Abstract of medical phd thesis: research on immune changes and treatment supporting efficacy of aloe vera cream al 04 in herpes zoster

In order to examine the efficacy of aloe in treating herpes zoster, we study the thesis:“Researchon immune changes and treament supporting efficacy of aloe vera cream AL-04 in herpes zo

M INISTRY OF EDUCATION AND TRAINING M INISTRY OF DEFENCE

108 IN STI TU TE OF C LI NI C A L M EDI C A L AN D P HA R M AC EU TI CA L SCI EN C ES

-

NGUYEN LAN ANH

RESEARCH ON IMMUNE CHANGES AND TREATMENT SUPPORTING EFFICACY

OF ALOE VERA CREAM AL-04 IN HERPES ZOSTER

Speciality: Dermatology Code: 62720152

ABSTRACT OF MEDICAL PHD THESIS

Hanoi – 2020

THE THESIS WAS DONE IN: 108 INSTITUTE OF CLINICA L MEDICA L AND PHA RMACEUTICAL SCIENCES

Supervisor:

1 Ass.Prof PhD Dang Van Em

2 PhD Bui Thi Van

Day Month Year

The thesis can be found at:

1 National Library of Vietnam

2 Library of 108 Institute of Clinica l Medica l and Pharmaceutical Sciences

3 Central Institute for Medical Science Infomation and Tecnology

HZ is associated with cellular immunodeficiency states, decline in the number and proportion of TCD4, CD16 + 56 The concentration of IgA, IgG and IgM ascends, peaks in week 2-3, then descends

Aloe vera cream AL-04 that contains Anthraquinon whichinhibits activity of Herpes simplex virustype 1 and 2, Acemannan has immunomodulation function and Glucomannanhelpshealing woundsrapidly In order to examine the efficacy of aloe in treating herpes zoster, we study the

thesis:“Researchon immune changes and treament supporting

efficacy of aloe vera cream AL-04 in herpes zoster"with following

purposes:

1 Surveyingrelated factors, clinical characteristics of herpes zoster thatareinpatient treated in the Department of Allergy- Dermatology, Central Military Hospital 108 from 6/2015- 6/2018

2 Determinatingchanges in humoral immunity (IgA, IgG and IgM) and cellular immunity (TCD3, TCD4, TCD8, CD19 and CD16+56) in blood of patients with herpes zoster before and after treatment

3 Evaluating the effectiveness of using aloe vera cream as supporting treatments in herpes zoster

Chapter 1 OVERVIEW 1.1 He rpes zoste r: Etiology, pathoge nesis, clinical presentations 1.1.1 Factors associate d with he rpes zoste r

-Prevalence: about 10-20% of adults are likely to suffer from HZ in their lives, whereas this rate in people over 85 of age is 50%

-Age: can occur at any age, but most likelytopeople in older age groups, especially to those who are above 50 years old

-Gender: The risk ofthe disease is higher to females, especially in elderly patients

-Immune status: People with immunodeficiency face a 20-100 times higher risk of suffering than normal people

1.1.2 Etiology

Varicella Zoster Virus (VZV) is a member of the Alpha herpes virus, w ith a diameter of 80-120 nm, molecular weight 80000 The double strainded DNA genome is covered by a 20-sided cube, followed by the capsid, a protein tergument seperates the capsid from the lipid envelope

1.1.3 Pathogenesis

The reactivated VZV in sensory ganglia causes herpes zoster Virus multiplies and spreads within the ganglion, causing neuronal necrosis and intense inflammation Then, the virus moves centrifugallyalong the sensory nerves, causing intense neuritis andinflammation to the skin, causing skin damages

-Pathogenesis of pain: peripheral nerves and ganglion neuritisdamaged triggers pain

1.1.4 Clinical prese ntations

-Basic lesions: erythematous plaques with vesicles and blistersthat arise in clusters along the peripheral nerve, stop in the middle of the body

