Immune Response and General Immune Health in Subjects Infected With Herpes Simplex Virus Type 1 (HSV-1)

Primary oral infection with the herpes simplex virus (HSV) typically occurs at a young age,
is asymptomatic, and is not associated with significant morbidity. After primary oral
infection, HSV may persist in a latent state in the trigeminal ganglion and later reactivate
as the more common herpes labialis, or "cold sores." Common triggers for reactivation are
well known and include ultraviolet light, trauma, fatigue, stress, fever, inflammation, and
menstruation. These lesions affect up to 45 percent of the U.S. population. They classically
manifest as a well-localized cluster of small vesicles along the vermilion border of the lip
or adjacent skin. The vesicles subsequently rupture, ulcerate, and crust within 24 to 48
hours. Spontaneous healing occurs over seven to 10 days. In immunocompetent patients, herpes
labialis usually is mild and self-limited. However, pain, swelling, and cosmetic concerns may
prompt physician consultation. Orally administered antiviral agents, such as acyclovir
(Zovirax) or valacyclovir (Valtrex), have a modest clinical benefit if initiated during the
prodrome. Topical treatment with 1% penciclovir cream (Denavir) may reduce healing time and
pain slightly, even if initiated after the prodrome. However, reduction in healing time with
systemic or topical agents is modest. Squaric acid dibutyl ester (SADBE) is a topical
immunotherapeutic agent used in the treatment of verruca vulgaris and alopecia areata. During
a recent FDA Compounding Advisory Committee Meeting, it was recommended that squaric acid
dibutylester be included on the list of bulk drug substances allowed for use in compounding
under section 503A of the Federal Food, Drug, and Cosmetic Act. And SADBE has now been so
listed under section 503A. A study completed by Lee et al of 29 patients with recalcitrant
warts demonstrated complete clearance in 69% of patients with application every 2-4 weeks.
Silverberg et al showed a complete clearance in 58% of patients (n=61) when SADBE was applied
3 times weekly. SADBE has also been used with some success in the treatment of alopecia
areata. In a review of the literature, Rokhsar et al noted a 50% to 60% success rate of SADBE
in use for hair re-growth in this population. SADBE has been reported to cause eczema,
lymphadenopathy, blistering, allergic contact dermatitis, skin hypopigmentation, a burning
sensation after application, and systemic reactions including fever and arthralgias. A study
completed by Oglio et al of eight patients treated with SADBE for warts noted only mild and
well tolerated side effects of erythema, desquamation, cutaneous edema, pruritus, burning,
and pain. SADBE induces a delayed-type hypersensitivity response which in warts, is believed
to induce the killing of virally infected cells by cytotoxic lymphocytes. This influx of
lymphocytes into lesional Page 4 of 14 tissue may also enhance the recognition and processing
of viral antigens, leading to clonal expansion of effector cells. It is hoped that SADBE will
offer subjects a safe and effective therapeutic option to decrease the frequency and severity
of future herpes labialis outbreaks through these mechanisms. A placebo-controlled clinical
study completed at Massachusetts General Hospital showed that squaric acid prevented
recurrence of herpetic lesions. The effect of SADBE of delaying new herpes labialis outbreaks
was highly significant (p<0.01) as compared to placebo.

Inclusion Criteria:

1. Age ≥18 and <65

2. Positive test for IgG against herpes simplex virus type 1 (HSV-1).

3. Groups A and B only: Clinical diagnosis of herpes labialis, which may be made at the
screening visit based on the patient's self-reported history of symptoms. An active
herpes labialis outbreak at the time of entry into the clinical trial will neither be
required nor will be an exclusion criteria.

4. Group A only: Self report having six or more episodes of herpes labialis in the past
12 months. Subjects will NOT be told that six-or-more episodes in the previous 12
months is the entry criterion. Subjects will be asked "How many separate episodes of
cold sores have you had in the previous 12 months?" They will be included if they give
an answer of six or more and excluded from Group A if they give an answer of five or
fewer.

5. Group A only: At least half of the subject's episodes of the previous 12 months should
be vesicular in nature and at least half preceded by prodromal symptoms.

6. Group B only: Self report having exactly 1 or 2 episodes of herpes labialis in the
past 12 months. Subjects will NOT be told that one or two episodes in the previous 12
months is the entry criterion. Subjects will be asked "How many separate episodes of
cold sores have you had in the previous 12 months?" They will be included if they give
an answer of one or two and excluded from Group B if they give a different answer.

7. Group C only: Self report having zero episodes of herpes labialis in the past 12
months. Subjects will NOT be told that zero episodes in the previous 12 months is the
entry criterion. Subjects will be asked "How many separate episodes of cold sores have
you had in the previous 12 months?" They will be included if they give an answer of
zero and excluded from Group C if they give an answer of one or more.

Exclusion Criteria:

1. Pregnant or lactating females.

2. Current or recurrent non-herpetic infection or any underlying condition that may
predispose to infection or anyone who has been admitted to the hospital due to
bacteremia, pneumonia or any other serious infection in the last 12 months.

3. Therapy with glucocorticoid or immunosuppressants at time of recruitment or within
past 4 weeks prior to the screening visit (including inhaled corticosteroids for
asthma), except for topical steroids in sites other than face.

4. History of malignancy (except patients with surgically cured basal cell or squamous
cell skin cancers).

5. History of organ transplantation.

6. HIV-positive status determined by history at screening or known history of any other
immunosuppressive disease.

7. Severe co-morbidities (diabetes mellitus requiring insulin, CHF (NYHA class II or
worse) MI, CVA or TIA within 3 months of screening visit, unstable angina pectoris,
oxygen-dependent severe pulmonary disease

8. Known hypersensitivity to Dimethyl sulfoxide (DMSO).

9. Any condition judged by the investigator to cause this clinical trial to be
detrimental to the patient.

10. Subject is currently enrolled in another investigational device or drug trial(s), or
subject has received other investigational agent(s) within 28 days of baseline visit.

11. Previous exposure to SADBE (squaric acid or squaric acid dibutyl ester).

12. Subject has an abnormal skin condition (e.g., acne, eczema, rosacea, psoriasis,
albinism, or chronic vesiculo-bullous disorder) that occurs in the area ordinarily
affected by herpes labialis.

13. Subject has had a vaccine for either HSV-1 or HSV-2.

14. Group A only: People that have had treatment with anti viral therapy within 2 weeks
before sensitization dose of SADBE.

15. Groups B and C only: People that have had treatment with anti-viral therapy any time
in the past 12 months.