Copyright © 2012
Efcacy and Tolerability Assessment of a
Topical Formulation Containing Copper Sulfate
and Hypericum perforatum on Patients With Herpes
Skin Lesions: A Comparative, Randomized
Amy Clewell ND,a Matt Barnes MS,a John R. Endres ND,a Mansoor Ahmed PhD,b Daljit K. S. Ghambeer MDc
Background: Topical Acyclovir has moderate effcacy on recurrent HSV symptoms, requiring repeat applications for several days.
Topical Dynamiclear, which requires only a single dose application, may provide a more effective and convenient treatment option for
symptomatic management of HSV.
Objectives: The study assessed the comparative effcacy and tolerability of a single use, topical formulation containing copper sulfate
pentahydrate and Hypericum perforatum that is marketed as Dynamiclear™ to a topical 5% Acyclovir cream standard preparation and use.
Methods: A prospective, randomized, multi-centered, comparative, open-label clinical study was conducted. A total of 149 partici-
pants between 18 and 55 years of age with active HSV-1 and HSV-2 lesions were recruited for the 14-day clinical trial. Participants
were randomized into two groups: A (n=61), those receiving the Dynamiclear formulation, and B (n=59), those receiving 5% Acyclovir.
Effcacy parameters were assessed via physical examination at baseline (day 1), day 2, 3, 8, and 14. Laboratory safety tests were
conducted at baseline and on day 14.
Results: Use of the Dynamiclear formulation was found to have no signifcant adverse effects and was well tolerated by participants.
All hematological and biochemical markers were within normal range for the Dynamiclear group. Statistically, odds for being affected
by burning and stinging sensation were 1.9 times greater in the Acyclovir group in comparison to the Dynamiclear group. Similarly,
the odds of being affected by symptoms of acute pain, erythema and vesiculation were 1.8, 2.4, and 4.4 times higher in the Acyclovir
group in comparison to the Dynamiclear group.
Conclusions: The Dynamiclear formulation was well tolerated, and effcacy was demonstrated in a number of measured parameters,
which are helpful in the symptomatic management of HSV-1 and HSV-2 lesions in adult patients. Remarkably, the effects seen from
this product came from a single application.
J Drugs Dermatol. 2012;11(2):209-215.
