JADA Continuing Education
Treatment modalities and medication recommended by health care professionals for treating recurrent herpes labialis
G. WAYNE RABORN, D.D.S., M.S.,
KAREN S. CHAN, B.Sc., R.D.H. and
MICHAEL GRACE, Ph.D.
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ABSTRACT
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Background. The authors conducted a survey to determine how health care professionals respond to patients’ inquiries about cold sores, also known as recurrent herpes labialis, and their choices of treatment modalities and medications.
Methods. The authors mailed a one-page, pretested survey to a random sample of dentists, pharmacists and family physicians in Alberta, Canada. After receiving ethics approval from the University of Alberta, Edmonton, the authors mailed 998 surveys. The response rate was 51 percent.
Results. Topical antiviral medication was the most common treatment recommended (63 percent). Over-the-counter medication was the first choice for pharmacists (83 percent) as compared with dentists (15 percent) and physicians (16 percent). Emotional stress (60 percent) was reported by patients to be the most common trigger, and pain or discomfort (81 percent) was their primary concern. Acyclovir ointment was the most common antiviral drug recommended or prescribed by health care professionals (60 percent), and cost was the major reason they gave for not recommending or prescribing antiviral drugs (73 percent).
Conclusions. The authors found variation in treatment modalities and recommendations by each health profession, despite the fact that patients reported similar triggers and concerns. This may be due to individual patient need and the health care professional’s lack of knowledge.
Practice Implications. Survey results may serve as a reference for health care professionals to use to determine how their choices of medications and treatment modalities compare with those of other practitioners. Professionals should know the benefits and limitations of all therapies, discuss them with the patients and select a treatment.
Cold sores, also known as recurrent herpes labialis, or RHL, are caused by a herpes simplex type 1 virus that remains dormant in the sensory ganglia until it is reactivated by triggers such as sun exposure, stress, and illness or trauma. RHL is a viral infection that affects an esti mated one-third of the world’s population1 and can cause pain, disfigurement and embarrassment to the patient. In a Swedish population of people between birth and 60 years of age, it was noted that 26.6 percent reported having a history of RHL and 19.45 percent reported having a recurrent episode during the past two years.2 A study of more than 20,000 Swedes reported that 3.1 percent had RHL at the time of assessment.3 More recently, a German study reported that RHL was reported in 1.3 percent of the adult and 1.4 percent of the elderly population at the time of examination.4 Although there is no cure for RHL, numerous clinical trials have been conducted to find better forms of treatment and medica tions for this disease. Research also is being conducted to determine how the virus establishes or maintains a dormant state and reactivates itself within the sensory ganglia.
Pharmacists are more likely than dentists and physicians to see customers when they have cold sores.
Antiviral drugs are the main mode of treatment prescribed for RHL.5 These drugs can be used as an intermittent, suppressive or topical form of therapy. A range of over-the-counter, or OTC, medications may be recommended to relieve cold sore symptoms. Various forms of alternative therapy also are available for people who have cold sores.
Treatment modalities for RHL are numerous, and many clinical trials have been conducted to show the effectiveness of different forms of treatment.6–14 It should be well-known in the health care community what types of treatment and medications can be used, but no research has been conducted to determine which are being prescribed or recommended in everyday practice. Through a postal questionnaire survey, we sought to determine how dentists, pharmacists and family physicians respond to inquiries about cold sores and what were their choices of treatment modalities and medications. We also wanted to find out what treatment strategies are most suitable in a practical setting, as health care professionals communicate directly with people who have cold sores.
No research has been conducted to determine which medications and types of treatment are being prescribed or recommended in everyday practice.
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METHODS
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We designed and conducted the survey to maximize validity and response rates.15,16 With approval from the University of Alberta Health Research Ethics Board, we mailed a pretested and modified one-page survey to a random sample of active dentists, pharmacists and physicians in the province of Alberta, Canada. We included prestamped return envelopes and enclosed a cover letter that included the names of the researchers in case participants had questions or concerns. The cover letter also explained the purpose of the survey, that ethics approval had been granted and that we had the cooperation of professional societies. A proportionate random sample of 201 dentists, 398 pharmacists and 399 physicians was chosen from computerized databases provided by the professional groups for each of health care professions. No follow-up surveys were mailed to the selected health care professionals, as the surveys had no codes printed on them and participants’ names were not required.
