Clinical efficacy of topical docosanol 10% cream for herpes simplex labialis: A multicenter, randomized, placebo-controlled trial.

BACKGROUND: Recurrent herpes simplex labialis (HSL) occurs in 20% to 40% of the US population. Although the disease is self-limiting in persons with a healthy immune response, patients seek treatment because of the discomfort and visibility of a recurrent lesion. OBJECTIVE: Our purpose was to determine whether docosanol 10% cream (docosanol) is efficacious compared with placebo for the topical treatment of episodes of acute HSL. METHODS: Two identical double-blind, placebo-controlled studies were conducted at a total of 21 sites. Otherwise healthy adults, with documented histories of HSL, were randomized to receive either docosanol or polyethylene glycol placebo and initiated therapy in the prodrome or erythema stage of an episode. Treatment was administered 5 times daily until healing occurred (ie, the crust fell off spontaneously or there was no longer evidence of an active lesion) with twice-daily visits. RESULTS: The median time to healing in the 370 docosanol-treated patients was 4.1 days, 18 hours shorter than observed in the 367 placebo-treated patients (P =.008; 95% confidence interval [CI]: 2, 22). The docosanol group also exhibited reduced times from treatment initiation to (1) cessation of pain and all other symptoms (itching, burning, and/or tingling; P =.002; 95% CI: 3, 16.5); (2) complete healing of classic lesions (P =.023; 95% CI: 1, 24.5); and (3) cessation of the ulcer or soft crust stage of classic lesions (P <.001; 95% CI: 8, 25). Aborted episodes were experienced by 40% of the docosanol recipients versus 34% of placebo recipients (P =.109; 95% CI for odds ratio: 0.95, 1.73). Adverse experiences with docosanol were mild and similar to those with placebo. CONCLUSION: Docosanol applied 5 times daily is safe and effective in the treatment of recurrent HSL. Differences in healing time compared favorably with those reported for the only treatment of HSL that has been approved by the Food and Drug Administration.

The antiviral drug docosanol as a treatment for Kaposi's sarcoma lesions in HIV type 1-infected patients: a pilot clinical study.

Docosanol inhibits a broad spectrum of lipid-enveloped viruses in vitro including HSV-1, HSV-2, VZV, CMV, HHV-6, and HIV-1. These observations led us to conduct a pilot clinical study with docosanol 10% cream as a topical treatment for Kaposi's sarcoma (KS) in HIV-1-infected patients. In this open-label study 28 cutaneous KS lesions in 10 HIV-1-infected patients were treated topically five times daily for 4 weeks with evaluation of lesion characteristics of area, edema, and color. All patients elected to enroll in an extended treatment protocol and continued to treat for up to 35 weeks. Within 28 days, 2 of 10 patients exhibited a partial response based on standardized criteria exhibiting 74 to 83% reductions in total target lesion areas. With extended treatment, a partial response was exhibited in two additional patients where total target lesion area was reduced by 52% in one patient and target lesions in another patient that had been large, swollen, and painful at study initiation were no longer visible. No patient experienced disease progression or signs of visceral disease. The average percent decrease in lesion area for all target lesions was 20% (p < 0.01). A patient's response to therapy appeared to be independent of anti-HIV regimen, HIV viral load, or previous KS treatments. These results suggest that docosanol merits further investigation as a potential topical therapy in the treatment of AIDS-associated Kaposi's sarcoma lesions.

Topical application of docosanol- or stearic acid-containing creams reduces severity of phenol burn wounds in mice.

Because of their reported antiviral and anti-inflammatory activities, cream formulations containing n-docosanol (docosanol) or stearic acid were tested for effects on chemically-induced burns in mice. In this model, injury was induced by painting the abdomens of mice with a chloroform solution of phenol. This was followed by the topical application of test substances 0.5, 3, and 6 h later. Progression of the wounds was assessed by a single evaluator after 8 h, using a numerical score of gross morphology. Docosanol- and stearic acid-containing creams substantially and reproducibly lessened the severity and progression of skin lesions compared to untreated sites with a 76% and 57% reduction in mean lesion scores, respectively. Untreated wounds appeared red and ulcerated; docosanol cream-treated wounds showed only slight erythema.

