Pharmacology and Treatment
GENITAL HERPES: TREATMENT WITH METHYLENE BLUE AND LIGHT EXPOSURE TE-WEN GHANG, M.D., NIGHOLAS FlUMARA, M.D., AND LOUIS WEINSTEIN, M.D.
ABSTRACT: Fifty-six patients with genital herpes were treated by photodynamic inactivation of herpesvirus by methylene blue (36 patients), proflavine (10) or neutral red (10). The first 35 patients were randomly selected for treatment with one of the three dyes. All the others were initially treated with methylene blue. The disease was temporarily eradicated in about 70% of instances by exposure of the lesions to light plus topically applied methylene blue, neutral red or proflavine. Relapses, however, were not prevented or appreciably reduced.
Studies from our laboratory have indicated that methylene blue possesses photodynamic activity against herpesvirus. The pattern of the activity is almost identical to that of neutral red, but different from that of proflavine, which is viricidal in the dark for many strains. In addition, only 73% of hypervirus strains were photosensitive to methylene and neutral red, and the strains resistant to methylene blue and neutral red were photosensitive to proflavine.' A controlled study of the effect of locally applied neutral red plus light in patients with superficial herpetic lesions has indicated that the clinical course is shortened and the frequency of relapse reduced.^ Proflavine, a derivative of acridine, has produced similar results. However, a controlled study of
From the Infectious Disease and Dermatology Services, New England Medical Center Hospital and the Departments of Medicine and Dermatology, Tufts University School of Medicine, Boston, Massachusetts.
the use of this agent has not been carried out. The purpose of our investigation was to evaluate the clinical effectiveness of this type of therapy on the management of genital herpes in man. Because of its chemical similarity to neutral red and proflavine, the effects of these were also investigated. Materials and Methods
Methods of Treatment All the dyes were prepared by dissolving them in distilled water to a concentration of 0.1%, which had been sterilized by boiling in a water bath for 15 minutes, and stored in brown bottles at refrigerator temperature. The dye was applied to the infected areas with a sterile cotton swab. Thirty to 50 minutes later, the stained lesions were exposed to a 15watt fluorescent lamp for 15 minutes; when convenient, exposure to sunlight was substituted for artificial light. No attempt was made to break the vesicle during the first part of study, when all 3 dyes were compared. Treatment was repeated once several hours later. If new lesions appeared the following day, the
Address for reprints: Te-wen Ghang, M.D., Tufts—New England Medical Genter Hospitals, 171 Harrison Ave., Boston, MA 02111.
69
70
INTERNATIONAL JOURNAL OF DERMATOLOGY Jan./Feb. 1975
Table 1. Results of Treatment of Cenital Herpes with Dye-Light Combination Methylene Neutral red blue Proflavine No. patients treated No. with symptomatic improvement* No reduction of relapse rate
15
10
10
11
6
8
10/11
5/8
6/8
* Evidenced by shortening of the duration of the disease and disappearance of symptoms within 2 days.
