¹Center for Clinical Studies, Houston, TX, USA
²Department of Dermatology, University of Texas Health Science Center at Houston, Houston, TX, USA

ABSTRACT
In the past three decades, major advances have been made in understanding the pathogenesis of psoriasis. The currently accepted theory is that T-cell mediated immune dysregulation triggers keratinocyte hyperproliferation in psoriasis. Recent research indicates that the Th17/interleukin (IL)-23 pathway plays a prominent role in the amplification phase of psoriasis. The discovery of the Th17/ IL-23 pathway provides targets for new drug development. This review focuses on the role of IL-23 in psoriasis pathogenesis and the current therapies targeting IL-23 that are in clinical trials.

Key Words:
cytokine, interleukin-23, IL-23, guselkumab, tildrakizumab, Th17, psoriasis

Introduction

In the past three decades, major strides have been made in understanding the pathogenesis of psoriasis. While psoriasis pathogenesis originally focused on keratinocyte hyperproliferation, the currently accepted theory is that of T-cell mediated immune dysregulation.^1,2 While the T helper cell (Th) 1/interferon-gamma (IFN-γ) pathway was originally heavily implicated in the amplification phase, recent research indicates that the Th17/interleukin (IL)-23 pathway plays the more dominant role.³ This review focuses on the role of IL-23 in psoriasis pathogenesis and the current therapies targeting IL-23 that are in clinical trials.

IL-23

IL-23 is composed of two subunits, p19 and p40, which are linked by a disulfide bond. The p19 subunit is a unique component of IL-23. Alternatively, the p40 subunit is a component of IL-12 as well.⁴ IL-23 is produced by keratinocytes and activated antigen-presenting cells (APCs), specifically Langerhans cells, macrophages and dendritic cells. IL-23 is expressed by APCs in the presence of Toll-like receptor (TLR) agonists (lipopolysaccharde, CpG and PolyI:C).⁵ The IL-23 receptor is present on memory T cells, natural killer (NK) T cells, macrophages, dendritic cells and naïve T cells.⁶

IL-23 is the key cytokine that propels naïve T cell differentiation to Th17 cells.⁶ It is essential in bridging the innate and adaptive immune responses and orchestrating the early local immune response. When IL-23 binds to the IL-23 receptor, the complex activates Jak2 and Tyk, members of the Janus family of tyrosine kinases, leading to phosphorylation of the receptor complex and eventually phosphorylation of signal transducer and activator of transcription 3 (STAT3). STAT3 phosphorylation triggers differentiation to Th17 cells.⁷ Transforming growth factor-beta (TGF-β), IL-6, IL-1β and IL-21 are also needed to coordinate production of Th17 cells.⁸ However, IL-23 appears to be the main cytokine in this process as studies have shown that IL-6, IL-1β and TGF-β in the absence of IL-23 result in production of regulatory T cells that inhibit inflammation.⁹

The Th17/IL-23 Pathway in the Immunopathogenesis of Psoriasis

In considering the pathophysiology of psoriasis, it can be divided into two distinct immune-mediated phases: the initial and amplification phases.⁵ In the initial phase, trauma to keratinocytes or stimulation of TLR receptors in genetically predisposed skin leads to activation of the innate immune system. This cataclysm of macrophages, dendritic cells and diverse cytokines triggers the production of IL-12 and IL-23. These two cytokines provide the bridge to the amplification phase, which is characterized by the adaptive immune response.⁵ The intricacies of this amplification have been the source of much debate over the last three decades, specifically in regards to which Th pathway drives this phase.