The confidential survey consisted of four short demographic questions and nine questions pertaining to the frequency of cold sore inquiries, patient concerns, treatment modalities, and the prescribing or recommending of antiviral drugs or OTC medications. Participants selected their answers from choices given (multiple responses were allowed) or wrote their own responses based on their experiences as immunocompetent people. We encouraged participants to provide additional comments.
We entered the survey responses into a database with each demographic factor and possible response entered as "yes," "no," "not applicable" or "blank." We placed many of the "other" responses that were synonymous with the remaining choices provided into the appropriate category. When many respondents gave similar responses in the "other" category, we treated the similar response as a new separate category. Not all respondents ranked their choices when they selected more than one, so we did not tabulate a ranking of responses. The total percentages for each question could be more or less than 100 percent, as we allowed respondents to give multiple responses and some respondents left questions blank.
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RESULTS
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The response rate overall was 51 percent; it was 41 percent for dentists, 60 percent for pharmacists and 48 percent for physicians (Table 1
). Twenty-nine percent of the dentists were women, and 69 percent were men. Among pharmacists, 46 percent were women, and 47 percent were men, while among physicians, 33 percent were women, and 58 percent were men. The lengths of time in practice for the three professional groups were similar and averaged 17 years ± 11 years standard deviation. Ninety percent of the dentists, 53 percent of the pharmacists and 66 percent of the physicians came from urban areas (50,000 people or more). Not all respondents provided information for each demographic category.
The frequency of receiving patients’ inquiries about cold sores was most prevalent for pharmacists; 30 percent were asked for information more than 10 times per month (Table 2). Dentists and physicians, however, received this number of requests infrequently. When we asked members of all three professional groups about cold sores, more than 90 percent indicated that they received at least one inquiry per month.
The primary concerns about and trigger factors for cold sores, as reported by patients, were similar for each health care group (Table 3). Sixty percent of patients cited emotional stress, 47 percent cited illness or trauma and 45 percent cited sun exposure. The major patient concerns reported were pain or discomfort (81 percent), social stigma (61 percent) and transmission risk (15 percent).
Health care professionals’ recommendations for suppression of recurrent lesions are provided in Table 4. Use of sunscreen (48 percent), prophylactic antiviral therapy (44 percent) and stress reduction (41 percent) were recommended. These choices were similar for the dentist, pharmacist and physician groups.
Treatment modalities recommended for patients who inquired about cold sores would, of necessity, differ for each patient, and, consequently, each health care professional may have made different recommendations based on individual patient needs (Figure 1, page 52). Topical antiviral therapy was the most common recommendation, with physicians (80 percent) and dentists (72 percent) making it their top choice. OTC medications were the first choice of pharmacists (83 percent), with dentists (15 percent) and physicians (16 percent) being less likely to recommend the OTC medications. Oral antiviral therapy was recommended by 57 percent of physicians, 35 percent of dentists and 24 percent of pharmacists. Home remedies were chosen 5 to 9 percent of the time, and dentists were twice as likely to select the "other" category than were pharmacists or physicians.
Antiviral medications prescribed or recommended by health care professionals are shown in Figure 2 (page 52). Fifty-eight percent of dentists, 69 percent of pharmacists and 51 percent of physicians said acyclovir ointment was their first choice of antiviral drug. Acyclovir cream (31 percent), oral acyclovir (31 percent), famciclovir (21 percent) and valacyclovir (16 percent) were other common choices. OTC medications recommended by health care professionals are shown in Figure 3. Lipactin gel cold sore treatment (Novartis Consumer Health Canada, Mississauga, Ontario, Canada) was recommended most (50 percent), and it was chosen primarily by pharmacists (87 percent). Zilactin cold sore treatment (Zila, Phoenix) was recommended the second most (22 percent). Dentists (55 percent) and physicians (71 percent) were less likely to recommend OTC treatment than were pharmacists (> 80 percent).