procedure was repeated. Treatment was carried out at home. Clinical Studies Fifty-six patients with genital infection were treated by topical application of a dye followed by exposure to fluorescent light. Thirty-five were treated in random fashion with neutral red, proflavine and methylene blue. The others were exposed initially to methylene blue; if there was no clinical response after the initial trial or after repeated use, a second dye was applied. With one exception, each episode of infection was treated with one dye. Clinical response was considered good when symptoms disappeared within 2 days after treatment. The lesions usually dried shortly and healed within the next 2-3 days. Because the clinical course of the disease is variable from individual to individual, a comparison with previous episodes from the same patient was always made. The patient's own judgment on the therapeutic response was also considered. Results Thirty-five patients were treated at random with methylene blue, neutral red
Vol. 141
or proflavine plus light (Table 1). Three women with diffuse lesions over the perineum were exposed to proflavine or methylene blue; none responded. All the other patients had localized disease.! The majority of them showed symptomatic improvement with disappearance of pain in 2 days and drying and healing of the lesions in 3-4 days. The usual duration of untreated cases was 7-10 days. Decrease in tenderness of the enlarged sentinel lymph nodes was evident 2-3 days after treatment was given. Pain in the upper and lower legs, present in 6 patients, also disappeared rapidly. Be-| cause of the demonstrated viricidal activity of proflavine,! 2 men with urethral herpetic infections were treated with topical application of this dye without exposure to light; both experienced rapid improvement of symptoms. Since the patients were instructed to start treatment at home as soon as the first sign appeared, it was possible to prevent the development of vesiculation in a third of cases. The sooner the treatment was started, the shorter the duration of the disease became. Relapses were neither prevented nor reduced in incidence in most of the 24 patients studied over a period of 3-8 months. The number of relapses varied from individual to individual. Therefore, their evaluation was made on an individual basis. Lesions of relapses were treated with the same dye until improvement was no longer produced. This happened in 7 of the 24 patients followed, after a varying number of recurrences. Those whose conditions failed to show clinical improvement after the use of one dye were treated with the other. Since methylene blue and neutral red had almost identical photodynamic inactivation pattern, they were considered one group. Proflavine, which exhibited somewhat different pattern, was
No. 1
GENITAL HERPES • Chang et a/.
useci as the alternative.^ A change of dye either after the first exposure or after repeated application in resistant cases vs/as followed by a good clinical response in most instances. Twenty-one additional patients with recurrent genital herpes were treated with methylene blue and light exposure. The response was similar to that observed during the earlier study. Six patients did not improve clinically on initial treatment with methylene blue and were subsequently treated with proflavine. All showed clinical improvement. These patients were not followed long enough to evaluate the effect, of methylene treatment on the relapse rates. Discussion
The most striking difference between effects of methylene blue, neutral red and proflavine is the in vitro viricidal activity of the latter in the absence of light.' Although the possibility of crossresistance between proflavine and the other dyes was not examined specifically, the results of our study suggest that this may not be a problem, since patients with recurrent herpetic infections whose diseases did not respond to the application of methylene blue and light responded satisfactorily to therapy with proflavine. Treatment of genital herpes with dye and light, although effective in ameliorating symptoms, did not reduce the frequency of clinical relapse. This result in our experiment is different from that of other investigators.^ It is possible that the failure to reduce the relapse rate in our patients may be related to differences In the method of photoinactivation. Rapp et al.3 reported that photoinactivation of herpes virus types 1 and 2 in the presence of neutral red destroyed
71
the infectivity of the virus but did not alter its oncogenicity. However, the frequency of transformation was low. This is in sharp contrast to adenovirus transformation, which is high in frequency both in vitro and in vivo. There is no evidence that adenovirus infection in man has resulted in the development of neoplastic lesions. Under ordinary circumstances, 90% of herpes virus particles in an infected fluid are noninfectious. Because treatment shortens the duration of the disease by 50% or prevents the development of vesiculation, the production of noninfectious particles should be greatly reduced. Therefore, it is reasonable to assume that treatment by photoinactivation should play no greater role in the initiation of cancer than does naturally occurring infection caused by herpesvirus hominis.'' Methylene blue is not a vital dye; therefore, it is not likely to share other biological activities of neutral red or proflavine. On theoretical grounds, methylene blue would appear to be less likely to potentiate the oncogenic property of herpes virus. However, it still disrupts viral DNA by the same photodynamic activity as neutral red and proflavine, thus producing identical defective viral particles from the extracellular infectious virus. References 1. Ghang, T. W., and Weinstein, L., Photodynamic inactivation of Herpesvirus by methylene blue. Proc. Soc. Exp. Biol. Med. (In Press). 2. Felber, T. D., Smith, E. B., Knox, J. M. et al., ' Photodynamic inactivation of herpes simplex: Report of a clinical trial. JAMA 223: 289, 1973. 3. Rapp, F., and Duff, R., Transformation of hamster embryo fibroblasts by herpes simplex viruses type 1 and type 2. Cancer Res. 33:1527, 1973. 4. Melnick, J. L., and Rawls, W. E., Letter to / the editor. JAMA 226:79, 1973.