In the 1990s, clinical studies demonstrated elevated levels of the p40 subunit in psoriatic lesions. At the time, the high expression of p40 was correlated to elevated levels of IL-12 (a component of the Th1 pathway) because IL-23 had not yet been discovered.¹⁰ This theory further propagated the theory that the Th1 pathway is key in orchestrating the amplification phase of psoriasis. However, recent evidence has revealed that the elevated p40 level in psoriasis is due to IL-23, not IL-12. In a study done by Lee and colleagues, p40 and p19 mRNA were elevated in psoriatic lesions, but p35 mRNA, which is specific to IL-12, was not increased in lesional skin.³ Another study highlighted the presence of IL-23- staining cells in palmoplantar pustulosis, hyperkeratotic hand dermatitis and lesional psoriasis biopsies. Furthermore, IL-23 levels in psoriatic skin appear to correspond with the clinical course of the patient.¹¹ IL-23 injections in mice skin have also induced histological changes seen in psoriatic skin, specifically epidermal acanthosis and parakeratosis. IL-12 injections did not have the same effect.¹² Finally, many genetic studies in psoriasis patients have demonstrated a strong association with genetic loci encoding the IL-23 p19 subunit and IL-12/23 p40 subunit, but not the IL-12 p35 subunit.^13,14 Taken together, this data points to the prevailing role of the Th17/IL-23 pathway in psoriatic disease.

The Th17/IL-23 pathway promotes chronic inflammation. Th17 cells secrete two IL-17 cytokines, IL-17A and IL-F, and also IL-21, IL-22, IL-26 and IFN-γ. All of these cytokines activate the inflammatory cascade and provoke irregular cellular replication and maturation in psoriasis.¹⁵ IL-17A is a potent pro-inflammatory cytokine that triggers keratinocyte production of pro-neutrophilic chemokines, including CXCL1, CXCL5, and CXCL8. These chemokines orchestrate neutrophilic migration into psoriatic lesions, which stimulates keratinocyte proliferation.¹⁶ IL-17 also inhibits neutrophil apoptosis, stimulates angiogenesis, augments tissue remodeling and synergistically with tumor necrosis factor-alpha enhances inflammation.¹⁷ IL-22 causes keratinocyte hyperproliferation and increases keratinocyte production of antimicrobial proteins. It is because of these antimicrobial proteins that psoriatic skin lesions are rarely infected.¹⁷ Both IL-17A and IL-22 have also been found to stimulate keratinocyte production of CCL20, a chemokine overproduced in psoriasis. It is hypothesized that CCL20 promotes maintenance of psoriatic lesions by enhancing chemotaxis of CCR6+ Th17 and dendritic cells to diseased skin.¹⁸

Although there is convincing data about the significant role the Th17/IL-23 pathway plays in late-stage psoriasis, there remain many questions. It is still unclear why IL-23 is preferentiallyproduced in psoriatic skin. Is it a genetic predisposition or a dysregulation of the innate immune response? Furthermore, it is unclear what the specific antigen is that dendritic cells present to antigen-specific Th17 cells. Hypotheses have ranged from an external antigen to an autoantigen.¹⁷

Psoriasis Therapies Targeting IL-23

Given the initial discovery of elevated p40 levels in psoriatic skin, novel biologics, specifically ustekinumab and briakinumab, were developed to target this p40 subunit. These agents target the p40 subunit of IL-12 and IL-23 and, thus, both the IL-12/Th1 and Th17/IL-23 pathways.¹⁰ Despite the efficacy and favorable safety profile of ustekinumab, drug development has moved towards solely targeting the IL-23/Th1 pathway given its dominant role in psoriatic disease and the theoretical risk of blocking the IL-12/Th1 pathway.

Tildrakizumab

Tildrakizumab, alternatively known as MK-3222 or SCH900222, is a human immunoglobulin G1 (IgG1) monoclonal antibody that targets only the p19 portion of IL-23. Since tildrakizumab does not target the p40 subunit of IL-23, it does not affect IL-12 activity.¹⁹

The results of a Phase IIb randomized, controlled, dose-ranging study for tildrakizumab were presented at the American Academy of Dermatology 71st Annual Meeting in March 2013. In this study, 335 patients with moderate to severe plaque psoriasis were randomized to receive tildrakizumab 5 mg, 25 mg, 100 mg, 200 mg or placebo at weeks 0, 4, and then every 12 weeks for 52 weeks. The primary endpoint, PASI-75 at week 16, was attained by 33%, 64%, 66%, 74%, and 4% of the 5 mg, 25 mg, 100 mg, 200 mg, and placebo groups respectively. The secondary endpoint, achieving a physician global assessment (PGA) of “clear” or “minimal” at week 16, was achieved by 33%, 58%, 62%, 74%, and 2% of the 5 mg, 25 mg, 100 mg, 200 mg, and placebo groups respectively. The adverse event rate in the treatment groups ranged from 60% to 71% compared to 69% in the placebo group. The most common adverse event was nasopharyngitis. Serious adverse events (including one death) were rare, occurring in only four patients. None of the serious adverse events were linked to tildrakizumab.^19,20

