Dengue

The rainy season is here. The rainfalls have freed us from the heat and sweating armpits. However, it poses an imminent threat of rising number of dengue cases owing to the damp weather. The stagnant water present, for instance, in the cans, plastic bags, pots after the rain may precipitate the growth and flourish of Aedes aegypti or Aedes albopictus mosquitoes - the vector carrying the virus.

source: thefloridanewsjournal.com

There are three phases for dengue fever - febrile > critical > recovery.The incubation period is usually 4-7 days. High fever (around 40 degree Celcius) , rash , headache ( muscle aches ) are the three main characteristics of the dengue. The other signs and symptoms, depending on the severity, may include:
- nausea and vomiting
-sire throat
- bleeding gums
- diarhoea
- leucopenia
-abdominal pain (due to liver tenderness)
- shock
- fluid accumulation (eg. ascites, pleural and pericardial effusion)
- respiratory distress
-organ failure

To further confirm the diagnosis, the doctor will usually order a test to see if there is the presence of either the viral antigen or dengue antibodies.

One of the major complications of dengue is that the plasma leakage mat lead to hypovolaemia, shock, organs failure and eventually death. Therefore, it is important to make sure the public and the healthcare professionals such as pharmacists are able to recognise the signs and symptoms of a possible dengue  case and seek for medical assistance for early treatment.

Usually, we need to be extra vigilant whenever our community area have cases of dengue. This increase the risk of contracting the disease. Any high episodes of fever for more than 3-5 days especially the children should always given medical attention.

Again, it is a viral disease (arthropod-borne). Hence, the treatment plan is based on the aim of relieving the signs and symptoms as well as preventing the complications. Controlling the fever, relieving the pain and aches, monitoring and treating shock syndromes are the main concerns during episodes of dengue.

Dengue can be caused by four virus serotypes. The patient will develop a lifelong immunity to the particular virus after the recovery, but not all other serotypes. So , it is possible for a person to get dengue again, mostly due to the infection of the other virus serotype. However, the disease would not be transmitted from person-to-person.

Steps needs to be taken to counter the dengue outbreak. Increasing the awareness of the public especially in the community where the number of dengue cases is on the rise. Reducing the mosquito habitat is also crucial in preventing the spread of this disease.


To prevent dengue:
- Make sure the Pour away the stagnant water in the surroundings of your house.
-Wear protective clothing or apply mosquito repellent especially during outdoor activities
-Use mosquito nets or make sure your bedroom is safeguarded from the "attacks: of the mosquitoes

To date, dengue vaccine is still not widely available. There is one live-recombinant-tetravalent Dengvaxia (from Sanofi Pasteur) registered in Mexico, however,  it is still currently under evaluation of Phase III trial. In addition, there are 5 other types of dengue vaccine that undergo research and clinical trials. 

source: play.google.com

References

CPG Malaysia - Management of Dengue Infection in Adults

http://www.mayoclinic.org/diseases-conditions/dengue-fever/basics/definition/con-20032868

http://www.who.int/denguecontrol/en/

http://www.webmd.com/a-to-z-guides/dengue-fever-reference?page=2

http://www.who.int/immunization/research/development/dengue_vaccines/en/

Cold Sore

What is cold sore? 

Cold sore, also known as fever blister. Medically, it is known as Herpes simplex labialis. It is a viral infection that happens on or around the lip. It is commonly caused by Herpes Simplex Virus (HSV), and it is mostly caused by HSV-Type 1. 

example of cold sore (stage 3) source: dermnetnz.org

Misconception on cold sore 

Hearing of the term 'herpes' might freak you out, merely because of  the thought - genital herpes comes into your mind. 

(This could be a point to note when it comes to patient counselling -  as a health professional, we should be careful in phrasing our words during the explanation to the patient about the causes of cold sore so that they do not misunderstand). 

Afraid not, cold sore is not tantamount to genital herpes. In fact, there are different kinds of herpes viruses present around us and each of them affects different parts of our body. Commonly, there are two types of herpes simplex virus, Type 1 and Type 2. HSV type 2 is the major 'culprit' for genital herpes. Nonetheless, our topic today is about HSV type 1 - the virus that causes cold sore.