The anti-herpes simplex virus activity of n-docosanol includes inhibition of the viral entry process.

n-Docosanol-treated cells resist infection by a variety of lipid-enveloped viruses including the herpesviruses. Previous studies of the mechanism of action demonstrated that n-docosanol inhibits an event prior to the expression of intermediate early gene products but subsequent to HSV attachment. The studies reported here indicate that n-docosanol inhibits fusion of the HSV envelope with the plasma membrane. Evidence suggests that antiviral activity requires a time-dependent metabolic conversion of the compound. Cellular resistance to infection declines after removal of the drug with a t1/2 of approximately 3 h. Reduced expression of viral genes in n-docosanol-treated cells was confirmed by a 70% reduction in expression of a reporter gene regulated by a constitutive promoter inserted into the viral genome. Inhibited release in treated cells of virion-associated regulatory proteins--an immediate post entry event--was indicated by a 75% reduction in the expression of beta-galactosidase in target cells carrying a stably transfected lacZ gene under control of an HSV immediate--early promoter. Finally, the fusion-dependent dequenching of a lipophilic fluorescent probe, octadecyl rhodamine B chloride, inserted into the HSV envelope was significantly inhibited in treated cells. Inhibition of fusion between the plasma membrane and the HSV envelope, and the subsequent lack of replicative events, may be the predominant mechanism for the anti-HSV activity of n-docosanol.

Analysis of the promoter elements necessary for IL-4 and anti-CD40 antibody induction of murine Fc epsilon RII (CD23): comparison with the germline epsilon promoter.

IL-4 and CD40 ligand stimulate transcription of CD23 (Fc epsilonRII) in B cells and are necessary for the expression of germline epsilon mRNA and production of IgE. Because in vivo studies have shown that the Fc epsilonRII is involved in the regulation of IgE, a study was initiated to compare how IL-4 and engagement of CD40 up-regulate the Fc epsilonRII and epsilon genes. Herein, we describe the preparation of a series of linker-scanning mutants that cover the IL-4 response region in the murine Fc epsilonRII promoter, and their function when transfected into M12.4.5 and M12.4.1 B lymphoma cell lines. Several discrete elements were found to be necessary for IL-4 induction of the Fc epsilonRII gene, some of which have homology with the binding sites of known transcription factors, including NF-IL-4 and NF-kappaB. In contrast, the response element for anti-CD40 (plus IL-4) mapped to a single discrete sequence, a NF-kappaB-like site. Aligning the Fc epsilonRII and germline epsilon promoters in the region that is highly conserved between the human and mouse homologues of both genes reveals a high degree of identity, particularly within discrete clusters. Comparing the function of linker-scanning mutants of the Fc epsilonRII promoter with a similar report for germline epsilon shows that both genes require at least two homologous and similarly located DNA elements in their promoters for a full IL-4 induction. Moreover, the similar response of Fc epsilonRII and epsilon promoter-driven chloramphenicol acetyl transferase plasmids to several cytokines and other agents suggests that the two proximal promoter regions are activated by a similar cassette of factors.

n-Docosanol 10% cream in the treatment of recurrent herpes labialis: a randomised, double-blind, placebo-controlled study.

n-Docosanol has been shown to have antiviral activity. To demonstrate the efficacy of n-docosanol 10% cream in the treatment of recurrent herpes labialis, a randomised, double-blind, parallel group, placebo-controlled study was undertaken in 63 patients. In a crossover extension, 22 of the patients used the alternative treatment for a further episode. A total of 98 episodes were evaluated. Application of n-docosanol 10% cream early in the prodromal or erythema stage of a recurrent episode of herpes labialis shortened mean healing time by approximately 3 days, as compared to late treatment with n-docosanol 10% cream and early or late treatment with the placebo. The crossover study revealed that late treatment with n-docosanol 10% cream significantly reduced mean healing time compared to placebo. Treatments were well tolerated.

Anti-herpes simplex virus activity of n-docosanol correlates with intracellular metabolic conversion of the drug.