GENITAL HERPES: TREATMENT WITH METHYLENE BLUE AND LIGHT EXPOSURE TE-WEN GHANG, M.D., NIGHOLAS FlUMARA, M.D., AND LOUIS WEINSTEIN, M.D.
ABSTRACT: Fifty-six patients with genital herpes were treated by photodynamic inactivation of herpesvirus by methylene blue (36 patients), proflavine (10) or neutral red (10). The first 35 patients were randomly selected for treatment with one of the three dyes. All the others were initially treated with methylene blue. The disease was temporarily eradicated in about 70% of instances by exposure of the lesions to light plus topically applied methylene blue, neutral red or proflavine. Relapses, however, were not prevented or appreciably reduced.
Studies from our laboratory have indicated that methylene blue possesses photodynamic activity against herpesvirus. The pattern of the activity is almost identical to that of neutral red, but different from that of proflavine, which is viricidal in the dark for many strains. In addition, only 73% of hypervirus strains were photosensitive to methylene and neutral red, and the strains resistant to methylene blue and neutral red were photosensitive to proflavine.' A controlled study of the effect of locally applied neutral red plus light in patients with superficial herpetic lesions has indicated that the clinical course is shortened and the frequency of relapse reduced.^ Proflavine, a derivative of acridine, has produced similar results. However, a controlled study of
From the Infectious Disease and Dermatology Services, New England Medical Center Hospital and the Departments of Medicine and Dermatology, Tufts University School of Medicine, Boston, Massachusetts.
the use of this agent has not been carried out. The purpose of our investigation was to evaluate the clinical effectiveness of this type of therapy on the management of genital herpes in man. Because of its chemical similarity to neutral red and proflavine, the effects of these were also investigated. Materials and Methods
Methods of Treatment All the dyes were prepared by dissolving them in distilled water to a concentration of 0.1%, which had been sterilized by boiling in a water bath for 15 minutes, and stored in brown bottles at refrigerator temperature. The dye was applied to the infected areas with a sterile cotton swab. Thirty to 50 minutes later, the stained lesions were exposed to a 15watt fluorescent lamp for 15 minutes; when convenient, exposure to sunlight was substituted for artificial light. No attempt was made to break the vesicle during the first part of study, when all 3 dyes were compared. Treatment was repeated once several hours later. If new lesions appeared the following day, the
Address for reprints: Te-wen Ghang, M.D., Tufts—New England Medical Genter Hospitals, 171 Harrison Ave., Boston, MA 02111.
69
70
INTERNATIONAL JOURNAL OF DERMATOLOGY Jan./Feb. 1975
Table 1. Results of Treatment of Cenital Herpes with Dye-Light Combination Methylene Neutral red blue Proflavine No. patients treated No. with symptomatic improvement* No reduction of relapse rate
15
10
10
11
6
8
10/11
5/8
6/8
* Evidenced by shortening of the duration of the disease and disappearance of symptoms within 2 days.
