Cold sore case Report PDF

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Just a pass; but it wasn't marked by tutor unlike other groups...

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Cold Sores A cold sore is a commonly encountered viral infection, that can be caused by two types of herpes simplex virus; HSV-1 and HSV-2 [1,2]. However, generally, HSV 1 is responsible for oral herpes and HSV-2 for genital herpes [3]. In Australia it is estimated just over 75% of adults, experience primary infection and are asymptomatic [4]. An individual may start to experience redness and tingling, which gives rise to fluid-filled red blisters on the border of the lips [5]. The virus cannot be killed while it is inactive but can be easily killed if it has been triggered by various internal and external factors. This report will briefly assess diagnosis and available treatment options. Subsequently, two effective options will be compared to address cold sore symptoms; topical acyclovir and oral famciclovir.

To differentiate cold sores from other conditions, it is important to ask symptom-specific questions and carry out a simple visual inspection, which helps determine if referral is necessary [1,6]. Assessment of appearance is important, as cold sores may be mistaken for conditions such as impetigo or angular cheilitis. Impetigo begins as painful reddish sores on the infected area and turns into blisters which form bright yellow crusts. Impetigo can occur near the lip area, however, can spread to other parts of the face or body. In contrast, angular cheilitis is located around the mouth and can be mistaken for cold sores. Most of the time patients with cold sores experience early symptoms before initial blister outbreak [7,8]. Pharmacists may assess if they have experienced intense symptoms such as fever, painful gums, sore throat, headaches, muscle aches or swollen lymph nodes [6]. Unlike cold sores, the patient will not foresee any warning signs if they experience impetigo or angular cheilitis. These differential conditions are caused by bacteria, whilst cold sores are virally transmitted. In addition, cold sore blister recurrence can be triggered by factors such as weather, hormonal changes, stress, fatigue, menstruation or even skin injuries [9]. These triggers are not associated with other similar conditions, and the patient should be asked if they can identify what caused the lesions [1].

There are many over the counter options as listed in Table 1. There are pharmacological options which will aid in pain relief and the recovery of cold sore outbreaks. While cold sores commonly heal within 1-2 weeks, there are non-pharmacological treatments which can naturally help the healing process of the cold sore outbreaks.

Table 1. Pharmacological options and non-pharmacological options for cold sores [1,10-12]

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Pharmacological Reduce pain and inflammation: ibuprofen

Non-pharmacological Kills infections: dilute apple cider vinegar to clean sores

Cold sore external creams/ointments: Acyclovir,

Reduce inflammation: Ice/ cold compressions

Lignocaine Antiseptic: speeds healing time of infection:

Healing of the cold sore: Vitamin E and cold

betadine ointment (contains povidone)

sore hydrocolloid patches

Fights infections: Vitamin C supplements

Boost immune system and cell repair: lysine supplements (Super lysine + Zinc)

However, the most effective pharmacological treatment options for cold sores include Zovirax (Acyclovir) and Famciclovir.

Acyclovir is available as a topical cream under the brand ‘Zovirax’ while ‘Famciclovir Once’ is obtained in a tablet form. Both acyclovir and famciclovir are antiviral drugs, which function by entering herpes infected cells, hence making the virus in our bodies latent [1]. These drugs undergo triphosphate formation and selectively inhibit the HSV-1 DNA polymerase, hence stopping viral synthesis [1]. However, prior to the achievement of this step, the Acyclovir undergoes a one-step conversion consisting of phosphorylation to acyclovir triphosphate. In stark contrast, the famciclovir is a two-step conversion, where it undergoes first pass metabolism to penciclovir and is followed by phosphorylation to penciclovir triphosphate [13]. Famciclovir is more advanced than acyclovir to reduce the severity and frequency of the outbreaks [14,15]. Zovirax 50mg cream is applied to the affected area by using a small amount, five times daily for 5 days. Once hands are clean, the cream should be applied using fingers or a cotton swab to cover the infected area on lips [16]. In a stark contrast, famciclovir is taken orally with or without food, as a single dose of 3 tablets containing 1500mg. [1,17]. Treatment should be commenced at the earliest especially when the patient experiences symptoms like pain and blister appearance [18].