Of note, data from the proof of concept study demonstrated that 18% of patients treated with three doses of tildrakizumab developed antidrug antibodies. Of these patients with antibodies, 55% had decreased serum drug levels in contrast to patients without antidrug antibodies. However, patients with antidrug antibodies still attained PASI improvement comparable to patients without antidrug antibodies. Similarly, the safety profile did not differ either.²¹

Tildrakizumab is the first anti-IL-23 therapy for psoriasis to enter Phase III trials. There are currently two Phase III trials underway. The projected date for final collection of primary outcome data is June or July 2015 for both trials. This data has yet to be published. The study completion date for both studies is 2019.^21,22

Guselkumab

Guselkumab, or CNTO 1959, is a humanized IgG1 monoclonal antibody that targets the p19 subunit of IL-23.²³

The results of X-PLORE, a Phase IIb randomized, controlled, doseranging study for guselkumab, were presented at the American Academy of Dermatology 72nd Annual Meeting in March 2014. In this study, patients with moderate to severe plaque psoriasis were randomized to receive either guselkumab 5 mg, 15 mg, 50 mg, 100 mg or 200 mg, placebo or adalimumab. The guselkumab was given at weeks 0, 4 and then every 12 weeks. The patients in the adalimumab group received an initial dose of 80 mg and then 40 mg every other week (starting one week after the initial dose). The primary endpoint, patients achieving a PGA of “clear” or “minimal” at week 16, was met by 34%, 61%, 79%, 86%, 83%, and 7% of patients in the guselkumab 5 mg, 50 mg, 15 mg, 100 mg, 200 mg, and placebo groups respectively. At week 16, PASI-75 was achieved by 44%, 76%, 81%, 79%, 81%, and 5% of the patients receiving guselkumab 5 mg, 15 mg, 50 mg, 100 mg, 200 mg, and placebo respectively. PASI 90 was achieved by 34%, 34%, 45%, 62%, 57%, and 2% of guselkumab 5 mg, 15 mg, 50 mg, 100 mg, 200 mg, and placebo-treated patients respectively. Comparatively, in the adalimumab group, 58%, 70%, and 44% of patients attained a PGA of “clear” or “minimal”, PASI-75 and PASI-90 respectively at week 16. At week 52, adverse events occurred in 66% of patients treated with guselkumab. Serious adverse events were experienced by 3% of guselkumab treated patients. Three patients had either a myocardial infarction or cerebrovascular accident but these were not linked to guselkumab treatment. No serious or opportunistic infections occurred in patients on guselkumab. One patient on guselkumab reported a malignancy (cervical cancer).²⁴

Based on the above promising Phase II results, Phase III trials to further asses the efficacy of guselkumab are planned.^25-27 Currently, there is a Phase II trial evaluating guselkumab for palmoplantar pustulosis as well as a Phase I trial to evaluate the pharmacokinetics of guselkumab in lyophilized versus liquid formulations.^28,29 The estimated primary completion date for the palmoplantar pustulosis study is August 2014.²⁸

Other Drugs Targeting IL-23 in the Pipeline

BI655066, manufactured by Boehringer Ingelheim Pharmaceuticals, is another drug targeting IL-23 that is currently in Phase II trials for psoriasis.³⁰ It is a human IgG1 monoclonal antibody. MP-196, another monoclonal antibody targeting IL-23, is manufactured by TcL Pharma and is in preclinical development for psoriasis. Finally, there are several IL-23 receptor antagonists that have been patented but not tested in pre-clinical or clinical trials. Neutralization of the IL-23 receptor is a promising approach for psoriasis management as the IL-23 is only present on developing Th17 cells. Thus, blocking the IL-23 receptor can prevent activation of STAT3 and naïve T cell differentiation to a Th-17 cell.⁵

Conclusion

The discovery of the Th17/IL-23 pathway adds to the complexity of psoriasis pathogenesis and provides targets for new drug development. Not only are there upstream IL-23 p19 and IL-23 receptor neutralizing drugs in development, there are currently also downstream IL-17 antagonists in trials as well. Although these drugs are still years away from being FDA approved, they offer promise of more targeted, efficacious and safe psoriasis therapy in the future.