- Functional symptoms: pain is varied, with various types of pain

-Complications: includingcutaneous complications, neurological complications (postherpetic neuralgia, cranial nerve damage, nerve palsies, encephalitis), vascular pathology, myelopathy, retinal necrosis

1.1.5 Subclinical fe atures

-Tzanck cell smear, PCR, direct immunofluorescent assay, viral culture, histopathology, serologic test,quantitating test of IgA, IgG and IgM

1.2 Immune changes

1.2.1 Ce llular immunity changes

Herpes zoster is associated with a decline in cellular immunity response, especially the number of TCD4 However, VZV also causes TCD4 cells to raise the production of activated cytokines TCD8, increase the number of TCD8 to destroy virus infected cells

CD19 is present in all B lymphocytes There have been no research in our country and in the world about changes of CD19 in shingles

Natural killer cells secreted IFN-γ, TNF-α, the interleukin (IL-10) very quickly and efficiently, play an important role in the immune response from the very early stage First response of the host body to VZV is the reaction of NK cells

1.2.2 Humoral immunity changes

IgG begins to grow rapidly from the 5th day, reaches the highest from the 9th day to the 23rd day and then began to decline IgA also begins to rise from the 5th day, peaksafter 6-23 days, then descents IgM is discovered from the 9th day, but only exists briefly

1.3 Tre atme nt

-Systemic treatments: antiviral drugs, analgesics, tricyclic antidepressants, antiepilepsy, oxycodone, glucocorticoid, antihistamines, antibiotics

-Topical treatment: Acyclovir cream, antiseptic solutions: Yarish, Jarish, reservoir

-Medicines with plant origin that are effective on zoster: Capsaicin, licorice, honey

1.4 Tre atme nt e fficacy of aloe cre am AL-04

-Some of the main mechanisms of aloe vera: healing woundrapidly, anti-infection, anti-inflammatory, immunomodulation, antibacterial -Some primaryeffects of aloe vera in zoster: local immunomodulation, anti-inflammatory, analgesic, antiseptic

-Some research of aloe vera cream in the treatment of viral skin diseases: treatment of herpes simplex type 1 and 2

Chapter 2 SUBJECTS AND METHODS 2.1 Subje cts and mate rial rese arch

2.1.1 Research subjects

405 patients diagnosed withHZthat are treated as inpatient in the department of Allergy- Dermatology, Central Military Hospital

108

-Diagnostic crite ria:

+ Clinical symptoms: vesicles, blisters that arise in clusters

from the erythematous plaque along the peripheral nerve, on one side

of the body

+ Functional symptoms: pain in various levels

+Other symptoms: fever, swollen local lymph nodes, insomnia, peripheral nerve damage

-Patient se lection crite ria:

Purpose 1: Surveying involved factors, clinical characteristics of

herpes zoster:all HZ patients of all ages, both genders, agreed to participate in the study

Purpose 2: Determining changes in humoral and cellular immunity

in blood of HZpatients before and after treatment

+ Group of herpes zoster (including research group-RGand control group-CG of purpose 3): 62 patients with HZ onset ≤ 5 days (from skin lesions); age ≥ 18; did not use any drugs previously such

as corticoid, zoster treatment drugs,are not suffering from immunodeficiency diseases or HIV/AIDS; follow the treatment process and agreed to participate in the study

+ The control group (the healthy people): 30 healthy people who havedone health examination in Central Military Hospital 108,

withthe same age and gender with the patients group

Purpose 3: Evaluating the effectiveness of supporting treatment of

aloe vera cream AL-04 in herpes zoster

+ Patients with HZ onset ≤ 5 days; age ≥ 18; did not use any

of drugs previously such as corticoid, zoster treatment drugs,are not suffering from immunodeficiency diseasesorHIV/AIDS; no ulcerative and necrotic les ions, no contraindications to drugs that used in the research; agreed to participate in the study; follow the treatment process