[To answer those who may still in doubt - cold sore could be caused by HSV Type 2. However, the percentage is very low. In most cases, cold sore caused by HSV-2 are resultant of the transmission  from those who have genital herpes]

How do I know if I have cold sore ?

Often, we may carry the virus without knowing it. Usually, when the virus infected a person, it may stay dormant in the nerve ending of the lip. It can be then transmitted to other people, often via close contact such as kissing. This could all happen while the infected person is still asymptomatic where the virus stay dormant. The symptoms start to appear when our immune system is weakened such as we are sick or under stress. 

The common symptoms of cold sore are the tingling, burning or itching sensation around the lips, then the eruption of blisters on or around the lips. For some, the blisters may become oozing and crusting.

Cold sore can be briefly divided into three stages:

1st stage - the appearance of the symptoms. This usually starts with the burning or tingling sensation of the lip. Or, sometimes, itchiness. 

2nd stage - the appearance of the blister. The blister may be oozing. A this stage, the risk of transmission is particularly high. 

Non-specific viral signs and symptoms such as fever,  sore throat, headache, swollen lymph nodes may also arise.

3rd stage - healing of the blisters. Fret not, the oozing and crusting blisters will usually heal without leaving scars. 

Cold sore usually heals in 7-14 days.

For recurrent cold sore, it is usually easy for the patient himself/herself to discern. This is because the symptoms appear usually similar ( since the virus stay at the similar nerve endings). For instance, the cold sore happen mostly at the same spot, typically around the lips. 

There is no cure for cold sore. What could we do then ? 

Once you have  contracted this virus, it will go latent in your body for the rest of your life - staying at your nerve cells and there are no obvious signs when the virus is not activated.

Whenever you are under stress again, the virus may be reactivated and manifest the symptoms - the blisters always re-emerge at the similar spots again - from time to time. Apart from that, recurrent cold sores may happen, owing to fatigue, bright sunlight and strong wind exposure, hormone changes (menstrual), fever etc.

Afraid not, the symptoms will become milder, as your body will start to develop antibodies and fight the virus, leaving no significant complications. 

Treatment

Even though cold sore is self-healing, the use of anti-viral medicines (cream, pill or patch) can relieve the symptoms and speed up the healing effects. In addition, the patch can hide the cold sore and prevent the exposure of the cold sore blisters in order to reduce the transmission risk. The treatment should be applied as early as possible. It should be initiated once you have the early signs of cold sores first appear, eg. the sensation of tingling or itchiness to prevent the cold sore getting worse or promote faster healing.

And, yes! You have to apply every two hours for five times a day for acyclovir cold sore cream (eg. Zovirax cream). 

OTC medicine : Zovirax cold sore cream
(image sourced from Google search) 

Competed cold sore patch (hydrocolloid-075 formulation)
(image sourced from Google search)

Some oral aid treatments (containing analgesics, steroids or antibacterial) can also be used to ease the symptoms (numb and relieve the pain or itchiness) and prevent secondary bacterial infection.

Butadiene Cold sore ointment (API: povidone-iodine 10%)
(image sourced from Google search)

You can also use a lip balm or vaseline to ease the itchiness or burning sensation of the lips. 

Of course, do ask your doctor or pharmacist if you have any question.

My little experience to share :

While working in the community pharmacy, I have encountered many cases of cold sores. Just like what the statistic told us, it is very common to have cold sore, 1 in 5 of the young adults will have HeSV-1, and the incidence increases with your ages (1) .  From my own experience,  every customer would have symptoms slightly different from one another. Some just complained about the tingling feelings of the lips, or itchiness (early stage of cold sore). Some showed the characteristic feature where there are clear blisters present around the lips. However, one thing to note is that there are no clear cut points as in how we determine if the patient is experiencing cold sore or not. The patients might come into the pharmacy at the different stages of cold sore. Bearing in mind that some even do not advance into the later stage, they may just have the tingling feelings in each episode of recurrence.

A good rule of thumb is that asking the patient's about his/her previous history - to see if they experience the similar symptoms before in order to figure out if the patient has cold sore. 