References

1. Braun-Falco O, Burg G. [Inflammatory infiltrate in psoriasis vulgaris. A cytochemical study]. Arch Klin Exp Dermatol. 1970 236(3):297-314.
2. Chan JR, Blumenschein W, Murphy E, et al. IL-23 stimulates epidermal hyperplasia via TNF and IL-20R2-dependent mechanisms with implications for psoriasis pathogenesis. J Exp Med. 2006 Nov 27;203(12):2577-87.
3. Chiricozzi A, Saraceno R, Chimenti MS, et al. Role of IL-23 in the pathogenesis of psoriasis: a novel potential therapeutic target? Expert Opin Ther Targets. 2014 May;18(5):513-25.
4. Costa VS, Mattana TC, da Silva ME. Unregulated IL-23/IL-17 immune response in autoimmune diseases. Diabetes Res Clin Pract. 2010 Jun;88(3):222-6.
5. Crabtree GR. Generic signals and specific outcomes: signaling through Ca2+, calcineurin, and NF-AT. Cell. 1999 Mar 5;96(5):611-4.
6. D’Elios MM, Del Prete G, Amedei A. Targeting IL-23 in human diseases. Expert Opin Ther Targets. 2010 Jul;14(7):759-74.
7. Duvallet E, Semerano L, Assier E, et al. Interleukin-23: a key cytokine in inflammatory diseases. Ann Med. 2011 Nov;43(7):503-11.
8. Elder JT, Bruce AT, Gudjonsson JE, et al. Molecular dissection of psoriasis: integrating genetics and biology. J Invest Dermatol. 2010 May;130(5): 1213-26.
9. Fitch E, Harper E, Skorcheva I, et al. Pathophysiology of psoriasis: recent advances on IL-23 and Th17 cytokines. Curr Rheumatol Rep. 2007 Dec;9(6):461-7.
10. Johnson-Huang LM, Lowes MA, Krueger JG. Putting together the psoriasis puzzle: an update on developing targeted therapies. Dis Model Mech. 2012 Jul;5(4):423-33.
11. Lee E, Trepicchio WL, Oestreicher JL, et al. Increased expression of interleukin 23 p19 and p40 in lesional skin of patients with psoriasis vulgaris. J Exp Med. 2004 Jan 5;199(1):125-30.
12. Levin AA, Gottlieb AB. Specific targeting of interleukin-23p19 as effective treatment for psoriasis. J Am Acad Dermatol. 2014 Mar;70(3):555-61.
13. Lowes MA, Kikuchi T, Fuentes-Duculan J, et al. Psoriasis vulgaris lesions contain discrete populations of Th1 and Th17 T cells. J Invest Dermatol. 2008 May;128(5):1207-11.
14. Nair RP, Stuart PE, Kullavanijaya P, et al. Genetic evidence for involvement of the IL23 pathway in Thai psoriatics. Arch Dermatol Res. 2010 Mar;302(2):139-43.
15. Nakajima K. Critical role of the interleukin-23/T-helper 17 cell axis in the pathogenesis of psoriasis. J Dermatol. 2012 Mar;39(3):219-24.
16. Novelli L, Chimenti MS, Chiricozzi A, et al. The new era for the treatment of psoriasis and psoriatic arthritis: perspectives and validated strategies. Autoimmun Rev. 2014 Jan;13(1):64-9.
17. Quatresooz P, Hermanns-Le T, Pierard GE, et al. Ustekinumab in psoriasis immunopathology with emphasis on the Th17-IL23 axis: a primer. J Biomed Biotechnol. 2012 2012:147413.
18. Singh TP, Lee CH, Farber JM. Chemokine receptors in psoriasis. Expert Opin Ther Targets. 2013 Dec;17(12):1405-22.
19. MedPage Today. Psoriasis yields to IL-23 drug. Source reference: Papp K, et al. Dose-dependent improvement in chronic plaque psoriasis following treatment with anti-IL-23p19 humanized monoclonal antibody (MK-3222). Presented at: 71st Annual Meeting of the American Academy of Dermatology, Maimi Beach, FL, March 1-5, 2013. Available at: http://www.medpagetoday.com/MeetingCoverage/AAD/37664. Accessed January 19, 2015.
