IJCRR - Vol 06 Issue 10, May, 2014
Date of Publication: 30-Nov--0001
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HONEY PHONOPHORESIS VERSUS LOW INTENSITY LASER THERAPY IN FEMALE GENITAL HERPES
Author: Intsar Salim Waked, Abdel Hamid N. Deghidi, Randa Shalaan
Abstract:Objective: To compare the efficacy of honey phonophoresis versus low intensity laser therapy in female genital herpes simplex II. Research Methodology: Forty female patients suffering from genital herpes simplex type II assigned randomly into 2 groups; honey phonophoresis group (A) and low intensity laser group (B). Intensity of pain and serological response were recorded before and after 3 weeks of treatment. Results: The results of study showed that there were significant differences between both groups post-treatment as p value< 0.05. Percentage of improvement in VAS, IgG, IgM after intervention were 60%, 45%, 8%, respectively for group (A ) while for group (B) were 82%, 66%, 56%, Respectively. Conclusion: The study concluded that low intensity laser was more effective than Honey phonophoresis in the treatment of genital herpes type II.
Keywords: Low intensity laser, genital herpes, honey phonophoresis, serological response, polymerase chain reaction.
Herpes simplex virus type II (HSV-2) gives rise to a variety of clinical disorders and is a major cause of morbidity and mortality worldwide. HSV-2 infections are common in genital area. Genital herpes infections are a major source of morbidity. These infections are responsible for significant health problems, including direct physical discomfort associated with outbreaks, potential complications such as neonatal transmission, and the often devastating psychological effects of a chronic illness1 . Herpes genitals is characterized by small, grouped, painful vesicles or pustules on an erythematous base, which break and form ulcers in 2-4 days. One of the important characteristics of all herpes viruses is latency. The life cycle of the herpes simplex virus is complex, comprising multiple stages. Following infection, the virus establishes life-long latency in its host and can reactivate at any time as a recurrent infection2 . There is evidence that latent infection also develops in tissues such as the epithelium of the vagina. The dormant virus then awaits a “trigger” to reactivate it. Triggers may include psychological stress, onset of menses, illness and physical trauma. Many patients experience a burning, tingling or itching sensation (a prodromal) at the location where a lesion later appears3. Herpes diagnosis is achieved by assessing the patient’s history and physical examination. However, further tests are necessary when HSV infection is asymptomatic, subclinical or atypical, or shows wide expression. The management of herpetic infection is indeed challenging, since none of the different methods of treatment guarantees full remission4 . Recently a range of infections can be potentially treated with honeyThis can include the common cold, eye infections such as conjunctivitis, as well as Herpes cold sores and genital lesions. Honey has antibacterial, antifungal and antiviral properties. Honey has also considerable anti-inflammatory properties as Antiinflammatory effects of honey in human plasma were measured5 . Phonophoresis is actually a combination of ultrasound therapy with topical drug therapy to achieve therapeutic drug concentrations at selected sites in the skin.. Honey had proven to be the best phonophoretic agent for transmission of ultrasound waves as honey is known to contain 17.20% water which is believed to be the best coupling agent in terms of acoustic properties as it reflects only 0.2 % of the sound waves at the water-soft tissue interface6 . Among treatment options, low-level laser therapy (LLLT) has shown promising clinical results as a longer-lasting suppression therapy. Additionally, it has been shown that this type of phototherapy might have an effect on several immunologic reactions7-9 . These findings have influenced a number of uncontrolled clinical studies about the effect of low-intensity laser therapy on herpes simplex infection10,11. . The purpose of this study was to evaluate the efficacy of honey phonophoresis versus low intensity laser therapy in female genital herpes.
PATIENTS AND METHODS
Subjects Forty female patients had genital herpes simplex infection type II were admitted to dermatology unit at El-Mataria Teaching Hospital, Cairo, Egypt, between July 2012 and September 2013. Age ranged from 25 to 45 years. Patients were free from any other diseases and not under any medications that could affect the immunity and influence the results.PATIENTS AND METHODS Subjects Forty female patients had genital herpes simplex infection type II were admitted to dermatology unit at El-Mataria Teaching Hospital, Cairo, Egypt, between July 2012 and September 2013. Age ranged from 25 to 45 years. Patients were free from any other diseases and not under any medications that could affect the immunity and influence the results.
