumab: Winning touchdown in osteoporosis or interception for the loss?

What is the efficacy and safety of romosozumab in postmenopausal women with osteoporosis?

Read Lire 0.25 credits available Crédits disponibles

Adrienne J Lindblad BSP ACPR PharmD

#377 How to slow the flow IV: Combined oral contraceptives

In premenopausal heavy menstrual bleeding due to benign etiology, do combined oral contraceptives (COC) improve patient outcomes?

Read Lire 0.25 credits available Crédits disponibles

Jennifer Potter MD CCFP

#376 Testosterone supplementation for cis-gender men: Let’s (andro-)pause for a moment (Update)

What are the benefits and harms of testosterone supplementation in healthy cis-gender men or those with age-related low testosterone?

Read Lire 0.25 credits available Crédits disponibles

August 19, 2013

This content is certified for MainPro+ Credits, log in to access

Ce contenu est certifié pour les crédits MainPro+, Ouvrir une session

🔒 Complete Activity

🔒 Compléter l’activité

Author(s)

Auteur(s)

Hoan LInh Banh BScPharm PharmD
Michael R Kolber MD CCFP MSc
Tony Nickonchuk BScPharm CDE APA

1. Spruance SL, Bodsworth N, Resnick H, et al. Single-dose, patient-initiated famciclovir: A randomized, double-blind, placebo-controlled trial for episodic treatment of herpes labialis. J Am Acad Dermatology. 2006; 55:47-53.

2. Spruance SL, Jones TM, Blatte MM, et al. High-dose, short duration, early valacyclovir therapy for episodic treatment of cold sores: results of two randomized, placebo-controlled, multicenter studies. Antimicrob Agents Chemother. 2003; 47:1072-80.

3. Spruance SL, Stewart JC, Rowe NH, et al. Treatment of recurrent herpes simplex labialis with oral acyclovir. J Infect Dis. 1990; 161:185-90.

4. Spruance SL, net R, Marbury T, et al. Acyclovir cream for treatment of herpes simplex labialis: results of two randomized, double-blind, vehicle-controlled, multicenter clinical trials. Antimicrob Agents Chemother. 2002; 46:2238-43.

5. Sacks SL, Thisted RA, Jones TM, et al. Clinical efficacy of topical docosanol 10% cream for herpes simplex labialis: a multicenter, randomized, placebo-controlled trial. J Am AcadDermatol. 2001; 45:222-30.

6. Dreno B, Malkin JE, Saiag P, et al. Patients’ profile, burden of disease and quality of life in recurrent herpes labialis: a survey conducted in USA and France. Journal of the European Academy of Dermatology and Venereology. 2012; 26:1454-60.

7. Valtrex [drug product monograph].Mississauga, ON. GlaxoSmithKline Inc, 2009.

8. FDA Drug efficacy supplemental approval in 2002. http://www.fda.gov/Drugs/DevelopmentApprovalProcess/HowDrugsareDevelopedandApproved/DrugandBiologicApprovalReports/EfficacySupplementApprovals/ucm081883.htm. Accessed June 7, 2013.

9. FDA Drug efficacy supplemental approval in 2006. http://www.fda.gov/Drugs/DevelopmentApprovalProcess/HowDrugsareDevelopedandApproved/DrugandBiologicApprovalReports/EfficacySupplementApprovals/ucm081895.htm. Accessed June 7, 2013.

10. Zovirax (capsules, tablets, suspension) [package insert]. Research Triangle Park, NC. GlaxoSmithKline, 2007.

11. Zovirax (5% cream) [package insert]. Research Triangle Park, NC. GlaxoSmithKline, 2011.

Authors do not have any conflicts of interest to declare.

Les auteurs n’ont aucun conflit d’intérêts à déclarer.

Most recent review: 29/01/2018

By: Ricky D Turgeon BSc(Pharm) ACPR PharmD

Comments:

Evidence Updated: None; Bottom Line: No change.

Download

Télécharger

Tools for Practice Outils pour la pratique