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Cold sores are due to an infection from the herpes simplex virus (HSV). Who can forget those nasty swollen, painful, oozing sores during childhood, or just before a big date? Herpes simplex 1 is the traditional subtype of the virus that causes cold sores. However, with sexual mores and simple skin-to-skin transfer, you stand about an equal chance of having that cold sore on your lip be due to HSV 1 as to HSV 2 (the subtype originally responsible for genital herpes). It used to be that patients were so caught up about determining whether they suffered from HSV1 or HSV2. However, treatment is the same, regardless of subtype, so it isn´t worth dwelling upon. Instead, concerns yourself about the actual condition.

Herpes infections are very interesting from a medical perspective. A single infected area from skin-to-skin contact (whether kissing, sexual contact or simple hand transfer) stays infected for life. The viral particles remain alive within the nerve endings that supply that specific location, which is why the sore always reoccurs in the same place. Whenever a patient tells me that the sore comes up in different locations each time, it means 1 of 2 things. Either they are dealing with more than 1 infected site, or they really do not have herpes in the first place.

The very first eruption due to a new herpes infection may be accompanied by systemic symptoms such as a general feeling of illness, low-grade fever, and perhaps greatly swollen local lymph nodes. The initial site may swell more than is normal for a herpes infection and be more painful. Fortunately these symptoms do not typically arise with each recurrence.

Herpes infections of the mouth (herpes labialis), is typically triggered by colds (hence the term “cold sore”), sunlight, stress and hormonal changes. Controlling trigger factors can limit outbreaks. For controlling sunlight exposure, the use of sun protective lip balms, EI Solutions Tea Tree Oil Therapeutic Lip Treatment SPF 18, for instance, does make a difference in minimizing sun-induced flares.

Blisters most commonly form on the edge of the lip known as the vermillion border, or nearby region. Ulcerations inside the mouth, such as on the tongue, gums or mucosal lip are not typically due to herpes, but rather most commonly are apthous ulcers due to stress. There are a variety of autoimmune blistering skin diseases that may also cause oral ulcerations inside the mouth.

Many people note that they feel a tingling or burning sensation prior to the eruption of the sore. This may precede the blisters by a few hours or a few days and is called a prodrome. Understanding the unique symptoms of your prodrome can allow you to start your HSV medication early on. Early intervention with medication may completely block the outbreak of the sore altogether for most patients.

Once the prodrome is over, a clear blister, often on a reddish base, arises or there may be a cluster of these blisters. The clear fluid in the blisters may ooze and the blisters may ultimately pop before the drying phase begins. It is a familiar site to see someone with an oozing crust located on the border of the lip. The entire phase may last up to 3 weeks before clearing.

Oral herpes simplex is not known to shed viral particles without the presence of a lesion, so it is not considered a contagious concern when there is not a sore present. While active, the cold sore is contagious until fully dried out. It is recommended that those with active cold sores avoid kissing and sharing drinking cups to limit spread of the disease. Frequent hand washing is very important, both to prevent infecting others but also to minimize the potential for autoinnoculation (spreading the viral infection to other areas of your own body). Autoinnoculation is very serious if the eyes become affected and may lead to blindness. Should you suspect that you have HSV affecting the eyes, contact your doctor (preferably your ophthalmologist) immediately.

It has always been fascinating to find HSV in unusual locations and presentations. This is called Herpes Whitlow. Most commonly associated with dentists and dental hygienists on their fingers, this is far less common due to the advent of infection control and the use of protective gloves. There are a multitude of other odd clinical presentations. I once saw an unfortunate toddler with literally 50+ blisters across the forehead. Turns out grandma couldn’t contain herself from kissing the baby when she had a cold sore! Once, an infant had blisters all over their diaper region. Turns out their grandparent who was immunosuppressed due to cancer, had been changing diapers with undiagnosed HSV on the hands. More commonly, someone prone to genital herpes may wipe themselves and not realize they are virally shedding and tranfer the virus to other areas such as the hip or buttock (autoinnoculation).

TESTING:

Tzanck Prep

The Tzanck Prep is a simple microscopic test done by the dermatologist right in the office. This is very simple for the dermatologist to perform and the results are immediately apparent. It is a wonderful test and easily tolerated by the patient. A blister is opened and the base is gently scraped and applied to a glass slide. It is stained and examined to see if multinucleated giant cells are present, the hallmark of a HSV infection. Unfortunately, the government has stepped in and requires costly licensing and labor-intensive paperwork for doctors to complete if they choose to perform this simple test they were board tested to do. So you may find fewer dermatologists around who go to the “bother” to perform the test in their offices.