The 22-carbon fatty alcohol, n-docosanol, exhibits in vitro antiviral activity against several lipid-enveloped viruses including herpes simplex viruses 1 and 2 by a mechanism that interferes with normal viral entry into target cells. We previously reported that mammalian cells incorporate significant quantities of radiolabeled n-docosanol. Herein, we report that cells extensively metabolize the internalized fatty alcohol. This is evidenced by incorporation of up to 60% of cell-associated radiolabel into phospholipids that copurify with phosphatidylcholine and phosphatidylethanolamine. Analysis by chemical (Vitride) reduction suggests that a significant portion of n-docosanol is oxidized to n-docosanoic acid and then incorporated as an acyl group on polar lipids. A measurable amount of radiolabel, however, is resistant to Vitride reduction, consistent with incorporation of n-docosanol into ether lipids. The rate and extent of metabolic conversion of n-docosanol vary with the cell type and surfactant used to suspend the compound. Furthermore, the anti-HSV activity of n-docosanol is quantitatively proportional to the amount of metabolism observed. These findings suggest that the anti-HSV activity of n-docosanol involves cellular uptake and metabolism of the drug.

IL-10 stimulates murine antigen-driven antibody responses in vitro by regulating helper cell subset participation.

The effects of IL-10 on in vitro antigen-driven murine antibody responses and helper cell IL-4 and IFN-gamma secretory capacity were investigated. Low antigen concentrations stimulated high responses in all antibody isotypes examined; IgD was not assayed. Under these conditions, exogenous IL-10 minimally potentiated synthesis of antigen-specific IgM, IgG1, IgG2a, IgG2b, IgG3, and IgA, but inhibited antigen-specific IgE secretion. High antigen levels stimulated antigen-specific IgM, IgG2a, and IgG2b responses, but inhibited synthesis of all other isotypes. In high antigen cultures, IL-10 augmented secretion of antigen-specific antibody in all isotypes except IgE. Essentially all of the antibody produced in the presence of high or low antigen concentrations was antigen-specific. Exogenous IL-10 substantially stimulated production of antigen-nonspecific antibody in all isotypes except IgG3. IL-10 allowed for greater Ig+ cell yield; comparable numbers of CD4+ and CD8+ cells were observed in the presence or absence of IL-10 in culture. The stimulatory effects of IL-10 for in vitro antibody responses were observed during a limited period of time after in vivo antigen priming of the responding cell populations. In contrast, IL-10 inhibited IgE synthesis at all time points tested. Low concentrations of antigen maintained the in vitro capacity of helper cells to secrete IL-4, while high antigen concentrations did not. Exogenous IL-10 potentiated IL-4 secretory capacity in high antigen cultures. The capacity for IFN-gamma secretion was comparable in high and low antigen cultures and exogenous IL-10 significantly inhibited such capacity under both sets of conditions. We conclude that IL-10 is generally stimulatory for murine antibody responses in vitro, with the possible exception of antigen-specific IgE. Such stimulatory effects appear to reflect increased activity of type 2 helper cells with concurrent decrease in type 1 helper cell activity.

Regulation of the murine Fc epsilon RII (CD23) gene. Functional characterization of an IL-4 enhancer element.

The murine B cell IgE receptor (Fc epsilon RII, CD23) has been implicated in various functions including IgE regulation, Ag presentation, and B cell differentiation/activation. We have undertaken a series of studies to identify promoter sequences that are important for the constitutive and IL-4-induced expression of the murine Fc epsilon RII in M12.4.5 B lymphoma cells. By use of RNase protection analysis it was established that murine splenic B cells and M12.4.5 cells predominantly express the Fc epsilon RIIa form and that this receptor subtype accounts for the vast majority of IL-4-induced Fc epsilon RII mRNA in B cells. A 101-bp segment of the murine Fc epsilon RII proximal promoter coupled to a heterologous SV40 promoter was found to impart IL-4 inducibility in reporter assays. Removal of either 10 bp from the 5' end or 17 bp from the 3' end of this 101-bp fragment substantially reduced the IL-4 response. Both of these terminal deletions removed sequences that share homology with established IL-4 response elements of MHC class II and Ig (gamma 1 and epsilon) heavy chain genes. In addition, near the center of this 101-bp fragment lies a sequence that is highly homologous with NF-kappa B/LPS response elements previously identified upstream of the A alpha gene. DNA fragments containing this sequence together with one of the putative IL-4 response elements were able to impart a small LPS/IL-4 response in M12.4.5 cells. These results suggest that IL-4 and LPS induction of murine B cell Fc epsilon RII expression is mediated by a complex of transcription factors.

