Herpes Infections ================= þ Anti-Herpes Drugs þ Ramsay Hunt Syndrome - AKA Herpes zoster oticus - with Zoster of face, paralysis of face (like Bell's Palsy) - antivirals appropriate but never shown to work, Cochrane Review could come to no conclusion [Uscategui, T., C. Doree, et al. (2008). "Antiviral therapy for Ramsay Hunt syndrome (herpes zoster oticus with facial palsy) in adults." Cochrane Database Syst Rev(4): CD006851. BACKGROUND: Herpes zoster oticus (HZO) is a viral infection of the ear and when associated with acute facial paralysis is known as Ramsay Hunt syndrome. Antiviral agents are the standard first-line treatment for herpes zoster infections at other body sites and are thought to reduce or minimise nerve damage, thereby improving outcomes. It has been suggested that these agents improve the chance of facial weakness improving or resolving completely in patients with Ramsay Hunt syndrome. OBJECTIVES: To determine the effectiveness of antiviral agents in the treatment of adult patients with Ramsay Hunt syndrome (HZO with facial palsy). SEARCH STRATEGY: We searched the Cochrane ENT Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, current issue), Medline (1950 - 2007), PubMed 2007 - 2008, EMBASE (1974 onwards) and other relevant databases. The date of the most recent search was June 2008. SELECTION CRITERIA: Two authors scrutinized all possible citations to identify randomised controlled trials in which antiviral agents alone or in combination with other therapies (using different routes of administration and dosage schemes) were given as treatment for Ramsay Hunt syndrome. We contacted an author for further information. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed eligibility and trial quality. MAIN RESULTS: Only one randomised, controlled trial was identified and included. It was of low quality and included only 15 participants. In this 1992 trial, intravenous acyclovir and corticosteroids were compared with corticosteroids alone. Our analysis found no statistically significant difference between the two groups. AUTHORS' CONCLUSIONS: We found no evidence that anti-viral agents have a beneficial effect on outcomes in Ramsay Hunt syndrome, despite their widespread use in this condition. The use of these drugs in patients with herpes zoster infections in other parts of the body might suggest that they have a role in herpes zoster oticus. As usual, the absence of positive evidence of benefit (or, in this case, the 'negative' result of one small, statistically under-powered study) does not necessarily indicate that antivirals are ineffective. However, these drugs are associated with a number of adverse effects and this must be taken into consideration when undertaking the requisite risk-benefit analysis before instigating treatment. - adding steroids may or may not help, Cochrane Review could come to no conclusion (2009) [Uscategui, T., C. Doree, et al. (2008). "Corticosteroids as adjuvant to antiviral treatment in Ramsay Hunt syndrome (herpes zoster oticus with facial palsy) in adults." Cochrane Database Syst Rev(3): CD006852. BACKGROUND: Inflammation and oedema of the facial nerve due to viral infection by the herpes zoster virus are implicated in the aetiology and clinical manifestation of Ramsay Hunt syndrome (herpes zoster oticus with facial palsy). Corticosteroids, with their powerful anti-inflammatory effect, have a potential role to play in the reduction or minimisation of nerve damage when administered together with antiviral therapy, and therefore may improve the outcome for patients with Ramsay Hunt syndrome. OBJECTIVES: To determine the effectiveness of corticosteroids as an adjuvant to antiviral therapy in adult patients with Ramsay Hunt syndrome (herpes zoster oticus with facial palsy). SEARCH STRATEGY: We searched the Cochrane ENT Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), (The Cochrane Library Issue 4, 2007), MEDLINE (1950 to December 2007) and EMBASE (1974 to December 2007), CINAHL (1982 to December 2007), LILACS, KoreaMed, IndMed, PakMediNet, ZETOC, Cambridge Scientific Abstracts (Conference Proceedings Database), ISI Proceedings (Web of Science), the National Research Register (NRR), the UK Clinical Research Network Portfolio Database (UKCRN), the World Health Organization International Clinical Trials Registry Platform (ICTRP), the Research Findings Register (ReFeR) and the metaRegister of Controlled Trials (mRCT). SELECTION CRITERIA: All randomised controlled trials in which corticosteroids (by any route of administration at any dosage) were given as an adjuvant to antiviral agents in the treatment of Ramsay Hunt syndrome. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed eligibility and trial quality of the available studies, whether they were published or unpublished. No trials were found and therefore no data were analysed. MAIN RESULTS: This is an empty review as no trials were found that fulfilled the inclusion criteria. AUTHORS' CONCLUSIONS: Since no randomised controlled trials investigating the use of corticosteroids as an adjuvant to antiviral treatment in Ramsay Hunt syndrome were identified, such studies are needed to assess the effects of such therapy.] - but, a recent meta-analysis disagrees with the Cochrane reviews and recommends that you use both: [de Ru, J. A. and P. P. van Benthem (2011). "Combination therapy is preferable for patients with Ramsay Hunt syndrome." Otol Neurotol 32(5): 852- 855. OBJECTIVE: To critically appraise the topic, questioning whether administering antiviral medication in case of Ramsay Hunt syndrome improves the restoration of facial nerve function. METHODS: We reviewed the literature on this subject and calculated the odds ratios for the different treatment modalities. RESULTS: Our study clearly shows that antiviral medication in combination with corticosteroids improves the outcome for patients with Ramsay Hunt syndrome. CONCLUSION: Contrary to a recent Cochrane Library review, we conclude that patients with Ramsay Hunt syndrome should be treated with combination therapy including antivirals.] þ Kaposi's Varicellaform Eruption - Single outbreak of more-or-less dermatomal large vesicles/bullae/erosions, often on face, from Herpes Simplex -- looks like localized chickenpox. þ Herpetic Gingivostomatitis in Kids - Aciclovir suspension 15 mg/kg five times a day for seven days [Amir J, Harel L, Smetana Z, Varsano I Treatment of herpes simplex gingivostomatitis with aciclovir in children: a randomised double blind placebo controlled study [see comments] BMJ 1997; 314 1800-3] Abstract: þ Hutchinson's Sign for Herpes: - involvement of the tip of the nose - may indicate corneal involvement - caused by involvement of the nasociliary nerve off V1 (gives off branches to cornea, the ciliary nerves, as well as to the tip of the nose, just prior to the autonomic ciliary ganglion; wonder if the virus hides in this ganglion?) - Herpes pustules at the tip of the nose (Hutchinson’s sign) are thought to be a classic predictor of ocular involvement. Although patients with a positive Hutchinson’s sign have twice the incidence of ocular involvement, one third of patients without the sign can experience ocular manifestations. A common complication of HZV infection is an injected and edematous conjunctiva, often with petechial hemorrhages. This conjunctivitis will usually resolve in 1 week unless secondary bacterial infection occurs. The use of topical antibiotics may help to prevent secondary infection, whereas cool compresses and lubrication drops can be used for comfort. In corneal involvement, HZV dendrites appear as a branching or ‘‘medusa-like’’ pattern with tapered ends in contrast to HSV dendrites, which often have terminal bulbs. This pattern can be viewed by Wood’s lamp or slit lamp examination after fluorescein staining. These patients need preservative-free artificial tears every 1 to 2 hours and an ocular lubricant ointment nightly. An ophthalmologist should be consulted regarding systemic or topical antiviral agents; topical steroids are occasionally indicated depending on the ocular manifestations of HZV and should be prescribed only in consultation with ophthalmology. [Mahmood AR, Narang AT. Diagnosis and management of the acute red eye. Emergency medicine clinics of North America 2008;26:35-55, vi.] þ Disseminated Zoster - As long as no evidence of visceral involvement, some ID specialists treat as outpatient þ Zoster Immune Globulin - Under 15, immunocompromised - Pregnant near-term þ Post-Herpetic Neuralgia - Steroids decreased pain initially but no change in longterm pain. Steroids decreased pain acutely and made rash heal faster (also gave antiviral drug to each group) (also found acyclovir for 7 as good as 4 days) [Wood, NEJM Mar 1994] Steroids caused faster resolution of pain, and improved quality of life (sleep and activity) but no long-term difference [Whitley, Ann Int Med Sept 1996] þ Distinguishing Herpangina from Gingivostomatitis - Herpangina (Coxsackie virus) involves the posterior pharynx, whereas gingivostomatitis (herpes virus) usually affects the anterior oral cavity more severely. Also, herpangina may involve the hands and soles. [Schwartz, Prinicples and Practice of Emergency Medicine, 3rd ed. p 2529]