20. PeerView Press. Investigational drug provides significant symptom improvement in chronic plaque psoriasis: presented at AAD.
21. Merck Sharp & Dohme Corp. A 64-week, phase 3, randomized, placebocontrolled, parallel design study to evaluate the efficacy and safety/ tolerability of subcutaneous tildrakizumab (SCH 900222/MK-3222), followed by an optional long-term safety extension study, in subjects with moderate-to-severe chronic plaque psoriasis (protocol no. MK-3222-010). In: ClinicalTrials.gov, Identifier: NCT01722331. Last updated November 24, 2014. Available at http://clinicaltrials.gov/ct2/show/NCT01722331. Accessed January 19, 2015.
22. ClinicalTrials.gov. US National Institutes of Health. Search results for tildrakizumab.
23. Skin & Allergy News. Psoriasis drug pipeline extrudes progress.
24. Johnson & Johnson. Press release dated March 24, 2014. Anti-interleukin-23 monoclonal antibody guselkumab shows significant efficacy in treatment of moderate to psoriasis plaque psoriasis. Results from phase 2b X-PLORE study through week 40 report efficacy of guselkumab across multiple dosing regimens and compared with adalimumab.
25. Janssen Research & Development, LLC. A phase 3, multicenter, randomized, double-blind, placebo and active comparator-controlled study evaluating the efficacy and safety of guselkumab for the treatment of subjects with moderate to severe plaque-type psoriasis with randomized withdrawal and retreatment (VOYAGE 2). In: ClinicalTrials.gov, Identifier: NCT02207244. Last updated December 30, 2014.
26. Janssen Research & Development, LLC. A phase 3, multicenter, randomized, double-blind study to evaluate the efficacy and safety of guselkumab for the treatment of subjects with moderate to severe plaque-type psoriasis and an inadequate response to ustekinumab (NAVIGATE). In: ClinicalTrials.gov, Identifier: NCT02203032. Last updated December 31, 2014.
27. Janssen Research & Development, LLC. Phase 3, multicenter, randomized, double-blind, placebo and active comparator-controlled study evaluating the efficacy and safety of guselkumab in the treatment of subjects with moderate to severe plaque-type psoriasis (VOYAGE 1). In: ClinicalTrials.gov, Identifier: NCT02207231. Last updated: January 5, 2015.
28. Janssen Pharmaceutical K.K. A multicenter, randomized, double-blind, placebo-controlled, parallel group study to assess the efficacy, safety and tolerability of CNTO 1959, a human anti-IL 23 monoclonal antibody, following subcutaneous administration in subjects with palmoplantar pustulosis. In: ClinicalTrials.gov, Identifier: NCT01845987. Last updated: November 18, 2014.
29. Janssen Research & Development, LLC. Phase 1, open-label, randomized, parallel study to assess the pharmacokinetic comparability of 2 formulations and to evaluate pharmacokinetic comparability of guselkumab (CNTO1959) delivered by 2 different devices in healthy subjects. In: ClinicalTrials.gov, Identifier: NCT01866007. Last updated: March 10, 2014.
30. Boehringer Ingelheim. A 48 weeks study of three different dose regimens of BI 655066 administered subcutaneously in patients with moderate to severe chronic plaque psoriasis (randomised, dose-ranging, activecomparator- controlled (ustekinumab), double-blind within dose groups of BI 655066). In: ClinicalTrials.gov, Identifier: NCT02054481. Last updated: January 7, 2015.

