Dr Cormac Convery discusses the relationship between HSV reactivation and aesthetic treatments and outlines appropriate methods of prevention
Patients having elective aesthetic procedures often have a low tolerance for complications, particularly those that have a negative impact on their long-term aesthetic outcome such as scarring.
Aesthetic procedures that cause trauma to the skin have the potential to activate cold sore recurrence. Cold sores are a common affliction and are usually caused by herpes simplex virus (HSV) type 1 (usually oral herpes), with the minority (10%) being caused by HSV type 2 (usually genital herpes).1
Many primary infections of HSV-1 are asymptomatic, while recurrent infections can present as cold sores at the vermillion border.1 Although cold sores may not cause any long-term skin damage, they do have the potential to cause scarring at the infected area.2,3
This article will detail the aesthetic treatments that are likely to cause a reactivation of HSV-1 (the main cause of cold sores). The appropriate prevention methods and protocols of HSV will also be explained and an investigation into practitioner awareness of these treatment protocols will be presented.
Causes of HSV It is estimated that two-thirds of the global population under 50 are infected with HSV-1.4 Primary infection usually occurs in childhood through non-sexual contact, for example by sharing towels or utensils, but it is better known as a condition that spreads through kissing. If symptoms do present with primary infection, they occur two to 20 days after exposure.
These may include a prodrome of fever, oral lesions (herpetic gingivostomatitis)5 and regional lymphadenopathy. Recurrent lesions, usually referred to as herpes labialis, present as a cluster of vesicles on the lip or vermillion border. These recurrent infections can be triggered by a number of factors including fatigue, bright sunlight, menstruation and trauma.6
Aesthetic procedures such as lasers, injectables, microneedling and chemical peeling often involve limited or deliberate, controlled trauma to the skin, which has the potential to trigger cold sore recurrence. When a cold sore appears after an aesthetic treatment, it can be devastating for the patient due to discomfort, pain and potential scarring of a cosmetically sensitive area. There is a particular risk of scarring after ablative procedures.2,3
As an example, during facial dermal filler injections, virus reactivations can be provoked by direct damage to the axon by the needle. In addition, tissue manipulation and inflammatory reaction after filler injection could play a role in viral reactivation.
The traumatic damage is believed to mainly cause infection reactivation, but the hyaluronic acid itself has been demonstrated to act as a protective agent, preventing viral replication.7 Virus reactivation will appear in the area where the filler has been injected (the most common sites are the perioral area and the nasolabial folds).8
In some cases, virus reactivation can extend and thus affect neighbouring areas. The viral outbreak is commonly observed 24 to 48 hours after filler injection. Despite the possibility of reactivation, for many of these procedures the risk is low. For example, figures from the FDA suggest that the frequency of occurrence is less than 1.45% of cases for dermal filler injections to the lip.8
However, aesthetic treatments do have the potential to increase the possibility of a patient developing cold sores and despite there being a low risk of this happening, it is vital that this is reduced as much as possible to maintain patient comfort and to reduce the risk of scarring.
Minimising the risk of cold sore reactivation and awareness of this is extremely important, as is having an index of suspicion, depending on the procedure, and of the likelihood of reactivation.
Practitioners must acknowledge that patients have a low tolerance of complications after aesthetic procedures and even a small risk of scarring must be taken seriously, and managed with an initially preventative approach.
I conducted a literature search to determine the effectiveness of prevention for aesthetic treatments. The findings suggested that it is common practice in laser resurfacing for all patients to be treated prospectively with antivirals to prevent reactivation and dissemination of HSV-I.9
It is important to note that the studies outlined below include participants who had not reported a history of HSV-1, however because their primary infection may have been subclinical and they may not currently show symptoms of HSV-1, they are still relevant to include.
Study 1: Two groups of patients receiving CO2 laser resurfacing were observed (P=121). The group with a known history of HSV (27) were prescribed 250mg of famciclovir for seven days, while another group (94) with no known history was prescribed 125mg.10 There was only one case of HSV-1 reactivation, which came from the group with no known history.