The patient is randomly divided into 2 groups: The research

group (RG): 32 patients and the control group (CG): 30 patients

- Exclusion crite rias:

Purpose 1: The patient does not agree to participate in the study Purpose 2: Patientsbelow 18 years old, onset of the disease over 5

days (from the date of the lesions), have immunodeficiency disease, have contraindication for drugs that used in the research, do not agree to participate in the research or not follow the right treatment procedure

Purpose 3: As purpose 2

2.1.2 Research mate rials

-Aloe vera cream Al-04

-Ayclovir cream 5% from Korea

-Chemicals for examination:

Becton-Dickinson's reagents, flow cell counting solutions on the Callibur FASC, PBS buffer, mono clone antibodies CD3-ECD, CD4-

PE, CD8-FITC, CD45-PC5, cell counting solution on the ADVIA 2120i, erythrocyte separatial solution

-Tes t machines:

-Autochemistry machine ADVIA 2120i, machine FASC Callibur,

AU 640

2.2 Research me thodology

2.2.1 Study des ign

-Purpose 1: cross-sectional, prospectivestudy

-Purpose 2: cross-sectional, prospective, comparativestudy

-Purpose 3: clinical trials, randomized controlled, comparative and prospectivestudy

2.2.2 Study sample size

-Purpose 1: Convenient sample, n = 405 patients

-Purpose 2: Calculate the sample size according to the WHO’s formula, RG: 62 patients, CG: 30 patients, same age and gender -Purpose 3: Calculate the sample size according to the clinical trials

of WHO: RG: 32 patients, CG: 30 patients The patient is dividedinto

2 groups by parity selecting and same age, sex and disease degree

HZ group (RG group and CG of purpose 3):

+ Select patients who have suitable standards for the group of diseases (namely RG: 32 patients and ĐC: 30 patients of target 3) + Do the first blood test (before treatment) including: Counting the number of TCD3, TCD4, TCD8, CD19 and CD16 + 56 (according to each blood sample), quantitative IgA, IgG and IgM

+ Patient receiving treatment for 20 days

+ Do the second blood test (after treatment) including: Counting the number of TCD3, TCD4, TCD8, CD19 and CD16 + 56 (according toeach blood sample), quantitative IgA, IgG and IgM

Healthy group (CG): 30 healthy people chosen in the health

examination at Military Central Hospital 108: have the same age and gender with RG, do the blood test only one time, count the number

of TCD3, TCD4, TCD8, CD19 and CD16 + 56, quantitative IgA IgG and IgM

-Evaluating the e ffe ctive ness of using aloe ve ra cre am AL-04 as supporting tre atme nts in he rpes zoste r:62 patients divided into 2

Also both groups take the same drugs: Pregabalin 75mg x 2 tablets/day x 20 days, desloratadin 5 mg x 1 tablet/day x 20 days, vitamin 3B x 2 tablets/day x 20 days, rotundin 30 mg x 1 tablet/day x 20 days

Evaluating results: After 20 days with the following cr iterias:

clinical symptoms (basic lesions), pain symptoms, treatment results (good, quite good, moderate, bad), unexpected effects (redness of the skin, itching and dryness of the skin)

2.2.4 Techniques use d inthe research

-The rules of hands of Blokhin and Glumov: One patient's hand

1-2 Least painful Stressful expression

3-4 Rather painful Grimace expression

5-6 Mediun painful Mourning, deploring

7-8 Severe painful Crying

9-10 Terrible painful Miserably

-Classification of disease degrees:

+ Mild degree: Area of damage: < 1%ofbody area (BA); Likert ≤ 4;

No local lymph nodesswollen; no peripheral nerve damage; sleep disturbance: little; physical condition: no fever, not tired

