Question of the Week # 37

A 34 year old man with no significant past medical history is seen in your office for a painful blister that appeared on his lower lip yesterday. He compians of burning and itching in the area. He never had similar lesions in the past. He denies any fever or chills. Vital signs reveal a temperature of 98.4, HR 88, RR18 and BP of 120/76. On physical examination a lesion is seen on his lower lip as shown in the picture. rest of the physical examination is benign.

What is this?

The most appropriate next step in management is:

A) Oral Acyclovir

B) Re-assurance

C) Topical Penciclovir

D) Cold compresses

E) Oral Cephalosporin

12 Responses

  1. a

  2. A) Oral Acyclovir

  3. c

  4. Ans. is C Topical penciclovir

    The patient has Herpes Labialis:Caused by Herpes simplex Virus Type I. Most people are asymptomatic but only few people have recurrent outbreaks. Triggers for outbreak are cold weather, stress, trauma.

    Treatment: Topical Penciclovir as your first choice.
    Recurrent severe cases can be treated with oral Acyclovir.

    Ans. A is incorrect. Oral acyclovir is the treatment option for severe or recurrent herpes labialis.

    Ans. B is incorrect. This patient requires topical penciclovir.

    Ans. D is sub-optimal management.

    Ans. E is incorrect. This is not suggestive of a bacterial infection.

  5. If only we apply anti-herpetic medication before vesicular eruption could limit the duration and severity of the crops. Once there is erruption, no medication can help but the nature. Using unnecessary medication would increase the cost of treatment. Simple reassurance and avoiding contact, giving rather Tylenol for pain and fever!might help in this case.

    • I’m sorry screamer but you have got your stats wrong. Treatment with an antiviral agent such as oral acyclovir brings the pain and infection down by 20-30% or else the sore on the lip keeps hurting! 😉 You definately need alcohol swabs and tylenol. On the other hand, topical penciclovir is not appropriate because Antiviral skin creams are expensive and often only shorten the outbreak by a few hours to a day. Dr Redd the answer to this question is wrong 🙂

      • you are wrong because you main argument is the cost of medication which is always wrong in step 3 exams, its the clinical effect that is the most important, the patient is complaining of pain and itching, therefore you MUST use therapy to reduce this regardless of whether the infection can resolve without treatment in 1 -2 weeks, also recurrence rates need to be reduced if possible with medication, so it would be negligent not to do any treatment. topical penciclovir will reduce the pain and itching and will reduce recurrence rates.

  6. You r right Dr.Nagmi here is link http://www.cfp.ca/content/54/12/1683.full
    That means ans is B

  7. I hate to be the one reminding all of us that there is a very thin line between courtesy/respect/regards and insensitivity and disrespect. It is very easy to wash away. We should desist from blatantly telling our senior colleagues, colleagues and junior colleagues that they are ‘wrong’. I know this is common practice in residency training. But still, it is impolite and unprofessional and an uncivilized way of relating with people and conveying information. There are subtle ways of saying your mind. A colleague or a senior colleague or junior colleague is wise enough to realize his mistake when you say something that is more informative or more appealing or when he makes a mistake. When you say your mind, you are making a point. When you say someone is ‘wrong’ you are insensitive and difficult to approach other than being verbally offensive. I can go ahead and say that I have followed Dr Archer and like other great teachers, mistakes are rare; and unless information you are reading has not been updated or if there is a printing error, the chances are rare. The chances are more that you are the one who is missing out some information or crucial fact somewhere in your research or findings. But that is not the point.
    Great teachers are hard to find. They should be respected for sharing their thoughts with us. This is hard to understand. Only true savants of knowledge can comprehend what I just said. What they teach is priceless and no one else can say it the way each one of them says it. We are fortunate to have Dr Archer. He is of no less value to us than Einstein is to his students. The information on this blog alone is priceless. (and so graciously free!) Respect this man who has flooded us with information. You will not find his kind of coaching ever again. It’s like DNA finger printing. He is unique, no one can replace him and we are fortunate to have him with us.

    Now, back to the question; the answer is Penciclovir. Studies have shown that Penciclovir is superior to Acyclovir. Antivirals make a difference in treatment of Herpes Labialis and prevention of recurrence.
    The cost of Penciclovir is $60 for single prescription. It should be used in the first episode becuase we want the most effective treatment to decrease the risk of recurrence. When the disease becomes recurrent, we try to prevent it with acyclovir which is $4 per prescription. We offer the best treatment. This is the most appropriate next step. But at the end of the day, the patient chooses what he can afford.
    Topical Docosanol is $15 per tube. It is a new drug launched in 2010. It is comparable to antiviral therapy and has less chances of drug resistance because of its mechanism of action. This drug is not in the list of options.
    Reassurance? – left alone, this lesion will go away without treatment in 1-2 weeks but antivirals will reduce pain and make the symptoms go away sooner. they will also help in the future against recurrence. Clearly, to decrease the misery of the patient, topical antiviral is a better option
    Cold compress – will make patient feel better but it will not shorten the course of the disease. And it will not prevent recurrence.
    Cephalosporin – this is helpful to treat secondary infections.But the most appropriate next step is to treat the disease itself.

    I hope you guys forgive me if I offended anyone of you. I respect your opinion and I value each one of you highly. My answer is C. Same as Dr Archer’s.

  8. Many thanks to Dr. Archer ! u r giving us a lots of info. Teaching us many things with out any fees! we are really appreciate! u r the only person have a time and concern , what we are suffering!

    Thanks for explanation and giving us wonderful mcqs with out any cost! I hope everybody appreciate and understand u r hard work, dedication and kindness! God bless everybody!

  9. Respectfully, the answer here should be A, according to Epocrates: Oral antivirals are the primary treatment. They are safe and effective and are used for both suppressive and episodic therapy. The goal of daily suppressive treatment is to decrease the number of outbreaks (70% to 80% reduction) and/or reduce the risk of genital herpes transmission (48% reduction).
    All the references given by Dr. Adnan above are comparing topical acyclovir with topical penciclovir and came to conclusion that topical penciclovir is better.

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