Identification of a T cell membrane protein possibly involved in IL-4-induced B cell immunoglobulin class switching to IgE.

The murine T cell hybridoma line, MBI-1.15, secretes a 17-kDa protein which decreases binding activity of the CD23 molecule for its natural ligand, IgE. This protein, denoted epsilon receptor-modulating protein (epsilon RMP), was previously characterized and shown to be a novel serine protease. The present studies show that, in addition to modulating CD23, epsilon RMP costimulates with IL-4 the de novo synthesis and secretion of IgE and IgG 1 by cultured B cells. Since such costimulating activity is reminiscent of a similar synergism with IL-4 previously observed with cell membranes from activated T cells, we examined isolated membranes from the epsilon RMP-producing MBI-1.15 T cell line for comparable activity; indeed, as shown herein, MBI-1.15 cell membranes do exhibit this synergism. Furthermore, we show that a monoclonal antibody (mAb), 2E5B, specific for the 17-kDa soluble form of epsilon RMP, blocks the costimulating activities of both the soluble epsilon RMP and MBI-1.15 T cell membranes for IL-4-induced de novo synthesis of IgE by cultured B cells. This anti-epsilon RMP mAb also detects a 36-kDa membrane-bound protein species which appears to be related to soluble epsilon RMP by immunochemical criteria. The membrane-bound proteins, present on MBI-1.15 T cells, induce germ-line IgE heavy chain transcripts (I epsilon) in I-29 B cells independently of IL-4, and this inductive event is also specifically blocked by the 2E5B anti-epsilon RMP mAb. These findings suggest that T cell membrane-bound epsilon RMP molecules are crucial proteins involved in contact-dependent B cell class switching in the course of IgE biosynthesis. Finally, both IL-4 and epsilon RMP induce I epsilon on I-29 B cells, but neither molecule by itself can induce class switching to IgE synthesis by splenic B cells. This clearly suggests that both epsilon RMP and IL-4 have another important molecular effect (which may or may not be identical) on B cells, that is essential for class switching, but only when both molecules are present simultaneously is the complete mechanism of class switching manifested.

Biphasic effect of kallikrein on IgE and IgG1 syntheses by LPS/IL-4-stimulated B cells.

epsilon receptor modulating protein (epsilon RMP) was identified and purified in our previous studies as a murine T cell-derived soluble 17-kDa chymotryptic serine protease which suppresses avidity of binding between IgE and CD23 (low affinity Fc receptor for IgE) without decreasing the quantitative expression of the CD23 molecule. Some, but not all, of the other known soluble serine proteases showed epsilon RMP-like CD23-modulating activities. Further studies indicated that epsilon RMP exists not only as a soluble protein but also as a 36-kDa T-cell surface form. Both soluble and membrane-bound epsilon RMP can induce purified splenic B cells to secrete IgE in the presence of IL-4 even without lipopolysaccharide (LPS). In this study, therefore, we have tested effects of several known serine proteases on Ig production in vitro and have found that: (i) coculture of splenic B cells in the presence of LPS and IL-4 with serine proteases which have epsilon RMP-like substrate specificity, such as kallikrein and alpha-chymotrypsin, results in a significant increase of IgG1 and a slight increase of IgE secretion at low concentrations, and significant suppression at high concentrations in an isotype-selective manner; and (ii) the effects of these proteases are blocked by phenylmethylsulfonyl fluoride but not by indomethacin, suggesting that serine protease activity but not prostaglandin E2 is involved. The biological significance of the possible involvement of serine proteases on Ig class switching is discussed.

Antigen concentration determines helper T cell subset participation in IgE antibody responses.

