Saturday, April 15, 2017

口服抗病毒藥物加上外用類固醇,可進一步預防唇皰疹復發

使用口服抗病毒藥物合併外擦類固醇藥膏,可以有效減少唇皰疹復發。如果唇皰疹已經長出,使用口服famciclovir或valciclovir的效果會優於口服或外用acyclovir。


很多人有脣皰疹一直復發的長期困擾。目前常見的預防方法是每天吃抗病毒藥,但根據筆者治療唇皰疹病人復發的經驗,這樣的治療只能稍微「減少」復發率。就算病人乖乖吃抗病毒藥,還是常常會長出一些病灶。

那麼有哪些方法可以進一步減少復發?有個在歐美各國一直流傳但又有點令人意外的做法,就是讓這些病人擦外用類固醇藥膏。


「什麼!?類固醇不是不好嗎?」「類固醇降低免疫力後,不會讓唇皰疹惡化?」


很多人討厭類固醇,但它是一種好藥,發現者得過諾貝爾獎,堪稱是二十世紀醫學最偉大的發現。類固醇可治療過去難治的許多皮膚病,有些會死的病人(例如天皰瘡,pemphigus)因此活下來了。實在不應受到這種污名化。目前三個先進國家(美國、荷蘭、與德國)都已經批准可以將抗病毒藥與類固醇的複方拿來治療唇皰疹。

然而類固醇降低免疫力或加重感染是事實,為何可以減少唇皰疹復發,其實歐美各國也一直在爭論這件事。比較可能的理由包括唇部濕疹造成的表皮缺損會誘發唇皰疹。如果用一些類固醇藥膏治好這些濕疹與表皮破損,就可以減少唇皰疹。(聽起來頗合理。)


事實勝於雄辯,抗病毒藥加上外用類固醇的作法贏了!


不管上述的推論多合理,一切都需要實證來證明。2015年時,有人統合了四個臨床試驗的結論,發現在使用抗病毒藥的時候同時使用外用類固醇,確實對減少唇皰疹復發有額外好處,比單獨使用抗皰疹藥有效(OR, 0.50; 95% CI, 0.39-0.66; P < .001)。治療過程也不會產生其他不良反應。

然而如果皰疹已經長出來,使用類固醇加上抗病毒藥跟單獨使用抗病毒藥雖然都有效,但沒有顯著統計差異,因此只要單純用抗病毒藥就好。而口服抗病毒藥比外用藥效果更好。


對於唇皰疹復發的對策


根據上面提到的資料,我們大概可以得到兩個處理唇皰疹復發的結論。

1. 使用抗病毒藥物(口服或外用)合併外擦類固醇藥膏(1% hydrocortisone or 0.05% fluocinonide),可以有效減少唇皰疹復發。

2. 如果唇皰疹已經長出,使用口服藥(famciclovir、valciclovir、或acyclovir)的效果優於外用acyclovir。多使用外用類固醇不會比較有效。

臨床實務上,國外可買得到acyclovir 5%與1% hydrocortisone的複方藥膏,一天擦五次。但台灣目前沒有類似產品,且一天擦五次其實很麻煩,因此比較合理的方式是使用口服藥(acyclovir 400mg,每天兩次),配上外用類固醇藥膏一天兩次,可節省很多時間。

台灣國內可取得的外用類固醇產品,個人推薦使用皮質醇(Cort-S,美時),這是一種油性的1% hydrocortisone藥膏 ,對許多慢性唇部濕疹的病人很有效。而且其類固醇的強度甚低,幾乎不用擔心長期使用與吃到的副作用。


皮質醇軟膏(美時),台大藥劑部網站


參考資料

 2015 Feb 21;15:82. doi: 10.1186/s12879-015-0824-0.

Effectiveness of topical corticosteroids in addition to antiviral therapy in the management of recurrent herpes labialis: a systematic review and meta-analysis.

Abstract

BACKGROUND:

Recurrent herpes labialis (RHL) is one of the most common viral infections worldwide. The available treatments have limited efficacy in preventing the recurrence of ulcerative lesions and reducing the duration of illness. The objective of this review was to identify the effectiveness of topical corticosteroids in addition to antiviral therapy in the treatment of RHL infection.

METHODS:

A systematic review of randomized clinical trials comparing the efficacy of combined therapy (topical corticosteroids with antiviral) with placebo or antiviral alone in the management of RHL was conducted. MEDLINE, EMBASE, CINAHL, Web of Science, the Cochrane library, and Google Scholar databases were searched. We used RevMan software to conduct the meta-analysis. A fixed-effects model was used for mild to moderate heterogeneity, whereas a random-effects model was used for significant heterogeneity. Heterogeneity among trials was established using I(2) and chi-square test for heterogeneity.

RESULTS:

Four studies that fulfilled the selection criteria were included in this review. The total number of participants across included studies was 1,891 (range, 29 to 1,443). The antiviral drugs used were acyclovir, famciclovir, and valacyclovir. Corticosteroids used were 1% hydrocortisone and 0.05% fluocinonide. Pooled results showed that patients receiving combined therapy had a significantly lower recurrence rate of ulcerative lesions compared to those in both the placebo group (OR, 0.50; 95% CI, 0.39-0.66; P < .001) and the antiviral treatment alone group (OR, 0.73, 95% CI, 0.58-0.92; P = .007). The healing time was also significantly shorter in combined therapy in comparison to placebo (P < .001). However, there were no significant differences in healing time between combined therapy and antiviral alone. The adverse reactions in combined therapy were not significantly different than the placebo group (OR, 1.09; 95% C, 0.75-1.59; P = .85).

CONCLUSION:

Treatment with combined therapy is safe and more effective than placebo or antiviral alone for preventing the recurrence of ulcerative lesions in RHL infection.

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