Viral Culture

Testing for HSV by way of a viral culture is difficult as the viral particles are fragile and difficult to grow. A negative HSV culture does not completely exclude the possibility that you have had a herpes outbreak. A viral culture is a very simple test to have performed. The roof of the blister is opened and the blister fluid is captured onto a Q-tip that is then immersed into the culture media tube. The drawback to a viral culture is that it takes time to get the results back (you may be clear by then!) and the virus is not nearly as hardy to grow as many bacteria. So you may conceivably get a false negative result. The plus is that the typing of the virus can be done (HSV 1 or 2) and even more importantly, if there is any mix-up between a herpes rash and one due to chickenpox or shingles, these will be distinguished here.

ELISA testing

Enzyme Linked Immunosorbant Assay can help determine the presence of HSV in approximately 2 hours. While it is not frequently used for the determination of cold sore diagnosis, it is more commonly used to determine neonatal herpes infections and other more serious HSV infections when time is of the essence and Tzanck prep is either negative or unable to be performed. ELISA testing is typically about 80-85% accurate.

TREATMENT:

Mainline treatment consists of a pill called Zovirax (generic name is acyclovir) taken in the standard dose of 200mg 5 times a day for 5 days. For first time out breaks that tend to be more symptomatic and difficult to control the medication is given for 10 days. Topical Zovirax has never been greatly effective in my opinion, and I have found it much more effective to go straight to the pill. Zovirax is relatively side effect free for healthy individuals. However, it is not supposed to be taken during pregnancy (at least on a routine basis) and dosing should be adjusted for anyone prone to kidney dysfunction. I always have recommended that 8 oz of water be taken along with each pill to wash it through the kidneys. Zovirax is also available in IV form for serious systemic infections and a syrup form for children.

Other oral medications for the treatment of oral HSV include Famvir and Valtrex. Less frequent dosing is required with these medications as they are better absorbed than Acyclovir. These 2 medications actually become metabolized in to Acyclovir during the absorption process.

To help treat cold sores that have formed either despite systemic therapy or before it could be started, Abreva is a brand new FDA approved topical therapy shown to help get rid of cold sores. It can help early on when you are just experiencing the first symptoms of tingling, itching or burning and can also help clear up that cold sore you woke up to find sitting on your lip. Abreva is appropriate for adults and children 12 and over. It is applied 5 times daily either until the presenting sensations are fully gone or the scab has fallen off. Domeboro Astringent Solution is very useful for achieving a rapid drying out of the area. I also recommend the application of a topical antibiotic ointment such as Polysporin Ointment to prevent secondary bacterial infection. As many people tend to carry staph aureus bacteria within their nasal passages, this close proximity may increase the potential for bacterial contamination of the open sore. The combined use of Domeboro and Polysporin help minimize this risk.

Denavir is the first antiviral cream to be approved for the treatment of cold sores. Denavir helps heal HSV-1 sores an average of one day faster than without treatment. It also stops viral shedding, and diminishes the pain. The cream should be started in the first hour of noticing the symptoms, and continue if for 4 more days. Application is every 2 hours (while awake). I think this is a good option for someone unable to take oral Acyclovir or its premetabolites for some reason. The use of a cream every 2 hours is cumbersome and in my experience is difficult for many patients to be compliant with.

While there has been little scientifically planned studies to determine the true effectiveness of this amino acid, L-lysine supplementation has long been a popular natural approach to preventing the development of herpes cold sores. However, care must be taken when taking herbal supplements due to the lack of control within the industry. There are certainly many excellent manufacturers, however, as was seen about 10 years ago when a bad batch of L-lysine caused several deaths in the Michigan area, it is important to try to stay with well known respectable brands.

Maintenance therapy for the control of chronically occurring HSV is very important in certain situations. First of all, anyone with an outbreak more than once a month is someone I seriously consider for maintenance therapy. It is amazing how much these frequent outbreaks can affect someone’s lifestyle. Also, for anyone prone to developing other skin manifestations due to the presence of active HSV such as erythema nodosum, erythema multiforme and some patients with chronic or recurrent hives, this can be a great method of preventing these associated conditions.

Cold sores are no fun for anyone to have, so it is remarkable that there is now such a variety of options to keep them at bay.

Thank you for taking the time to read my newsletter. I hope you have found it informative.

Audrey Kunin, M.D.

(Any topic discussed in the this newsletter is not intended as medical advice. If you have a medical concern, please check with your doctor.)
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