¹Department of Dermatology, Baylor College of Medicine, Houston, TX, USA
²Department of Dermatology, University of Texas Medical School at Houston, Houston, TX, USA
³Center for Clinical Studies, Houston, TX, USA

Conflict of interest:
None reported

ABSTRACT
Herpes labialis is a frequently occurring viral infection of the lips and oral mucosa. Recurring lesions are induced by viral reactivation and replication, but the symptoms leading to morbidity, such as pain and inflammation, are immune-mediated. The introduction of 5% acyclovir/1% hydrocortisone in a topical cream (Xerese™) represents a therapeutic strategy directed at both of these pathogenic processes. Applied at the onset of prodromal symptoms, this combination treatment has a good safety profile and is more effective in reducing healing time than antiviral or anti-inflammatory agents alone. Although it was US FDA-approved for herpes labialis in 2009, Xerese™ has only recently been approved for use in Canada in October 2013. Herein, we review the basic science and clinical studies that support the efficacy of this topical combination acyclovir-hydrocortisone product in treating herpes labialis and examine its safety profile, as well as touch upon other therapies that have been shown to be effective in treating this common viral condition.

Key Words:
cold sores, herpes labialis, Xerese, viral infection, Canada, drug approval

Introduction

Herpes labialis (colloquially known as “cold sores”) is a common viral infection characterized by vesicular lesions of the lips and oral mucosa. It is estimated to affect 1 in 5 Canadians annually and is associated with a negative stigma that can lead to depression, fear of rejection, and isolation for infected individuals during an outbreak.¹ Herpes labialis is mostly caused by the herpes simplex virus-1 (HSV-1), which enters the nerve during primary infection and remains latent in the ganglionic neuron for the rest of the individual’s life. Periodically, the virus travels back down the nerve to the skin and replicates, producing a clinical episode of reactivated HSV-1 infection. Intralesional viral replication is halted by the host immune response approximately 7 days after primary infection and 3 days after recurrent infection;² however, inflammation secondary to immune defense is also the cause of redness, swelling, and tenderness that is characteristic of herpes labialis lesions. As a result, although viral clearance happens rapidly following reactivation, the lesion often takes 7-10 days to heal completely.

Since the pathogenesis of herpes labialis is both viral- and immune-mediated, it is not surprising that administration of exclusively antiviral drugs has limited effects on the clinical parameters of the disease.³ Therefore, medications demonstrating dual mechanisms via inhibition of viral replication and modulation of the inflammatory response to facilitate healing, indicate a more successful therapeutic approach.⁴ Such an agent was introduced by Valeant Pharmaceuticals, consisting of 5% antiviral acyclovir plus 1% anti-inflammatory hydrocortisone (ACHC) in a topical cream formulation (Xerese™). Although it has been FDA-approved in the US for the treatment of recurrent herpes labials since 2009, authorization for Xerese™ in Canada was not officially granted until October 2013. In light of this recent Canadian approval, we review the data supporting the efficacy of this topical combination therapy and discuss the details regarding its clinical use, specifically incorporating our experience in prescribing ACHC for the past half-decade.

Drug Information

ACHC is intended for the early treatment of recurrent herpes simplex labialis (HSL) in adults and adolescents (12 years of age and older). It is designed for cutaneous use only and is applied to the lips and skin around the mouth. Usage should be avoided on the eyes, inside the mouth or nose, and on the genitals. The patient should be instructed to apply a thin layer across the affected area, including the outer margins of the cold sore. Treatment should be initiated at the first sign or symptom (prodromal stage), applying 5 times per day for a period of 5 consecutive days. If there is no noticeable improvement and/or the cold sore fails to heal within 2 weeks, patients are encouraged to seek further medical attention. At present, the efficacy of ACHC has not been established in the immunocompromised population.⁵

From Bench to Bedside: Duration and Efficacy

In order to obtain maximum clinical benefit from a topical antiviral medication, therapy should be initiated within 72 hours of onset of symptoms.⁶ Patients with recurrent herpes labialis experience a rapid onset of disease and a short viral shedding period, both of which make it difficult to measure responses to therapy.