simplex virus 2 (HSV-2), both distinguished by clinical mani-
festations, biological and serological criteria.1 Their character-
istic feature is a capacity to establish latency in the host after
the initial infection and to reactivate periodically. Major symp-
toms of active infection include prodromal numbness and tin-
gling around the affected area, induration, erythema, itching,
burning, pain in the area, and ulcerated lesions.2,3 In the U.S.,
over 70–90 percent of adults have the antibody to HSV-1 and
erpes simplex virus (HSV) is one of the most com-
mon viral diseases in humans. HSV exists as two
types, Herpes simplex virus 1 (HSV-1) and Herpes
approximately 22 percent have the antibody to HSV-2. HSV
is the fastest growing infectious disease in the world with
500,000 new cases reported each year. HSV active infections
are also associated with enhanced Human Immunodefciency
Virus (HIV) transmission.4-6
Oral and topical Acyclovir preparations are used as the current
standard of care for treatment of HSV symptoms, including
skin lesions. Acyclovir inhibits the replication of herpes virus
via inhibition of the viral DNA polymerase, thus preventing the
formation of the DNA replication complex and the elongation
A. Clewell, M. Barnes, J. R. Endres, et al.
of the viral DNA chain. Treatment of recurrent and persistent
infections with oral Acyclovir, and with other antivirals in-
cluding valacyclovir, famciclovir, and penciclovir has resulted
in clinical beneft, but also has resulted in the emergence of
drug-resistant variants and viruses that are more resistant due
to their relative defciency of viral thymidane kinase or DNA
polymerase—especially in immunocompromised individu-
als.3,7,8 Although resistant strains of HSV do not currently pose a
threat, in a number of decades it is likely that resistant strains
will replace wild-type strains in treated individuals.9
The primary beneft of topical antiviral treatments thus far has
been the reduction in healing time.10 However, topical treatments
do not mitigate the immune-mediated response of the host to
the virus. In a study done by Shaw et al, little to no clinical beneft
was seen when skin infections were treated with topical Acyclo-
vir.11 Topical Acyclovir also requires daily application, demands
good compliance and is relatively expensive. For these reasons,
a novel approach to anti-HSV therapy is desirable. Formulations
that enhance natural immune modulation and that cause viral
destruction and inactivation would be benefcial. Formulations
such as Dynamiclear, which require a single dose application and
which do not likely encourage drug-resistant variants or muta-
tion of HSV, may hold promise for this intended effect.7
Natural product formulations may serve as effective antiviral
and immune modulating agents.9,12-15 The constituent complex-
ity and diverse mode of action of a natural formulation does not
result in the type of mutations seen with single element pharma-
ceutical formulations.16 A number of natural products have been
shown to be antiviral, to promote tissue repair and to decrease
pain. Furthermore, many natural substances have been shown
to support local innate immune activity.16-18 For these reasons,
natural products may hold promise in the management of and
alteration of the natural progression of HSV recurrence.
Hypericum perforatum, commonly known as St. John’s Wort,
has been extensively investigated for its antiviral activities
against enveloped viruses like HSV and HIV. The bioactive con-
stituent, hypericin, displays multiple modes of actions, including
inhibition of new virion budding, prevention of viral uncoating,
and inhibition of protein kinase activity required for replication
of a number of viruses.19 Hypericum perforatum has additionally
been investigated with regard to its ability to relieve neuropathic
pain. Antihyperalgesic activity is also associated with the major
bioactive constituent hypericin. In studies, hypericin inhibits pro-
tein kinase C gamma and epsilon, which are proteins associated
with the development of neuropathic pain.20
Naturally occurring minerals such as zinc and copper also dem-
onstrate antiviral activity. Research has been conducted on the
copper-mediated inactivation of HSV. Copper ions have been
shown to inactivate several types of viruses, including members
of the Herpesvirus and Arenavirus families, various bacterio-
phages treated in vitro, and free as well as intracellular HIV.7,21
Mechanisms of action studies suggest that copper-mediated
damage occurs via binding with DNA causing DNA strand
breaks. HSV has also been shown to exhibit sensitivity to low
concentrations of copper. It is hypothesized that a potential
advantage of copper-mediated viral killing resides in broad mo-
lecular damage, in that the host cell has the ability to repair much
faster for itself than the virus. In addition, rather than suppress-
ing viral replication, copper ions render the viral DNA nonviable
for further replication. Interestingly, studies have been done with
copper bound to Acyclovir. This complex reportedly exhibited a
signifcant anti-HSV effect.22 In an in vitro study conducted by
Shishkov, et al., a copper complex was found to inhibit the in-
fectivity of free virions.21 The maximum safe level for topical
anhydrous copper sulfate use is 5%, which equates to approxi-
mately 2% of copper ions.23 Skin exposure to copper can cause
allergic reactions in some individuals.
The Dynamiclear formulation used in this study contains copper
sulfate pentahydrate (5.0%) and Hypericum perforatum (0.10%).
Unlike the majority of topical treatments marketed for symptom-
atic relief of HSV lesions, this formulation is recommended as a
single application. It has been clinically tested for safety, effcacy,
and tolerability by an independent CRO (Apothecaries Ltd, India)
using Good Clinical Practice in accordance with the principles
that originate in the Declaration of Helsinki. Dynamiclear has
been listed on the Australian Register of Therapeutic Goods as a
Complementary Medicine since July 2008.
The aim of this clinical study was to investigate the effcacy of
a single topical application of the Dynamiclear formulation
compared to topical Acyclovir, and to determine Dynamiclear’s
tolerability in adult patients with recurrent skin, oral, and genital
HSV lesions. The trial was a prospective, randomized, multi-
centered, comparative, open-label clinical study in patients aged
between 18 and 55 years old. No blinded comparator product,
placebo or active formulation was suitable for the study. Blinding
was considered not feasible without placebo, as the formulation
and dosage forms of the Dynamiclear formulation and Acyclovir
were completely different.