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Figure 3. Over-the-counter medications recommended by health care professionals. Lipactin gel is manufactured by Novartis Consumer Health Canada, Mississauga, Ontario, Canada; Zilactin is manufactured by Zila, Phoenix; Cepacol Viractin gel manufactured by Combe, White Plains, N.Y.
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Reasons for not prescribing antiviral drugs were cost (73 percent), with more than 80 percent of pharmacists and physicians citing this as a factor (Figure 4, page 53). Lack of effectiveness (29 percent), antiviral drug resistance (14 percent) and side effects (10 percent) were less likely to be an issue. Dentists’ number one reason for not prescribing antiviral drugs was lack of effectiveness (45 percent).
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DISCUSSION
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While RHL is a low-grade infection, it is extremely widespread and sometimes can have serious consequences. Prescription medication, OTC treatments and home remedies are commonplace internationally, but most people who have RHL look for preventive measures or an approach that reduces healing time and minimizes pain. They also look for advice from those in a position of experience and knowledge such as dentists and physicians. However, given that RHL may be a secondary issue when patients have contact with their dentists or physicians, they are more likely to ask pharmacists who are more accessible when their need is immediate. This pattern is borne out by our findings, as pharmacists reported being asked questions about cold sores much more frequently than did dentists and physicians, though all groups received inquiries on a regular basis. This is in contrast to another study in which people who had cold sores reported having sought treatment from a physician (54 percent) more often than from a dentist (17 percent) or pharmacist (29 percent).17
Treatments recommended by each group of health care professionals in our study varied; dentists’ and physicians’ first preference was topical antiviral therapy, whereas pharmacists said they recommended OTC medications more often. As pharmacists are unable to prescribe medications, and as people are likely to approach pharmacists while they have a cold sore, the need for immediate action may account for pharmacists’ tendency to recommend OTC products. Professionals are affected by their scope of responsibility and patient goals; therefore, pharmacists may prefer OTC treatments, while dentists are more concerned about specific dental problems, and physicians are geared toward providing treatment.
A survey in the United Kingdom showed that patients had a positive attitude toward their physicians when the physicians discussed and recommended OTC drugs, but patients were more hostile toward OTC drug recommendations made by pharmacists.18 Since an increasing variety of OTC products are available and, therefore, the potential for drug interactions is rising, dentists and physicians should inquire about OTC drug usage more frequently before prescribing antiviral drugs. Docosonal, the first OTC medication approved by the U.S. Food and Drug Administration for the treatment of RHL, was not available in Alberta at the time this survey was conducted.
The trigger factors reported by patients to each professional health care group were similar. Emotional stress was the factor reported most often, while illness or trauma and sun exposure were mentioned with almost equal frequency. Contrary to our findings, patients in other studies have reported that sun exposure (63 percent) was the major trigger as compared with stress (15 percent).17 This implies that patients have set ideas as to what causes their cold sores (usually based on recurrent patterns), while they have different expectations of each group of health care professionals.
Dentists, pharmacists and physicians reported that the primary concern (81 percent) for patients seeking treatment was pain or discomfort. Social stigma was of concern to patients, with 61 percent telling their health care providers that it was a major issue. This suggests that health care professionals should not focus on treating only the disease but that they should consider the patient’s needs on a psychological level as well.
Each professional group’s first choice of a prescribed or recommended medication was acyclovir ointment. Acyclovir cream and oral acyclovir were prescribed or recommended equally as the second most common antiviral drug choice. Acyclovir therapy was reported by patients in a small study in the United Kingdom to be the most common treatment modality.17 In our study, famciclovir was the next most common medication, and it was chosen primarily by physicians who were more than twice as likely to prescribe this medication than were pharmacists and seven times as likely than were dentists. A similar pattern emerged for valacyclovir. Health care professionals’ selecting penciclovir was almost nonexistent, as, despite a report of positive results in a recent penciclovir study,19 it is not available in Canada.