References

http://www.webmd.com/skin-problems-and-treatments/guide/understanding-cold-sores-basics

http://www.mayoclinic.org/diseases-conditions/cold-sore/basics/definition/con-20021310

http://medsask.usask.ca/professional/guidelines/cold-sore.php

http://www.dermnetnz.org/viral/herpes-simplex.html

http://www.healthline.com/health/herpes-labialis#Overview1

http://www.medscape.com/viewarticle/557162

https://www.compeed.com.au/compeed-coldsore

Cold Sore

What is cold sore? 

Cold sore, also known as fever blister. Medically, it is known as Herpes simplex labialis. It is a viral infection that happens on or around the lip. It is commonly caused by Herpes Simplex Virus (HSV), and it is mostly caused by HSV-Type 1. 

cold sore
source: dermnetnz.org 

Misconception on cold sore 

Hearing of the term 'herpes' might freak you out, merely because of  the thought that it might be genital herpes. 

(This could be a point to note when it comes to patient counselling -  as a health professional, we should be careful in phrasing our sentence while explaining to patients about the causes of cold sore so that they do not misunderstand). 

Afraid not, cold sore is not tantamount to genital herpes. In fact, there are different kinds of herpes viruses present around us and each of them affects different parts of our body. Commonly, there are two types of herpes simplex virus, Type 1 and Type 2. HSV type 2 is the major 'culprit' for genital herpes. Nonetheless, our topic today is about HSV type 1 - the virus that causes cold sore.

[To answer those who may still in doubt - cold sore could be caused by HSV Type 2. However, the percentage is very low. In most cases, cold sore caused by HSV-2 are resultant of the transmission  from those who have genital herpes]

How do I know if I have cold sore ?

Often, we may carry the virus without knowing it. Usually, when the virus infected a person, it may stay dormant in the nerve ending of the lip. It can be then transmitted to other people, often via close contact such as kissing, touching or sharing personal items. This could all happen while the infected person is still asymptomatic where the virus lies dormant in your nerve. The symptoms start to appear when our immune system is weakened such as we are sick or under stress.  and the viral travel down your nerve to skin and manifest the signs and symptoms.  

The common symptoms of cold sore are the tingling, burning or itching sensation around the lips, then the eruption of blisters on or around the lips. For some, the blisters may become oozing or weepy and crusting after a few days. Eventually, the cold sore will dry up and form yellow crust (may look similar to impetigo - need to be careful while doing differential diagnosis) 

Cold sore can be briefly divided into three stages:

1st stage - the appearance of the symptoms. This usually starts with the burning or tingling sensation of the lip. Or, sometimes, itchiness. 

2nd stage - the appearance of the blister. The blister may be oozing or wheezing. A this stage, the risk of transmission is particularly high. Avoid KISSING, sharing personal items with others.

Non-specific viral signs and symptoms such as fever,  sore throat, headache, swollen lymph nodes may also arise.

3rd stage - healing of the blisters. Fret not, the oozing and crusting blisters will usually heal without leaving scars. 

Cold sore usually heals in 7-14 days.

For recurrent cold sore, it is usually easy for the patient himself/herself to discern. This is because the symptoms appear usually similar ( since the virus stay at the similar nerve endings). For instance, the cold sore happen mostly at the same spot, typically around the lips.

There is no cure for cold sore. What could we do then ? 

Once you have  contracted this virus, it will go latent in your body for the rest of your life - staying at your nerve cells and there are no obvious signs when the virus is not activated.

Whenever you are under stress again, the virus may be reactivated and manifest the symptoms - the blisters always re-emerge at the similar spots again - from time to time. Apart from that, recurrent cold sores may happen, owing to fatigue, bright sunlight and strong wind exposure, hormone changes (menstrual), fever etc.

Afraid not, the symptoms will become milder, as your body will start to develop antibodies and fight the virus, leaving no significant complications. 

Treatment

Even though cold sore is self-healing, the use of anti-viral medicines (cream, pill or patch) can relieve the symptoms and speed up the healing effects. In addition, the patch can hide the cold sore and prevent the exposure of the cold sore blisters in order to reduce the transmission risk. Also, keeping the cold sore moist using lip balm or topical ointment containing natural products such as lemon balm or propolis can prevent the splitting of the wound. The treatment should be applied as early as possible. It should be initiated once you have the early signs of cold sores first appear, eg. the sensation of tingling or itchiness to prevent the cold sore getting worse or promote faster healing.