A) Measurement of pain
Intensity of pain was measured by visual analogue scale (VAS). A VAS is usually a horizontal line, 100 mm in length, anchored by the verbal descriptors "No pain" and" Worst pain imaginable". Measurement was conducted by asking the patient to place a vertical mark on the line below which indicate how she feel pain at the time of assessment. The VAS score was determined by measuring in millimeter from left hand end of the line to the point that patient marked and was represented by a number from total ten 12.Fig (1).
b) Laboratory Assessment Serological Response and polymerase chain reaction ELISA reader and ELISA washer equipment were used for laboratory assessment of (HSV-II) IgG and (HSV-II) IgM.
Treatment Procedures Honey
Nonius, sonopuls 434, S. No. 03-202 type 1463.900 is a therapeutic US device manufactured by Enraf Holland. The Enraf nonius machine delivered the ultrasound wave, with a frequency of 1-3 MHz. Sonopuls 434 has a digital screen for time and intensity. It allows either pulsed or continuous mode Honey phonophoresis group received honey phonophoresis for 5 minutes; once daily for 3 weeks. Honey was the ultrasound coupling medium and was obtained from the National Research Center. The treated area was divided into zones which are approximately 1.5 times the area of the ultrasound treatment head, and then treat for 1 minute per zone, Frequency was 1.0 MHz, intensity was 1 w/cm2 pulsed waves 13 .
Low intensity Laser Treatment
Patients in the laser group received low-intensity laser therapy by an infrared diode laser with a wave length 905nm, intensity 0.2 mw, frequency 100 Hz and enegy 20 mJ per cm2 for 100 seconds once daily for 3 wk at the site of original lesion. Protective glasses were worn during application of laser to avoid permanent eye damage resulting from direct exposure to laser beam14 .
Mean, the standard deviation and the standard error were calculated for all patients. Paired t-test used to compare within each group to detect level of significance in each group. Unpaired t-test was used to detect significance level between two groups. The statistical package for social science (SPSS) was utilized for data analysis and the level of significance was set at the 0.05 level .
Data concerning age, VAS, IgG, IgM had been collected at the beginning of the study. Follow up evaluation of VAS, IgG, IgM, variables had been performed after three weeks of treatment. As shown in table (1), there were no statistical significant differences (P>0.05) observed between both groups concerning age, VAS, IgG, IgM, before intervention.
Results of group B (Laser group)
As shown in table (3) the mean value, standard deviation and p value of VAS, IgG, IgM, for group B pre and after intervention. The results showed highly significant difference as p value <0.05.