A recently developed in vitro system for antigen-stimulated primary and secondary murine IgE antibody responses has been used to define (a) the relative participation of the Th1 and Th2 cell-derived lymphokines IFN-gamma and IL-4, respectively, in such responses, and (b) the role of antigen concentration in determining functional helper T cell activity. These studies confirm that IL-4 and IFN-gamma exert regulatory effects on IgE synthesis, but the nature and extent of their respective effects on primary and secondary IgE responses differ. Thus, primary IgE responses are considerably more sensitive to and dependent on IL-4 than are secondary IgE responses since (1) anti-IL-4 monoclonal antibody totally inhibited primary IgE responses, but only partially affected secondary responses; and (2) exogenously added IL-4 could stimulate primary IgE responses to optimal antigen concentrations, but had no effect on secondary IgE production. Likewise, antigen-stimulated primary IgE responses are about eightfold more sensitive than are secondary responses to the inhibitory effects of IFN-gamma. Studying the effect of antigen dose on the quantity of IgE antibody produced revealed that although IFN-gamma could be detected by ELISA in cultures exhibiting high-dose antigen-dependent diminution of IgE production, anti-IFN-gamma monoclonal antibody could not reverse this phenomenon. Thus, IFN-gamma is not solely responsible for decreased IgE synthesis associated with high-dose antigen exposure. IL-4 activity was detected in the fluid from cultures stimulated with low, but not high, levels of antigen. Moreover, addition of exogenous IL-4 restored IgE production to normal levels in cultures exposed to high antigen concentrations. Therefore, it appears that high levels of antigen result in selective stimulation of Th1 cells which produce IFN-gamma, and diminished activation of IL-4-producing Th2 cells. These results help explain observations regarding the influence of antigen dose on the generation of experimental and clinical IgE antibody responses in vivo.

B cell sensitivity to IgE-suppressive activity of IFN-gamma is polymorphic and controlled by a non-H-2-linked gene.

It has been suggested that at least two distinct genetic factors are involved in developing atopic diseases. One is the major histocompatibility complex which controls antigen-specific polymorphism of IgE antibody responses and the other is an unidentified factor(s) which controls isotype selection, i.e., class switching to IgE. It is conceivable that both expression of and sensitivity to lymphokines that play central roles in controlling IgE biosynthesis may be involved in the latter polymorphism. To explore this possibility, we have examined the sensitivities of several mouse strains to interleukin (IL)-4 and interferon-gamma (IFN-gamma). The results show that (1) the sensitivity to IgE-suppressive activity of IFN-gamma, but not to the IgE-enhancing activity of IL-4, is polymorphic (e.g., C57BL/6 is 8- to 16-fold more sensitive than BALB/c to IFN-gamma); (2) F1 of these two strains (CByB6F1) are BALB/c type and H-2 congenic mice of d haplotype with B6 background are C57BL/6 type, suggesting that low sensitivity is a non-H-2-linked dominant trait; (3) the polymorphism is determined at B cell levels; and (4) sensitivity to IFN-gamma is not associated with mRNA expression of IFN-gamma receptors (R) by B cells. These data collectively indicate that BALB/c mice have a non-H-2-linked gene which decreases B cell sensitivity to IFN-gamma, but the gene effect is not associated with the expression of IFN-gamma R mRNA on B cells. The possible biological significance of the non-H-2-linked gene is discussed.

B cell activator. Effects on B cell expression of CD23, proliferation, and antibody secretion.

The studies herein describe a B cell hybridoma-derived, low m.w. (less than 1000 Da), hydrophilic mediator denoted B cell activator (BCA). BCA stimulates B cell expression of IgE-specific FcR (Fc epsilon RII or CD23) in a manner similar to IL-4. However, BCA can be readily distinguished from IL-4 because it does not 1) enhance B cell Ia expression; 2) bind 11B11 anti-IL-4 mAb; or 3) elicit superinduction of Fc epsilon RII expression or IgE production in cultures of LPS-activated B cells. Moreover, BCA is considerably more mitogenic than IL-4 for LPS-activated B cells and, in contrast to IL-4, lacks mitogenicity for anti-mu-activated B cells. BCA can enhance IgG2b and IgG3 production by LPS-activated B cells, responses that are suppressed by IL-4. BCA alone did not stimulate IgE and IgG1 production by LPS-activated B cells, but exerted synergistic activity when combined with IL-4 in stimulating secretion of these antibody isotypes. Finally, secondary Ag-driven IgG1, IgE, and IgA antibody responses can be stimulated by BCA in vitro. Thus, BCA appears to be a novel mediator with broad B cell activation properties.

