30 Infectious Diseases FAMILY P RACTICE N EWS • August 15, 2005 Patient Ignorance One Root of Herpes Prevalence

BY TIMOTHY F. KIRN 30% during the last 2 2 have a cure,” he said. “This is just Sacramento Bureau decades, Dr. Tyring one more tool in the armamen- noted. UMBER tarium.”

N APLES, FLA. — Patients It is now estimated 20. N The new genital herpes vac- with genital herpes often believe that 45 million people in cine has been shown to be high- they can’t transmit the infection the United States, or OLUME ly effective, but, unexpectedly, while they are asymptomatic, 15% of the population, . V only in women. LINICS

and the majority of transmis- are seropositive for C A major new trial is underway sions are probably borne of this HSV-2. to better understand why this ignorance, Stephen K. Tyring, It is estimated that might be, and, specifically, the M.D., said at the annual meeting 80% of transmissions mucosal immunity women ap- of the Florida Society of Der- occur when the carrier ERMATOLOGIC pear to develop. matology and Dermatologic is asymptomatic, Dr. Genital herpes increases the Surgery. Tyring said. 2002, D risk of HIV transmission two- to Many patients may be incred- Women are at greater fivefold, Dr. Tyring said. This in- ulous when you tell them this, risk of acquiring the AUNDERS creased risk occurs because there because they have been told they virus, he said. The over- is a reduced epithelial barrier in