MATERIAL AND METHODS
Men and women between 18 and 55 years of age with active
HSV-1 and HSV-2 skin or mucocutaneous lesions were enrolled
at eleven centers in India. Prospective study patients were
screened by medical history, physical examination, and blood
examinations. All patients signed an informed consent form
approved by an Indian Ethics Committee (IEC). IEC approval
number and date were: SC/111/06version07 31May06. The study
was carried out in compliance with the ICH GCP: “Guidelines
for Clinical Trials on Pharmaceutical Products in India GCP
A. Clewell, M. Barnes, J. R. Endres, et al.
or discomfort, 1=pain can be easily ignored, 2=pain does not
interfere with daily activities, 3=pain interferes with concentra-
tion or sleep, 4=pain interferes with all but basic needs, 5=pain
requires rest or bed rest); and local cutaneous assessments
such as erythema, induration, itching, vesiculation and stinging
sensation. Treatment began immediately after the participants
had been consented into the study. These end points were mea-
sured at baseline (day 1) prior to application of preparations,
and at day 2 (natural product Dynamiclear group only), day
3, day 8 and day 14. These parameters were either objectively
determined by study clinicians or subjectively reported (e.g.,
presence of pain) by the patient during an interview with the
The sample size to be used in the study was calculated based
on the postulation that the treatment effect would be 30 percent
with a likely 80 percent cure rate in the Dynamiclear group and
50 percent in the comparator group. It was determined that a
total of 116 participants were required to reach statistical signif-
cance at 80 percent power and P≤0.05.
Overall effcacy was analyzed using proportion of change over
a period of 14 days calculated using the Chi Square test and dif-
ference in the proportion of change between the groups (95%
CI). To account for the correlated dichotomous response, the
generalized estimating equation was used to analyze effcacy
parameters. Analysis of covariance (ANCOVA) could not be
used with the generalized estimating equation (GEE). The GEE
was used to compare the total development of risk between the
test preparation and the standard drug over a period of 14 days.
Laboratory parameters were compared between Acyclovir and
the Dynamiclear formulation at screening and at the end of the
study using t-test for independent samples/Wilcox rank sum
test based on the nature of the distribution of these parameters.
The percentage change was compared between the groups
over a period of time using Wilcoxon rank sum test.
From June 2006 to December 2006, 149 patients (104 men and
45 women) entered the study at one of nine of a total of eleven
approved sites. Based on serological testing 86 percent of adults
presenting had secondary infections and 11 percent were pri-
mary infections. Group A (Dynamiclear) fnal participants n=61
(14 participants were excluded or dropped during the study) and
Group B (Acyclovir) fnal participants n=59 (15 participants were
excluded or dropped during the study). The majority of partici-
pants fell between the ages of 18 and 34, with the majority being
male (70.3%). No statistically signifcant difference between
Group A and Group B occurred in baseline characteristics of age,
weight, height and gender. The clinical and laboratory safety pa-
Guidelines, ” which was issued by Central Drugs Standard Con-
trol Organization, Ministry of Health, Government of India. The
study design and conduct also complied with the ethical princi-
pals originated from the Declaration of Helsinki. All changes to
the protocol were also approved by the IEC. Enrollment began
in June 2006 and lasted through December 2006.