Antiviral activity of 1-docosanol, an inhibitor of lipid-enveloped viruses including herpes simplex.

This article reports that 1-docosanol, a 22-carbon-long saturated alcohol, exerts a substantial inhibitory effect on replication of certain viruses (e.g., herpes simplex virus and respiratory syncytial virus) within primary target cells in vitro. To study the basis for its viral inhibitory activity, a suspension of 1-docosanol was formulated in an inert and nontoxic surfactant, Pluronic F-68; this suspension exerted potent inhibitory activity on the ability of susceptible viruses to infect cultured target cells. Susceptible viruses included wild-type herpes simplex viruses 1 and 2 as well as acyclovir-resistant herpes simplex virus 2 and also respiratory syncytial virus--all of which are lipid-enveloped. In contrast, nonenveloped poliovirus was not susceptible to the inhibitory action of 1-docosanol. Although the precise mechanism has yet to be defined, current evidence suggests that 1-docosanol inhibits viral replication by interfering with the early intracellular events surrounding viral entry into target cells. It is possible that interaction between the highly lipophilic compound and components of target cell membranes renders such target cells less susceptible to viral fusion and/or entry. If this mechanism proves to be correct, 1-docosanol may provide a broad spectrum activity against many different viruses, especially those with lipid-containing envelopes.

Collagen-induced arthritis in mice. Relationship of collagen-specific and total IgE synthesis to disease.

The relationship between production of IgE and collagen-induced arthritis in mice was examined. Collagen-specific IgE was produced as a consequence of immunization of DBA/1 mice with chicken type II collagen emulsified in CFA. We observed a rise in collagen-specific IgE antibody levels at the onset of CIA clinical and histologic signs in DBA/1 mice. This rise in IgE paralleled that of IgG2a anticollagen antibodies, an isotype implicated in the pathogenesis of CIA by other laboratories. The collagen-specific IgE contained in the plasma of mice with CIA could arm basophils for Ag- (collagen) dependent degranulation. Collagen-specific IgE may thus contribute to CIA by promoting mast cell degranulation in the synovia of susceptible mice immunized with chick type II collagen; but, further work is required to establish such a role for IgE in CIA. However, genetic differences in disease susceptibility could not be accounted for by quantitative differences in collagen-specific IgE production. Further, comparable levels of IgE anticollagen antibodies were observed in animals with active CIA and after spontaneous remission, thereby confirming that the presence of such antibodies is insufficient for disease. Total IgE levels peaked just before spontaneous remission indicating active production of IL-4. IL-4 was administered to animals with CIA to determine if this lymphokine could be involved in the remission process. IL-4 facilitated remission of CIA. Enhanced total IgE production may thus be a marker for activation of Th2 cells that produce lymphokines such as IL-4 and IL-10, factors that may be involved in the spontaneous remission process.

The murine epsilon receptor modulating protein: a novel serine protease which modulates CD23 binding of IgE.

In our recent previous studies, we have identified and purified a murine 17-kDa protein which diminishes the avidity of binding between IgE and CD23 (low-affinity Fc receptor for IgE) without decreasing the quantitative expression of the CD23. The protein was thus designated epsilon receptor modulating protein (epsilon RMP). In this study, we have further characterized this protein and have found that (i) epsilon RMP is inactivated by phenylmethylsulfonyl fluoride and decomposes N,alpha-benzyloxycarbonyl-L-lysine thiobenzyl ester, as well as N-succinyl-Ala-Ala-Pro-Phe p-nitroanilide; (ii) epsilon RMP does not work directly on B cells but requires CD4+ T cells to decrease functional expression of CD23 on B cells; and (iii) the partial internal amino acid sequence of epsilon RMP, obtained by using in situ cyanogen bromide cleavage on polyvinylidene difluoride membrane is unique. These data thus clearly demonstrate that epsilon RMP is a novel serine protease controlling the functional expression of CD23 through the participation of CD4+ T cells. Mechanisms of the involvement of CD4+ T cells are discussed.