Aciclovir + hydrocortisone. Herpes labialis: a topical antiviral drug perhaps, but not a steroid

Management of episodes of herpes labialis (cold sores) in otherwise healthy individuals is mainly based on hygiene measures intended to avoid transmitting the virus. At best, topical treatment with aciclovir, an antiviral drug, simply reduces the duration of the episode. A cream containing 5% aciclovir and 1% hydrocortisone has been authorised in France for symptomatic treatment of herpes labialis in adults and adolescents 12 years of age and older. In a double-blind randomised trial comparing the combination versus topical aciclovir alone in 1443 adults, the cream did not significantly reduce the number of patients whose lesions became ulcerated, or the duration of the episode. In another comparative double-blind randomised trial in 107 immunocompromised patients, the efficacy of the aciclovir and hydrocortisone combination did not differ from that of aciclovir alone. Whatever the mode of administration, corticosteroids might aggravate infections. In clinical trials involving immunocompetent adults or adolescents, most adverse effects associated with the hydrocortisone + aciclovir combination were local and mild. Hypersensitivity reactions are possible, however. This combination should be avoided during pregnancy, given the mild nature of herpes labialis and concerns over the risks of corticosteroids for the unborn child. In practice, there is no firm evidence that the aciclovir + hydrocortisone combination is more effective than aciclovir alone. Given the inherent risks associated with hydrocortisone, it is better to recommend simple hygiene measures and, possibly, aciclovir alone.