At the initial visit, patients to be included in the trial gave their
written informed consent to participate in the study. Predefned
clinically signifcant limits of change were used to determine
laboratory safety parameters. Patients having values outside of
these predetermined values were excluded or removed from
the study. Participants that qualifed for the study were ran-
domly assigned to either Group A: the Dynamiclear formulation
containing 5.0% copper sulfate pentahydrate and 0.10% Hyperi-
cum perforatum in a base of glycerin and water (Global Herbal
Supplies Pty Ltd, Australia) or Group B: 5.0% Acyclovir (Zovirax;
Glaxo Smithkline, India). The Dynamiclear formulation came
from a single batch, while Acyclovir came from one of seven
batches. Patients received their Acyclovir on an outpatient basis
and were instructed to apply the topical cream fve times daily
for a period of seven days. Participants using the Dynamiclear
formulation received a single topical application at the respec-
tive clinic on day 1 of the study. No subsequent application was
made for the duration of the study. Subsequent visits occurring
on days 2, 3, and 8 included patient diary assessment, physical
exam, clinical effcacy evaluation, local tolerability and adverse
event assessment. The last visit of the study (day 14) included
repeat laboratory tests.
Patients were excluded from the trial if they met the pre-determined
exclusion criteria that included a history of hypersensitivity or al-
lergic reaction to any dosage form of study drugs, lesions inside of
the oral mucosa, pregnant women and immunodefcient persons.
No concomitant antiviral treatment was permitted. Concomitant
medications that were used were recorded by the investigator.
None of the patients used steroids or home remedies in the study.
Routine safety laboratory tests that included complete blood
cell count with differentials, erythrocyte sedimentation rate,
liver enzymes and urinalysis, were conducted by various quali-
fed laboratories in and around the participating clinical sites.
Biochemical parameters were evaluated to assess for adverse
events and were not used for effcacy measurements.
The primary effcacy assessments were based on the end-
points measured at predetermined times. Primary endpoints
included: appearance of crusting or healed rash of herpes; dis-
appearance of pain (evaluated based on a pain scale: 0=no pain
A. Clewell, M. Barnes, J. R. Endres, et al.
At day 1, the percentage of patients suffering with erythema
was not statistically signifcantly different (P=0.730) between
the groups. From day 3 onwards, the percentage of patients
suffering from erythema was higher in the Acyclovir group
compared to the Dynamiclear group, which was statistically
signifcant on day 8 (P=0.009) and day 14 (P=0.015).
The percentage of patients suffering from itching on day 1 was
higher for the Acyclovir group (81.4%) compared to the Dynami-
clear group (78.7%), but was not statistically signifcantly different
(P=0.715). Throughout the study period the percentage of patients
suffering from itching was higher in the Acyclovir group compared
to those using Dynamiclear, which was statistically signifcant on
day 8 (P=0.044).
The percentage of patients suffering with induration was higher
in the Dynamiclear group on day 3 to day 8 as compared to Acy-
clovir and was not statistically signifcant (P=0.479, P=0.386).
However, at day 14, there were a higher percentage of patients
suffering from induration in the Acyclovir group in comparison
to the Dynamiclear group, although the difference was not sta-
tistically signifcant (P=0.184).
At day 1, the percentage of patients suffering with vesiculation
was not statistically signifcantly different (P=0.275) between
the groups. The percentage of patients suffering from vesicu-
lation on day 3, day 8 and day 14 in the Dynamiclear group
was 36.1 percent, 9.8 percent, 3.3 percent, and in the Acyclovir
group was 76.3 percent, 40.7 percent, and 15.3 percent, respec-
tively, which was statistically signifcantly different for day 3
and day 8 (P=0.001, P=0.001) (Tables 2 and 3).
Overall, topical application of Dynamiclear was well tolerated.
There was no statistically signifcant difference among the
treatment groups in the frequencies of adverse events. One pa-
tient in the investigational product treatment group reported
a possible drug related non-serious laboratory adverse event.
No patients in the investigational product group necessitated
discontinuation from the study.
The primary objective of this study was to report the compara-
tive proportion of effcacy in patients treated with Dynamiclear
and topical Acyclovir. Both ITT and PP analysis of scabbing and
crusting were not statistically signifcant between the groups.
