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Herpes simplex - oral - Management
Which topical antiviral preparation is recommended for cold sores?

  • Recommend aciclovir 5% cream as a suitable topical antiviral for the treatment of cold sores.
Clarification / Additional information
  • Two topical antiviral preparations are available on prescription and over the counter without prescription:
    • Aciclovir 5% cream is available to buy in pharmacies, supermarkets, and other stores as it is classed under the General Sale List (GSL).
    • Penciclovir 1% cream is only available through pharmacies.
  • For further information on the use of topical antiviral preparations, see How to apply topical antiviral preps
Basis for recommendation
  • Aciclovir 5% cream is preferred over penciclovir 1% cream:
    • It requires less frequent application (five times a day for 5 days) than penciclovir 1% cream (every 2 hours during waking hours for 4 days).
    • it is licensed for use under 12 years of age.
    • It is less expensive than penciclovir 1% cream.
  • CKS found no good evidence to indicate that either aciclovir 5% cream or penciclovir 1% cream is superior to the other. Consequently, the choice of topical antiviral will be influenced by the ease of application, its licensed uses and cost.
    • One Chinese double-blind RCT (n = 248) found no significant differences in terms of efficacy endpoint, clinical cure rate, and safety, between those treated with aciclovir 3% cream (unavailable in UK) and penciclovir 1% cream [Lin et al, 2002].
    • Another published study (n = 40) found that penciclovir 1% cream reduced healing time and duration of pain more than aciclovir 5% cream [Femiano et al, 2001]. However the sample size was small (n = 10 in each of four treatment arms). No information was given as to whether the trial was double blinded or randomized.
  • Topical antivirals not recommended:
    • Topical idoxuridine: one double-blind RCT found idoxuridine (15%, in 80% dimethyl sulfoxide) to be effective in reducing the mean duration of pain and healing time by approximately 1–2 days compared to control [Spruance et al, 1990a]. However, treatment was associated with a higher level of skin irritations. The 15% solution is not available in the UK. Only the 5% solution (Herpid®) is available commercially in the UK.

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