Study 2: 60 patients with and without a known HSV-1 infection (study did not specify exact numbers of each), used famciclovir 250mg for 14 days as a preventative treatment for the same procedure. Authors did not report any cases of HSV-1 in any patients.3
Study 3: 120 participants (number with and without known history unspecified) who also received laser resurfacing treatments were prescribed valacyclovir 500mg for either 10 or 14 days did not report HSV-1 reactivation. The authors also reported that 70% of participants who didn’t report a history of HSV-1, actually were serology positive for previous infection.2
Study 4: Another study considered other methods of resurfacing, including laser (CO2, Er:YAG), chemical peeling, dermabrasion, or a combination of these techniques.11 In total, 84 patients (number with and without known history unspecified) who presented for facial resurfacing were enrolled, and were randomly assigned to start valacyclovir 500mg twice daily either the morning before or the morning of the procedure. Valacyclovir was 100% effective in the prevention of HSV reactivation in both regimens with no adverse effects reported.11
Study 5: For the above studies, prophylaxis has generally been successful, however one example shows it did not work so well, with the reactivation rate being much higher compared to other studies. 99 patients (number with and without known history unspecified) who had a full-face laser or perioral resurfacing procedure received either 500mg or 250mg famciclovir twice daily, beginning 24 hours prior to laser resurfacing and continuing for 10 days. The study found an overall 10% reactivation rate. The subgroup with a history of known HSV-1 infection had a reactivation in 33%, while those with no known history of infection had a 5% reactivation rate.12
A limitation to some of these studies is that they did not provide information on which participants had a history of HSV-1 and which did not. However, from the evidence presented, prophylaxis appears to reduce reactivation of HSV.
There appears to be no studies considering prevention of HSV reactivation in micro-needling therapy. I could not find any studies that considered aciclovir; instead they all used valaciclovir or famciclovir. A lot of current evidence is extrapolated form laser treatments and we must be cautious to assume it applies to other treatments in the same way.
The Aesthetic Complications Expert (ACE) Group has a protocol for aesthetic treatments, which is the only one to be found that recommends prophylaxis in the following circumstances:13
The group recommends first line prophylaxis of aciclovir 400mg twice daily (three times if immunocompromised or high risk). As mentioned, I could not find any studies for the use of aciclovir for prevention in aesthetic treatments, however it is commonly used as a first line treatment for HSV-1 outbreaks and herpes zoster. Further study is required to develop an evidence base for the use of aciclovir in HSV prophylaxis. Valaciclovir 500mg daily (twice daily if immunocompromised or high risk) is recommended by the ACE Group as a second line.
Through my training role, I have noticed a surprising number of aesthetic practitioners who seem unaware of the potential need for HSV prophylaxis. This has prompted reflection on, and consideration of, ways to raise standards for all practitioners and outcomes for patients.
To gauge knowledge and awareness of the need for HSV prophylaxis and to also establish what approaches were being used, I conducted a survey of aesthetic practitioners using an online survey tool. There were 59 respondents, who were each asked six questions relating to their clinical practice and protocols for treating patients. The data indicated the following:
While 98% said they ask about a history of cold sores, only 88% said it affects management; this suggests that there is limited understanding of the relevance of the question. Almost 78% said they follow a protocol but only 16.95% prescribe following the ACE Guideline. It is unclear what other protocol is being followed, as no other protocol was found in published literature. 10% refer to a GP for prophylaxis, while nearly 14% selected ‘other’ which included use of a topical over the counter aciclovir cream.
Neither of these options represent appropriate care of a patient because the average GP will not know what to do in regards to aesthetic treatments, and topical over-the-counter aciclovir cream is not effective as a prophylactic agent.1
This data suggests that there is low awareness of the risk of HSV reactivation. According to the ACE guidelines, asking about history of infection and eruption frequency should be mandatory during assessment and on the consent form – patients should be aware that a positive history of cold sores impacts management.
Evidence does not support the use of topical prophylaxis1 and there is no evidence base for the use of oral aciclovir in prophylaxis. I suggest the routine adoption of the ACE Group protocol with further, ideally prospective comparative study, to include the usage of oral aciclovir. I would also highlight that referral or signposting to the GP, without agreed shared-care and protocol, is unlikely to result in best care of the patient.
This paper presents evidence that suggests that some practitioners have inadequate awareness of this simple, yet important aspect of patient management. While not a common issue, scarring resulting from herpetic eruption is avoidable. Practitioners should follow a protocol and there should be subsequent evaluation of this protocol, as well as further prospective studies on the use of aciclovir for prophylaxis.
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