must have a lesion or symptoms all rate of transmission S ©W.B. a person with herpes, but also be- to transmit the virus. from an infected part- Condoms can help prevent transmission of herpes simplex virus, but areas cause the individual with herpes With such patients, you can ner to an uninfected not completely covered by the condom remain susceptible to infection. has infiltrates of CD-4–positive point out that 80% of the popu- partner is about 10% cells where the lesions occur. lation is herpes simplex virus per year. women more than men. signed to 500 mg of valacyclovir Studies have shown that one type-1 seropositive, but almost The annual rate rises if the in- When men develop herpes le- or placebo once daily, Dr. Tyring can use acyclovir, valacyclovir, or nobody ever kisses someone fected partner is the male; the fe- sions or have viral shedding, they and colleagues reported that the famciclovir to keep herpes in when they have a fever blister on male partner has a 20% chance of tend to do so on the distal geni- rate of transmission was reduced check in the HIV-infected indi- their mouth, said Dr. Tyring, a becoming infected, and a 30% talia, which the condom covers. by 50% over an 8-month period vidual—which not only address- dermatologist and infectious dis- chance if she is seronegative for Women, however, shed virus into (N. Engl. J. Med. 2004;350:11- es the herpes but sometimes im- ease specialist who is medical HSV-1. If the female is the in- secretions that can get on the 20). proves the response to HIV director of the Center for Clini- fected partner, the male has a base of the penis or even the “The study used valacyclovir, therapy as well, Dr. Tyring said. cal Studies at the University of less than 10% chance of infec- scrotum. but you can substitute famci- For HIV patients with resistant Texas Health Sciences Center, tion. In a seminal study published clovir or acyclovir and probably herpes, the Centers for Disease Houston. Condoms protect against last year, in which almost 1,500 in- get the same result,” Dr. Tyring Control and Prevention recom- The prevalence of herpes sim- transmission but are not fool- fected individuals with seronega- said. mends using a topical formula- plex type-2 (HSV-2) increased by proof, and they probably benefit tive partners were randomly as- “The bad news is, we don’t tion of cidofovir. ■ Combine Topical, Systemic Therapies to Syphilis Outbreak Knock Out Tough Case of Crusted Scabies In Idaho Tapers Off n outbreak of syphilis in southern BY SHERRY BOSCHERT casionally three) doses. The patient time in a long-term care facility for reha- AIdaho that began in 2003 probably San Francisco Bureau should show improvement by 3 weeks bilitation. Scrapings of lesions on the has peaked, according to Tom Shanahan, and continue to gradually improve. soles of her feet were loaded with scabies a spokesman for the Idaho Department of K OHALA C OAST, HAWAII — Attack Don’t try to save a buck by skimping mites and feces. Health and Welfare. hyperkeratotic scabies both topically and on the ivermectin, Dr. Berger warned. Don’t be dissuaded from suspecting Four babies with congenital syphilis systemically or your treatment will fail, Don’t round down the dose but, rather, scabies just because a patient has failed were born in Idaho in 2003, and three Timothy G. Berger, M.D., said at a con- give the full dose of ivermectin (usually permethrin treatment or family mem- were born in 2004. “We started seeing a ference sponsored by the Center for Bio- 12-18 mg), and allow plenty of time to bers seem unaffected, Dr. Berger ad- rise in total cases of syphilis in 2002 and Medical Communications Inc. treat. In appropriate doses, the combina- vised. 2003; we are hopefully over the hump He divides patients with scabies into tion therapy has never failed him. Treat the whole family, but not neces- now,” Mr. Shanahan said. In addition to two categories to guide management— In a typical case, a family brought in an sarily immediately. Family members who the congenital cases, 45 cases of syphilis those with a low burden or a high burden 87-year-old woman who had had 6 are affected get immediate treatment, were reported in the state in 2003, and 78 of disease. For the typical pa- but otherwise Dr. Berger waits cases were reported in 2004. tient with a low burden, two ap- Don’t be dissuaded from suspecting scabies to treat the family until the pri- Although 21 cases of syphilis have been plications of permethrin 5% just because a patient has failed permethrin mary patient has been treated, reported in 2005, no congenital cases have cream a week apart will cure so that the patient is no longer occurred so far this year. 95% of cases. treatment or family members seem infectious. “Drug use was a significant risk factor,” But a double whammy usu- unaffected. High-burden cases often in- Mr. Shanahan said. Approximately 70% of ally is needed for patients with volve the scalp, so instruct pa- patients in Idaho’s third district were a high burden of disease—those with months of severe itching, though no one tients to apply permethrin to the scalp methamphetamine or other drug users. crusted or hyperkeratotic scabies, AIDS else in the family was itching. too, he advised. Ivermectin won’t help Consequently, management strategies to and scabies, or scabies acquired while in The patient had failed treatment with scabies involving the nail plate, so con- control the outbreak include spreading a long-term care facility or prison, said multiple courses of permethrin, systemic sider more aggressive treatments for nail the word about the association between Dr. Berger of the University of Califor- steroids, and other medications. scabies. drug use and syphilis, and educating the nia, San Francisco. She had a widespread papular eruption Ivermectin is secreted in sebum, he public through organizations that work He prefers to use these two categories on her trunk, proximal extremities, and noted, which is one reason monotherapy with drug addicts. because patients with a high burden of face, showing focal plaques, some of may not work in the elderly, children, The incidence of illness was highest in disease may present with multiple which were markedly hyperkeratotic, Dr. malnourished patients, or people with southwest Idaho, which reported 97 of the papules instead of crusts, but need the Berger said. Down syndrome, all of whom make less state’s 144 cases of syphilis from 2003 to combination therapy used for crusted “The British describe this as looking sebum. 2005. scabies. like a fine white sand on the skin. That’s Immunosuppression plus neural dis- The ages of the 97 patients ranged from The combination treatment consists exactly what it looks like,” Dr. Berger ease puts patients at risk for crusted sca- 15-81 years, with an average age of 24 of weekly applications of permethrin said. bies, one reason that people with AIDS or years; 14 of the 97 patients were 18 years 5% cream for 3-6 weeks plus ivermectin Her history was a tip-off: After a hip re- Down syndrome are at higher risk for or younger. 200 mcg/kg every 2 weeks for two (or oc- placement 9 months earlier, she had spent crusted scabies, he said. ■ —Heidi Splete