+ Medium degree: Area of damage: 1-2% BA; Likert: 5-6; local lymphadenitis: yes or no; no peripheral nerve damage; sleep discontinuity: little; physical condition: no fever, fatigue or not + Severity degree: lesion ≥ 2% BA; Likert ≥ 7; local lymphadenitis: yes or no; may have peripheral nerve damage; sleep discontinuity; physical condition: fever or not

-The techniques of immune and cellular immunity tests:

-Count cell TCD3, TCD4, TCD8, CD19, CD16 + 56:

Each patient take 2 ml of venous blood Countthe cell number and cell components of peripheral blood with automatic hematology machine ADVIA 2120i Determination of the number and proportion of T-lymphocytes by the flow cytometry analysis technique on Callibur FACS device For each blood sample, the

machine will give 5 immune indexs as the number of TCD3, TCD4, TCD8, CD19 and CD16 + 56

-Quantitative of Ig (A, G, M): Quantitative Ig in the patient's blood

by immuno turbidity meter

The patient is taken 2 ml of blood,centrifugal turn 4000 rounds for 5 minutes, separating the serum and automatic analysis on the AU640 machine

2.2.5 Study crite rias

- Purpose 1: Age, gender, time of having disease, time of prodome,

treated drugs; basic lesions, lesion area; pain: according the Likert score; accompanied symptoms: fever, insomnia, local lymph nodes swollen, nerve damage

- Purpose 2: Number of TCD3, TCD4, TCD8, CD19, CD16 + 56.;

Quantitative concentrations of IgA, IgG and IgM; Relation between TCDand Ig with clinica symptoms

- Purpose 3: Crusty time, time of crust over, scar status, pain

symptoms, treatment result assesment, unexpected effects

2.2.6 Method of res ults evaluation

-Good:skin healedwithout scar; pain: Out of pain, Likert = 0; no sequela; quality of life: does not affect

-Quite good:skin healedwithout scar; pain: reduced a lot, Likert ≤ 4;

no sequela; quality of life: affected just a little

-Medium: skin healedwithout scar; pain: reduced a little, Likert = 6; no sequela; quality of life: affected relatively

5 Bad:skinunhealedor heal with bad scars; pain: a lot, Likert ≥ 7; sequela: may be peripheral nerve damage; quality of life: affectedmany

2.2.7 Data processme nt

Use the SPSS 18 software with commonly used statistical tests

STUDY DESIGN

Chapter 3 RESEARCH RESULTS

3.1 Surve ying involve d factors, clinical characte ristics of he rpes zoste r

Conclusion: Results at table 3.2 show that the group of

patients over 70 age occupies the highest rate (36%)

Conclusion: The most common location of the lesion is the

intercostal 39.8%, followed by 31.9% head, face and neck

Conclusion: The most common lesion is vesicles that make

up 98.1%, followed by erythematous plaque 89.1%

Table 3.13: Relative between disease degree and age (n = 405)

Conclusion: There is a connection between disease degree

and age, with p< 0.05, the higher age, the heavier the shingles

Table 3.15: Relation between disease degree and damaged area (n = 405)

Dise ase degree

Conclusion: The percentage of mild and medium patients in

group with 1% damaged area is lowest, the incidence of severe patients in group 2% damaged area is highest, statistically significant difference, with p< 0.01

3.2 Immunity changes in HZ

3.2.2 Ce llular immunity changes in HZ

TCD between zoster group and healthy group

Table 3.18: Comparison of the TCD cell count of 2 groups

TCD Zos te r group

(n=62)

X ± SD

He althy group (n=30)

X ± SD

p

TCD3 1230,9 ± 670,8 1334,4±384,7 >0,05 TCD4 669,5 ± 355,5 682,9±240,0 >0,05 TCD8 477,8 ± 330,1 527,5±255,4 >0,05 CD19 265,5 ± 180,1 261,8±201,3 >0,05

CD16+56 252,7 ± 199,7 458,3±329,3 <0,05

Conclusion: CD16 + 56 of the research group is markedly

reduced compared to the healthy group with p < 0.05