Overall, both zovirax and famciclovir have potential side effects including dizziness, nausea, vomiting, diarrhoea, itchy rash and headache [1,17]. However, for zovirax, further side effects like dry lips, stinging, or flaky skin may occur. Most commonly, pharmacists should advise the benefits outweigh side effects as long as the recommended dosage is adhered to. In addition, read and follow the package label to ensure that the patient is not allergic to any ingredients. If an individual has

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progressed onto blister formation and intense pain, famciclovir loses efficacy, hence zovirax is a more suitable option [19]. However, trial data has failed to show any significant effects on speeding the resolution of established cold sores when using topical acyclovir [1]. Furthermore, famciclovir is preferred for earlier intervention as single doses of 1,500 mg, which demonstrated slightly better activity compared with topical acyclovir, shortening the healing time by approximately 1.8 days [20]. Also, it cannot be assured if individuals will apply topical products the correct amount of times and in the proper manner. Last but not least, we cannot control how long the cream stays on the cold sore during day to day activities. Hence these key differences often shape the decision for most pharmacists to recommend oral famciclovir over topical acyclovir.

A pharmacist may recommend antiviral products to treat the short-term symptoms of a cold sore through adequate verbal counselling supported by written information on the use and awareness of the product. Written information can be provided in many forms including leaflets, chemist apps, infection outbreak tracking apps such as “Trigger” and CMIs [21]. In addition, adherence to famciclovir can be ensured by the pharmacist through both visual placement (label 9 on the medicine box) and, through extensive verbal counselling to ensure the patient ‘Does not stop taking the medicine abruptly unless otherwise advised by the doctor or, in case of any situational change. Whilst assessing a patient's needs however, a pharmacist must ask the patient and consider signs and symptoms, frequency, age, and, prior treatment to properly evaluate whether the patient requires a referral to a GP or, in severe cases, to a hospital. For cold sores, referral to a GP is recommended when there is a painful mouth ulceration that is affecting oral intake or if a patient has a weakened immune system [22]. Finally, the pharmacist should assess response to previous treatment and recommend a consultation with a doctor promptly if symptoms persist and, if cold sore lesions spread or continue to be present for over 10-14 days. Recurrent attacks that are experienced more than three times a year or non-healing lesions may be associated with a more serious underlying condition (e.g. oral cancer, immunosuppression) [17, 23-25]. Conclusively, the patient may implement various lifestyle measures in conjunction with pharmacological treatment to ensure the harmful effects of infection are limited and not prevalent. For example, the use of sunscreen or hydrocolloid patches. Furthermore, patients may employ simple everyday measures such as washing hands, avoiding sharing cutlery and towels as well as refraining from any close contact. This minimises the risk of viral particles being shed and transmitted to others[1]. Evidently, cold sore is a condition that is easily treatable and manageable. REFERENCES

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1. Rutter P, Newby D. Dermatology. In: Community Pharmacy: symptoms, diagnosis and treatment ANZ [Internet]. 4th ed. Philadelphia, PA; 2020 [cited 2020 Sep 6]. p. 202–65. Available from: https://www-clinicalkey-com-au.ezproxy1.library.usyd.edu.au/#!/content/book/3-s2.0B9780729542883000077?scrollTo=%23hl000604 . 2. Publishing HH. Cold sores [Internet]. Harvard Health. [cited 2020 Sep 2]. Available from: https://www.health.harvard.edu/oral-health/cold-sores . 3. How Cold Sore Virus Hides During Inactive Phase [Internet]. ScienceDaily. [cited 2020 Sep 2]. Available from: https://www.sciencedaily.com/releases/2008/07/080702132213.htm 4. Branch; c=AU; o=The S of Q ou=Queensland H ou=Communicable D. Genital Herpes [Internet]. [cited 2020 Oct 19]. Available from: http://conditions.health.qld.gov.au/HealthCondition/condition/14/188/62/genital-herpes 5. Health Library - Women’s Health - Women’s Health Clinic - Obstetrics & Gynecology OBGYN Shreveport - Louisiana - A Part of the Willis-Knighton Physician Network [Internet]. [cited 2020 Sep 2]. Available from: https://www.whc-shreveport.com/Womens-Health-Information/Education.aspx? chunkiid=11950 6. Cold sore - Symptoms and causes [Internet]. Mayo Clinic. [cited 2020 Sep 6]. Available from: https://www.mayoclinic.org/diseases-conditions/cold-sore/symptoms-causes/syc-20371017 7. Skin Rash vs. Herpes Rash: Distinguishing Factors and Symptoms [Internet]. Healthline. 2018 [cited 2020 Oct 19]. Available from: https://www.healthline.com/health/rashes-herpes 8. Contact dermatitis - Symptoms and causes - Mayo Clinic [Internet]. [cited 2020 Oct 19]. Available from: https://www.mayoclinic.org/diseases-conditions/contact-dermatitis/symptoms-causes/syc20352742 9. Services D of H& H. Cold sores [Internet]. Department of Health & Human Services; [cited 2020 Sep 6].Availablefrom: https://www.betterhealth.vic.gov.au:443/health/conditionsandtreatments/cold-sores 10. How to Get Rid of a Cold Sore Fast: Treatments and Home Remedies [Internet]. Healthline. 2019 [cited 2020 Oct 19]. Available from: https://www.healthline.com/health/how-to-get-rid-of-a-coldsore-fast 11. Cold sores: Home remedies and other treatments [Internet]. 2020 [cited 2020 Oct 19]. Available from: https://www.medicalnewstoday.com/articles/311864 12. Betadine Antibiotic/Moisturize Topical : Uses, Side Effects, Interactions, Pictures, Warnings & Dosing - WebMD [Internet]. [cited 2020 Oct 19]. Available from: https://www.webmd.com/drugs/2/drug-15568/betadine-antibiotic-moisturize-topical/details 13. Zovirax Cold Sore Cream - AusDI [Internet]. [cited 2020 Oct 19]. Available from: https://ausdi-hcncom-au.ezproxy1.library.usyd.edu.au/productInformation.hcn?file=p02101