procedure was repeated. Treatment was carried out at home. Clinical Studies Fifty-six patients with genital infection were treated by topical application of a dye followed by exposure to fluorescent light. Thirty-five were treated in random fashion with neutral red, proflavine and methylene blue. The others were exposed initially to methylene blue; if there was no clinical response after the initial trial or after repeated use, a second dye was applied. With one exception, each episode of infection was treated with one dye. Clinical response was considered good when symptoms disappeared within 2 days after treatment. The lesions usually dried shortly and healed within the next 2-3 days. Because the clinical course of the disease is variable from individual to individual, a comparison with previous episodes from the same patient was always made. The patient's own judgment on the therapeutic response was also considered. Results Thirty-five patients were treated at random with methylene blue, neutral red
Vol. 141
or proflavine plus light (Table 1). Three women with diffuse lesions over the perineum were exposed to proflavine or methylene blue; none responded. All the other patients had localized disease.! The majority of them showed symptomatic improvement with disappearance of pain in 2 days and drying and healing of the lesions in 3-4 days. The usual duration of untreated cases was 7-10 days. Decrease in tenderness of the enlarged sentinel lymph nodes was evident 2-3 days after treatment was given. Pain in the upper and lower legs, present in 6 patients, also disappeared rapidly. Be-| cause of the demonstrated viricidal activity of proflavine,! 2 men with urethral herpetic infections were treated with topical application of this dye without exposure to light; both experienced rapid improvement of symptoms. Since the patients were instructed to start treatment at home as soon as the first sign appeared, it was possible to prevent the development of vesiculation in a third of cases. The sooner the treatment was started, the shorter the duration of the disease became. Relapses were neither prevented nor reduced in incidence in most of the 24 patients studied over a period of 3-8 months. The number of relapses varied from individual to individual. Therefore, their evaluation was made on an individual basis. Lesions of relapses were treated with the same dye until improvement was no longer produced. This happened in 7 of the 24 patients followed, after a varying number of recurrences. Those whose conditions failed to show clinical improvement after the use of one dye were treated with the other. Since methylene blue and neutral red had almost identical photodynamic inactivation pattern, they were considered one group. Proflavine, which exhibited somewhat different pattern, was
No. 1
GENITAL HERPES • Chang et a/.
useci as the alternative.^ A change of dye either after the first exposure or after repeated application in resistant cases vs/as followed by a good clinical response in most instances. Twenty-one additional patients with recurrent genital herpes were treated with methylene blue and light exposure. The response was similar to that observed during the earlier study. Six patients did not improve clinically on initial treatment with methylene blue and were subsequently treated with proflavine. All showed clinical improvement. These patients were not followed long enough to evaluate the effect, of methylene treatment on the relapse rates. Discussion
The most striking difference between effects of methylene blue, neutral red and proflavine is the in vitro viricidal activity of the latter in the absence of light.' Although the possibility of crossresistance between proflavine and the other dyes was not examined specifically, the results of our study suggest that this may not be a problem, since patients with recurrent herpetic infections whose diseases did not respond to the application of methylene blue and light responded satisfactorily to therapy with proflavine. Treatment of genital herpes with dye and light, although effective in ameliorating symptoms, did not reduce the frequency of clinical relapse. This result in our experiment is different from that of other investigators.^ It is possible that the failure to reduce the relapse rate in our patients may be related to differences In the method of photoinactivation. Rapp et al.3 reported that photoinactivation of herpes virus types 1 and 2 in the presence of neutral red destroyed
71
the infectivity of the virus but did not alter its oncogenicity. However, the frequency of transformation was low. This is in sharp contrast to adenovirus transformation, which is high in frequency both in vitro and in vivo. There is no evidence that adenovirus infection in man has resulted in the development of neoplastic lesions. Under ordinary circumstances, 90% of herpes virus particles in an infected fluid are noninfectious. Because treatment shortens the duration of the disease by 50% or prevents the development of vesiculation, the production of noninfectious particles should be greatly reduced. Therefore, it is reasonable to assume that treatment by photoinactivation should play no greater role in the initiation of cancer than does naturally occurring infection caused by herpesvirus hominis.'' Methylene blue is not a vital dye; therefore, it is not likely to share other biological activities of neutral red or proflavine. On theoretical grounds, methylene blue would appear to be less likely to potentiate the oncogenic property of herpes virus. However, it still disrupts viral DNA by the same photodynamic activity as neutral red and proflavine, thus producing identical defective viral particles from the extracellular infectious virus. References 1. Ghang, T. W., and Weinstein, L., Photodynamic inactivation of Herpesvirus by methylene blue. Proc. Soc. Exp. Biol. Med. (In Press). 2. Felber, T. D., Smith, E. B., Knox, J. M. et al., ' Photodynamic inactivation of herpes simplex: Report of a clinical trial. JAMA 223: 289, 1973. 3. Rapp, F., and Duff, R., Transformation of hamster embryo fibroblasts by herpes simplex viruses type 1 and type 2. Cancer Res. 33:1527, 1973. 4. Melnick, J. L., and Rawls, W. E., Letter to / the editor. JAMA 226:79, 1973.