Comparative analysis of VAS, IgG, IgM between both groups after intervention
As shown in table (4) the mean value, standard deviation and p value of VAS, IgG, IgM between both groups. The results showed highly significant difference as regard to VAS, IgG, IgM, as (p value <0.05). Percentage of improvement in VAS, IgG, IgM, after intervention were 60%, 45%, 8%, respectively for group A while for group B the percentage of improvement in VAS, IgG, IgM, after intervention were 82%, 66%, 56%, Respectively. Fig (7)
In the present study, effects of honey phonophoresis versus low intensity laser on female herpes simplex virus type II were investigated. According to results of this study, there were significant decrease in pain intensity after treatment with honey phonophoresis for group A. The efficacy of honey phonophoresis may be attributed in partly to anti-inflammatory, acidity, anti-osmotic and antibacterial effects of honey and also to efficacy of ultrasound for enhancement of delivering the honey as well as physical effects of ultrasound. Deissl and Frenkel,14 reported that IgM antibodies appear early in the course of an infection which is demonstrating IgM antibodies in patient’s serum which indicates recent infection and Fatahzadeh and Schwartz,15 demonstrated that IgG antibodies are predominantly involved in the secondary antibody response. In this study Immunological assays (ELISA) was used for detection of the presence of anti-bodies of the virus (IgG and IgM) and reflected the efficacy of application of honey phonophoresis by their highly significantly decrease after treatment. Previous studies agreed with this study and support the efficacy of honey therapy in the treating genital herpes simplex type II. Al-Waili;16 investigated the effect of raw honey, topically applied, on recurrent attacks of herpes lesions, labial and genital, and compared this with the effect of Acyclovir cream and he was concluded that topical honey application is safe and effective in the management of signs and symptoms of recurrent lesions, of labial and genital herpes. Honey is capable of reducing the associated symptoms by means of reducing inflammation. Honey has been shown to have antibacterial effects owing to its high osmolarity and low pH . Its low water activity inhibits microbial growth, particularly bacterial growth. When applied topically to wounds, water is drawn away from the wound by osmosis, helping to dry the infected tissue and inhibiting bacterial growth17,18 . Kwakman et al; 19 have reported on the role of sugar, hydrogen peroxide, methylglyoxal, and bee defensin-1 in the antibacterial properties of honey. In their study they show that the antibacterial effects of honey are reduced after the combined neutralization of these factors. Also the results of this study, showed that there were significant differences as regard to VAS, IgG, IgM, in group B (low intensity phonophoresis group) after intervention. This confirm the efficacy of low intensity laser therapy, this attributed to analgesic, anti-inflammatory and biostimulating effects of low intensity laser therapy. Previous studies agreed with this study and support the efficacy of low intensity laser therapy in the treating genital herpes simplex type II. Some studies confirmed the benefit of Low Level Laser Therapy in decreasing pain, improving wound healing compared to other treatment modalities like acyclovir20. Donnarumma et al; 21 have postulated a mechanism of action that laser irradiation “acts in the final stage of HSV-1 replication by limiting viral spread from cell to cell and that laser therapy acts also on the host immune response unblocking the suppression of pro-inflammatory mediators induced by accumulation of progeny virus in infected epithelial cells. Sanchez et al; 22 demonstrated that among treatment options, low-level laser therapy (LLLT) has shown promising clinical results as a longerlasting suppression therapy. Patients were symptom free for 17 months following initial treatment for recurrent simplex lesions with the laser. Schindl and Neumann23 found similar results in their LLLT study for the laser in delaying reoccurrence of the herpetic lesion outbreaks. The median recurrence-free interval in the laser-treated group was 37.5 wk (range: 2–52 wk) and in the placebo group 3 wk (range: 1–20 wk). VélezGonzalez et al 45 also discovered delays in reoccurrence of lesions after laser therapy.Marrotti et al 24 used a 660 nm wavelength laser, energy density of 120 J/cm², output power of 40 mW, during two minutes on spot and 4.8J of energy per spot on four spots. After 24 hours, the patients returned and then 3.8J/cm² and 15mW were applied to their lesions (the total dose was 0.6J). The same procedure was repeated after 72 hours and one week after. There were no significant side effects and herpetic lesions healed faster. De Carvalho RR et al; 25 reported a significant decrease in dimension of herpes labialis lesions and inflammatory edema using low level laser therapy. The reduction in pain level and monthly recurrences did not reach statistical significance To the best of our knowledge, there is no study compare the effect of honey phonophoresis versus low intensity laser therapy in treatment of herpes simplex type II. The results of this study showed that there were significant differences between honey phonophoresis and low intensity laser therapy after the treatment duration. Percentage of improvement in VAS, IgG, IgM, after intervention were 60%, 45%, 8%, respectively for group A while for group B the percentage of improvement in VAS, IgG, IgM, PCR after intervention were 82%, 66%, 56%, respectively. The limitations of our study were no control group included and no period of follow-up. Further studies including control group and follow-up are needed to further validate our findings.
The study concluded that low intensity laser was more effective than honey phonophoresis in the treatment of genital herpes type II.
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