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14. Famciclovir Oral : Uses, Side Effects, Interactions, Pictures, Warnings & Dosing - WebMD [Internet]. [cited 2020 Oct 19]. Available from: https://www.webmd.com/drugs/2/drug6157/famciclovir-oral/details 15. Famciclovir | Side Effects, Dosage, Uses, and More [Internet]. Healthline. 2017 [cited 2020 Oct 19]. Available from: https://www.healthline.com/health/famciclovir-oral-tablet 16. Zovirax Cold Sore Cream Pump 2g [Internet]. [cited 2020 Oct 19]. Available from: https://www.chemistwarehouse.com.au/buy/40000/Zovirax-Cold-Sore-Cream-Pump-2g 17. Sansom LN, ed. Australian pharmaceutical formulary and handbook. 23rd edn. Canberra: Pharmaceutical Society of Australia; 2015. Pg 582 -583 18. Famvir for Cold Sores Tablets [Internet]. NPS MedicineWise. [cited 2020 Oct 19]. Available from: https://www.nps.org.au/medicine-finder/famvir-for-cold-sores-tablets 19. Zovirax Topical : Uses, Side Effects, Interactions, Pictures, Warnings & Dosing - WebMD [Internet]. [cited 2020 Oct 19]. Available from: https://www.webmd.com/drugs/2/drug-5230-432/zoviraxtopical/acyclovir-cream-topical/details 20. Spruance S.L., Bodsworth N., Resnick H., Conant M., Oeuvray C., Gao J., et al: Single-dose, patient-initiated famciclovir: a randomized, double-blind, placebo-controlled trial for episodic treatment of herpes labialis. J. Am. Acad. Dermatol. 2006; 55: pp. 47-53 21. The Five Best Mobile Apps for Cold Sore Sufferers [Internet]. Stop Cold Sores. 2016 [cited 2020 Oct 19]. Available from: https://stop-coldsores.com/cold-sore-remedies/610/five-best-mobile-appscold-sore-sufferers/ 22. https://www.redhillpharmacy.com.au/wpcontent/uploads/2013/06/Cold_Sores_Oct2011_V4.pdf [Internet]. Australia: Pharmaceutical Society of Australia; 2010 [cited 17 September 2020]. Available from: https://www.redhillpharmacy.com.au/wp-content/uploads/2013/06/Cold_Sores_Oct2011_V4.pdf 23. Final decisions & reasons for decisions by delegates of the secretary to the department of health ageing [Internet]. Australia: TGA; 2012 [cited 2020 Sep 17]. Available from: https://www.tga.gov.au/sites/default/files/scheduling-decisions-1202-final.pdf 24. eTG Digital | Therapeutic Guidelines [Internet]. [cited 2020 Sep 17]. Available from: https://tgldcdp.tg.org.au/guideLine?guidelinePage=Antibiotic&frompage=etgcomplete 25. 5. Cook S. Herpes Labialis: to treat or not to treat [Internet]. Leeds: Dental Therapy Update; 2012 [cited 17 September 2020]. Available from: https://www.researchgate.net/publication/294582045_Herpes_Labialis_to_treat_or_not_to_treat

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