And, yes! You have to apply every two hours for five times a day up to 5-7 days for aciclovir cold sore cream (eg. Zovirax cream, Viraban). And one more important point to note - apply the anti-viral cream as early as possible ( at the first sign of cold sore starts) 

OTC medicine: Viraban cold sore cream (aciclovir 5%)
(image sourced from Google search) 

OTC medicine : Zovirax cold sore cream
(image sourced from Google search) 

Competed cold sore patch (hydrocolloid-075 formulation)
(image sourced from Google search)

Some oral aid treatments (containing analgesics, steroids or antibacterial) can also be used to ease the symptoms (numb and relieve the pain or itchiness) and prevent secondary bacterial infection.

Butadiene Cold sore ointment (API: povidone-iodine 10%)
(image sourced from Google search)

You can also use a lip balm or vaseline to ease the itchiness or soothe the burning sensation of the lips. My choice of lip balm will be Savex (not only can be used to soothe the symptoms of cold sore, but also for dry chapped lips). But there are many options available on the market. Lip balm with SPF is better in preventing the reactivation of cold sores as the sun exposure could be the trigger. (In fact, almost one in five people has cold sore triggered by sunlight exposure). 

Savex Original lip balm
(image sourced from Google search) 

Blistex medicated relief ointment (padimate, oxybenzone, camphor)
(image sourced form Google search) 

Of course, do ask your doctor or pharmacist if you have any further question.

Red signs 

Refer to the doctor if ..

1. the patient is very young, old, pregnant or breastfeeding 

2. the patient has high temperature and the cold sore is in the mouth instead of the lips or surroundings. 

3. the size of cold sore is usually large and do not heal after weeks 

4. the lesions spread over the face (not just around the lips) 

My little experience to share :

While working in a community pharmacy, I have encountered many cases of cold sores. Just like what the article told us, it is very common to have cold sore, 1 in 5 of the young adults will have HSV-1, and the incidence increases with your ages (1) .  From my own experience,  every customer would have symptoms slightly different from one another. Some just complained about the tingling feelings of the lips, or itchiness (early stage of cold sore). Some showed the characteristic feature where there are clear blisters present around the lips. However, one thing to note is that there are no clear cut points as in how we determine if the patient is experiencing cold sore or not. The patients might come into the pharmacy at the different stages of cold sore. Bearing in mind that some even do not advance into the later stage, they may just have the tingling feelings in each episode of recurrence.

A good rule of thumb is that asking the patient's about his/her previous history - to see if they experience the similar symptoms before in order to figure out if the patient has cold sore. 

Advice 

- If you are experiencing cold sore, do not share personal items including towels and dining utensils.

- Yes, avoid kissing when the cold sores are still visible 

-Use lip balm with sun protecting factor (SPF) to keep your lip moist 

- Personal hygiene is important too - wash your hands frequently and avoid touching your eyes and genitals area to prevent spreading of the virus

-If you often experience cold sore, natural remedies such as lysine could be trialled (2). Take the oral lysine regularly to reduce the reoccurrence. 

Example of product containing lysine 

References

https://www.healthychildren.org/English/health-issues/conditions/skin/Pages/Herpes-Simplex-Virus-Cold-Sores.aspx
http://www.webmd.com/skin-problems-and-treatments/guide/understanding-cold-sores-basics

http://www.mayoclinic.org/diseases-conditions/cold-sore/basics/definition/con-20021310

http://medsask.usask.ca/professional/guidelines/cold-sore.php

http://www.dermnetnz.org/viral/herpes-simplex.html

http://www.healthline.com/health/herpes-labialis#Overview1

http://www.medscape.com/viewarticle/557162

http://kidshealth.org/en/teens/hsv1-sores.html

http://www.berkeleywellness.com/supplements/other-supplements/article/lysine-cold-sores

https://gohealthy.co.nz/products/product/go-lysine-1000mg/