However, between the Dynamiclear and Acyclovir treatments,
the changes observed in acute pain, erythema, induration
and vesiculation were signifcantly greater in the Dynamiclear
group in the direction of disappearance. In all the effcacy pa-
rameters except for induration in PP analysis, the Dynamiclear
group showed a higher rate of healing in comparison to the
Acyclovir group. The proportion of change of effcacy param-
rameters of temperature, blood pressure and pulse rate at all
time points remained similar between the two groups. All points
remained within normal range.
Reported Herpes Locations
Of the patients recruited for the study, 81 had orofacial lesions,
46 had genital lesions, fve had lesions on the chest or abdomen,
three had neck lesions and one had a lesion occurring on a limb.
The effcacy evaluation was analyzed using both Intention To
Treat (ITT) and Per Protocol (PP) methods. Per protocol data are
Effcacy Evaluation Based on Per Protocol Analysis
The difference in the percentage of scabbing and crusting in the
Acyclovir group (47.4%) versus the Dynamiclear group (42.6%)
was not statistically signifcantly different (P=0.595) at day 1. At
day 3, the percentage of scabbing and crusting in those using
Acyclovir (54.2%) was signifcantly lower (P=0.005) as com-
pared to Dynamiclear, whereas at day 8 the percentage for the
Acyclovir group (47.4%) was higher than the Dynamiclear group
(35.0%), which was not statistically signifcant (P=0.167). At day
14, the percentage of scabbing and crusting in the Dynamiclear
group was 18.0%, and in the Acyclovir group was 18.6%, which
was not statistically signifcant (P=0.931).
At day 1, the difference in the percentage of patients suffer-
ing with pain was not statistically signifcant (P=0.426) between
the groups. The percentage of patients suffering from pain was
higher during the study period in the Acyclovir group compared
to the Dynamiclear group. Whereas at day 8 the percentage of
patients suffering from pain using Dynamiclear (37.7%) was
signifcantly lower (P=0.018) compared to those using Acyclovir
(59.3%) (Table 1).
Mean Pain Scores
Mean (95% CI)
At day 0
At day 14
0.11 (-0.05, 0.26)
aThe Mean Standard Error Pain Score between Dynamiclear and
Acyclovir was 1.91 (0.08) and 2.02 (0.08) respectively, which is not
statistically significant (0.11(-0.05, 0.26)). However, the difference in the
mean pain score between day 0 and day 14 within each group was found
to be statistically significant.
A. Clewell, M. Barnes, J. R. Endres, et al.
Change in Efficacy Parametersa
Proportion of Change (SE)
Difference in Proportion of
Change (95% CI)
OR (95% CI)
Scabbing & Crusting
Burning & Stinging
0.10 ( -0.06, 0.26)
0.03 ( -0.12, 0.18)
0.01 ( 0.14, 0.17)
0.05 ( -0.11, 0.20)
0.05 ( -0.10, 0.20)
0.10 ( -0.05, 0.25)
0.06 (-0.10, 0.21)
0.9 (0.6, 1.5)
1.7 (0.9, 3.2)
2.1 (1.2, 3.8)*
2.1 (1.2, 3.8)*
2.3 (1.2, 4.4)*
0.9 (0.5, 1.6)
5.4 (2.8, 10.6)*
aThe difference in the proportion of change was higher in the Dynamclear group in all the efficacy parameters as compared to the Acyclovir group, but was
not statistically significant. The odds for being affected by burning and stinging sensations is 2.1 times more in the Acyclovir group in comparison to the
Dynamiclear group. Similarly, the odds of being affected by symptoms of acute pain, erythema and vesiculation are 2.1, 2.3, and 5.4 times higher in the
Acyclovir group in comparison to the Dynamiclear group.
Efficacy Parameters of Dynamiclear Over Timea
No. (%) Proportion of change
Scabbing & Crusting
Burning & Stinging
aThe effect of Dynamiclear on scabbing and crusting was revealed on day 2 (72.1) and day 3 (78.7), and a 22% (12%, 32%) change was observed during
the study period that was statistically significant. There was significant change (P<0.05) in the direction of cure of itching, burning and stinging, acute pain
erythema, induration and vesiculation in those patients who received a single application of Dynamiclear.