In an early basic science study conducted in 2003, researchers used mice that had undergone adaptive transfer of immunity and infected the skin on the mice’s ear pinna with HSV-1.⁷ After the mice developed a zosteriform infection, treatment groups received topical ACHC, 5% acyclovir (Zovirax®), 1% hydrocortisone, or no treatment at all. Medication was applied 3 times daily for 4 days. The treatment groups were analyzed based on ear thickness increase and zoster score. The zoster scores were adapted from a scale previously described in another study, and the scores used were: 0 for unchanged ear, 1 for isolated zosteriform lesions, and 2-4 for describing the ulceration of confluent zosteriform lesions from mild to severe.⁸ ACHC outperformed both 5% acyclovir and 1% hydrocortisone creams, with an average increase in ear thickness of only 0.15 ± 0.03 mm compared to 0.48 ± 0.08 mm and 0.23 ± 0.03 mm, respectively. The average increase in ear thickness for ACHC was only 34% of that experienced by the mice in the control group, compared to 110% observed with acyclovir and 52% with hydrocortisone. The average zoster score for the ACHC group at day 9 was also the lowest of the four groups at 2.0 ± 0.2 (58% of control), compared to 2.4 ± 0.3 (70% of control) for acyclovir and 2.8 ± 0.2 (80% of control) for hydrocortisone.⁷

In a 2012 Phase 3 study, Strand et al instructed their human subjects to apply ACHC 5 times daily for 5 days at the onset of prodromal symptoms, preferably before the appearance of actual papules or vesicles. Of the 131 test subjects, 78 (59.5%) had nonulcerative recurrences, and 53 (40.5%) had ulcerative recurrences. At the follow-up visit, all 131 of the test subjects had returned to the stage of normal skin, 3 weeks after the last dose, with no signs or symptoms of herpes labialis recurrence. In the 40% of subjects who experienced ulcerative herpes lesions despite applying the ACHC cream, the mean maximum lesion area was 39 mm², which was a 48% decrease from the mean lesion area size of 75 mm² typically reported in immunocompetent adults.^9,10

A similar study published in 2011, also using a dosing regimen of applying cream 5 times daily for 5 days, studied a much larger patient population in a randomized, double-blind, placebocontrolled trial.¹¹ The 2,437 volunteers were randomized to receive either ACHC, acyclovir in the ACHC vehicle, or placebo in the form of the ACHC vehicle. Of the 1,443 subjects who experienced a recurrence of herpes labialis during the trial and initiated treatment, 42% used ACHC, 42% acyclovir, and 16% placebo. The authors reported that 58% of the patients on ACHC developed an ulcerative lesion, vs. 65% in the acyclovir group and 74% in the placebo group. In patients who experienced an ulcerative lesion, the healing times were reduced in those who received ACHC or acyclovir, compared with placebo. The patients using ACHC also had a smaller cumulative lesion area (~50% less) than the placebo group (Tables 1 and 2).

Finally, in a simulated 2002 trial, researchers tested the efficacy of ACHC in patients whose latent HSV-1 infection was intentionally reactivated using ultraviolet (UV) light.¹² Of the 380 subjects, 120 patients developed classical cold sores 2 days after UV light exposure, which was followed by initiation of treatment with either ACHC or placebo. Treatment with ACHC reduced lesion size, healing time, and lesion tenderness when compared with placebo. Healing time (defined as the time to restoration of normal skin) was reduced from 10.1 days in the placebo group to 9.0 days in the ACHC group (Table 2).

Adverse Effects

The combination cream of 5% acyclovir and 1% hydrocortisone has been shown to induce only minimal side effects when used to treat herpes labialis infections. In Strand et al’s 2012 Phase 3, open-label, multicenter study, 131 of 134 subjects were categorized with recurrence at the post-treatment visit.¹⁰ Of these 131 subjects, only 5 reported any adverse events. The events were classified as mild to moderate in intensity and consisted of secondary herpes labialis recurrences (n=2), infectious rhinitis (n=1), application site inflammation (n=1), and bronchial asthma (n=1). Additional studies have corroborated the safety of ACHC, observing only minor side effects.^11,12 The most common adverse reactions reported in clinical trials were drying or flaking of the skin, burning or tingling at the application sight, erythema, and pigmentation changes; these infrequent adverse effects occurred in less than 1% of patients studied.⁵

Other Therapies for Herpes Labialis

Prior to the authorization of Xerese™ by Health Canada, the mainstays of treatment for recurrent HSL included over-thecounter docosanol cream, and prescription-only members of the acyclovir family (oral and topical). If ACHC is contraindicated for use in a particular patient due to adverse effects, docosanol or acyclovir may provide therapeutic benefit.