The main OTC medication recommended (50 percent) was Lipactin gel; it was recommended primarily by pharmacists (87 percent). Zilactin was the next choice, but it was chosen by 50 percent less of the respondents. Fifty-four percent of dentists and 69 percent of physicians did not recommend OTC treatment. The pattern for recommending OTC treatment is understandable, given that pharmacists are more likely than dentists and physicians to see customers when they have cold sores.
The primary reason pharmacists and physicians cited for not prescribing antiviral drugs was cost. For dentists, the primary reason they cited for not prescribing antiviral drugs was lack of effectiveness, with cost being a secondary issue. This may be because dentists are less likely to be prescribing the drugs than are physicians, and pharmacists are more aware of prices because they receive payment at time of purchase. As drug coverage is optional on Alberta health care insurance plans, some patients are underinsured, which means they have to pay more of drug costs out of pocket. With cost being the major reason for not prescribing antiviral drugs, our findings suggest that health care professionals are sensitive toward financial concerns when providing treatment.
Although the response rate to this survey was very high compared with those of other surveys of health care professionals, the validity of the results still can be an issue, despite the fact that we followed appropriate methodologies such as obtaining accurate lists, conducting pilot projects and obtaining appropriate survey samples through randomization. The response rate for dentists was lower than that of the other two groups. Therefore, given that we sampled a smaller number of dentists to conform to the fact that their population was one-half the size of the other groups, the variability of their overall responses would be greater. The response rate of dentists to postal questionnaires can vary from 17 to 100 percent, depending on the questionnaire subject, incentives offered and the length of the questionnaire.20 The lower response rate from dentists may be because they are less likely to encounter questions from patients about cold sores.
In addition, the survey form was limited, owing to space and timing considerations. We encouraged participants to be flexible, and this was noticeable in the response patterns and from comments made by 13 percent of respondents. Participants contributed valuable information and interesting anecdotal asides (particularly those who had had cold sores), which could provide assistance for further surveys or focus groups.
Few similar surveys have been conducted to determine trends and patterns of treatment among these three health professions. One study used the same method of a mailed questionnaire to determine attitudes of general practitioners, pharmacists and consultant geriatricians on the use of sugar-free and sugar-containing medicines for the elderly.21
The development and marketing of new drugs or OTC products are dependent on surveys of consumers and health care professionals. Information from surveys can contribute to clinical guidelines, while making professionals more aware of consumers’ needs. Physicians and pharmacists have their own respective knowledge bases, and an improved partnership between these professions can help provide optimal drug therapy that is more cost-effective.22 With the increasing need for interdisciplinary collaboration, it is important that dentists, pharmacists and physicians communicate with one another to achieve quality patient care.
The overall response rate of 51 percent shows a clear interest in the issue of cold sores, enough that RHL should be a topic for continuing education programs. The willingness of so many professionals to cooperate demonstrates that they encounter people who have cold sores on a regular basis, and they would like to be better informed to assist these patients.
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CONCLUSIONS
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The response rate for this survey was high, which suggests that there is considerable interest in RHL and its treatment. With pharmacists being more likely to receive cold sore inquiries and with ease of purchase and lower costs being important factors, the market for OTC drugs is greater than that for prescription antiviral drugs. As additional studies emerge that clearly show a significant improvement in preventing or controlling the size of cold sore lesions or lessening the length of term and pain, it will be important to share the information via refereed journals and continuing education courses and in the training of undergraduate health care professionals.
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Dr. Raborn is a professor, Department of Dentistry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada T6G 2N8, e-mail "wayne.raborn{at}ualberta.ca". Address reprint requests to Dr. Raborn.
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Dr. Grace is a clinical professor, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.
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FOOTNOTES
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This project has been funded in part by GlaxoSmithKline, Mississauga, Ontario, Canada; the Associate Dean’s Research Fund, Department of Dentistry, University of Alberta, Edmonton, Alberta, Canada, and Medivir AB, Huddinge, Sweden.
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REFERENCES
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ABSTRACT
METHODS