Docosanol 10% cream (Abreva®) is an approved treatment for recurrent herpes labialis, with efficacy demonstrated in two identical double-blind, placebo-controlled studies conducted at 21 sites.¹³ Therapy was initiated at the onset of prodromal symptoms or the erythema stage in subjects who were otherwise healthy adults with documented histories of herpes labialis. Treatment was administered 5 times daily until healing occurred, with twice-daily visits to the investigative clinic for the first 7 days. For the 370 patients who were treated with docosanol, the median time to heal was 4.1 days, which was 18 hours shorter than the healing time for the 367 patients treated with placebo (Table 2). The patients treated with docosanol also reported earlier cessation of pain and exhibited complete healing, as well as experienced reduced lesion progression to the ulcer or soft crust stage.

A well-established mainstay in the treatment of recurrent herpes labialis is valacyclovir. This prodrug of acyclovir has proven to be a safe and effective therapy for long-term HSV suppression.¹⁴ It has been studied in children, pregnancy, and immunocompromised patients. The most common adverse events associated with oral valacyclovir are headache, rhinitis, infection, nausea, and pharyngitis, with all of these occurring infrequently. Despite many years of use by clinicians, HSV resistance remains low at approximately 0.1-0.4% in the UK and the US.¹⁴

A new form of acyclovir was recently approved by the US FDA in April 2013. This medication consists of acyclovir in the form of a mucoadhesive buccal tablet (ABT) (Sitavig®), which is applied to the upper gum region within the first hour of prodromal symptoms. A Phase 3 double-blind trial found that acyclovir, utilizing the proprietary Lauriad® technology, decreased the median duration time and development of primary vesicular lesions when compared to placebo (Tables 1 and 2).¹⁵

Lastly, a non-pharmacologic treatment for recurrent HSL involves low-level light therapy. A paper published in 2013 demonstrated that 1072 nm light-emitting diode therapy applied 3 times a day for 2 days was able to shorten healing time in patients with HSL to a median of 129 hours vs. 177 hours for the control group (Table 2).¹⁶

Clinical Observations

When taken daily (along with topical sunscreens), oral acyclovir, famciclovir, or valacyclovir are better at preventing herpes labialis than topical therapies are at treating outbreaks; however, it is the authors’ experience over the past 5 years that when used appropriately, ACHC is the superior topical therapy. Because the signs and symptoms of herpes labialis are attributable to both viral and inflammatory mechanisms, prescription topicals exerting only antiviral or anti-inflammatory activities have limited efficacy. Most over-the-counter therapies fail to target underlying pathogenic mechanisms (i.e., viral and inflammatory) and, thus, have little to no efficacy. While the optimal strategy is to prevent herpes labialis outbreaks via reduction of sun exposure, as well as through the use of sunscreen and oral anti-viral agents (especially in individuals experiencing frequent outbreaks), we recommend to our patients that they fill their prescriptions for ACHC as soon as possible and keep the cream at home, at work, and/or carry it with them while on vacation. At the onset of prodromal symptoms, therapy should be initiated immediately and no later than the appearance of the first sign of a recurrence.

Conclusion

Herpes labialis still lacks a cure, but several options are now available to limit inflammation and decrease healing time. The introduction of 5% acyclovir/1% hydrocortisone topical cream represents a forward step in understanding disease pathogenesis and targeting both the viral and immunogenic components of recurrent HSL.

References

1. Kuehl B. Cold sores – how to prevent and treat them
2. Spruance SL, Rea TL, Thoming C, et al. Penciclovir cream for the treatment of herpes simplex labialis. A randomized, multicenter, double-blind, placebocontrolled trial. Topical Penciclovir Collaborative Study Group. JAMA. 1997 May 7;277(17):1374-9.
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