Australian Herpes Management Forum
Managing Oral Herpes
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Health Professionals |
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Managing Oral Herpes |
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Diagnosis of HSV |
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Herpes & the Eye |
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Clinical Images |
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Patients |
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Cold Sores Essential Facts |
| Dermatitis/Whitlow Essential Facts | |
| Varicella/Chickenpox | |
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Research Update |
What are cold sores?
Cold sores are a manifestation of recurrent herpes simplex virus (HSV) infection around the mouth. They can occur spontaneously or be brought on by exposure to ultraviolet light (e.g. sun exposure in summer or skiing). The commonest site is on the lips but some people get cold sores on other parts of the face such as around the nostrils. Aphthous ulcers in the mouth are not caused by herpes simplex virus.
The symptoms of cold soresTypical cold sores appear as a crop of blisters grouped in an area about the size of a five cent coin (Figure 1). Their appearance may be preceded by a few hours by a tingling, burning or itching sensation, but not everyone experiences this so-called prodrome. The blisters quickly dry to form an unsightly scab, which then heals in about five days (Figure 2). Generally there is no permanent scar or loss of sensation. Take diagnostic swabs during the infectious periodCold sores are most infectious when the blisters are newly formed, that is for the first 1-2 days of an outbreak. This is the best time to swab a cold sore if laboratory confirmation of the diagnosis is required. Once the sore has formed a dry scab, infectivity is low and HSV usually cannot be recovered from the sore at this stage. |
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TransmissionSpread occurs by close physical contact between an infected and a previously uninfected person. Infection is most commonly acquired as a baby or infant from contact with relatives (kissing). The source does not always have typical cold sore symptoms at the time of transmission. For instance, virus is often shed from the saliva before or while the blisters are present. It is also possible to shed infectious virus particles without lesions or symptoms. When the virus is transmitted, the newly infected person is usually asymptomatic but may occasionally get symptoms of a primary infection around and inside the mouth (gingivostomatitis) lasting up to three weeks (Figure 3). |
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Gingivostomatitis is different to a cold sore, presenting as ulcerated inflamed gums and mouth ulcers and occurs only once. Severe gingivostomatitis may be accompanied by severe pain and fever. Whether or not there are noticeable symptoms associated with primary infection, latency is established in the sensory nervous system and recurrences (cold sores) may occur thereafter. Remember that cold sores are the clinical manifestation of recurrent, not primary, infection. That is, appearance of a cold sore does not indicate a newly acquired HSV infection.
Pathogenesis
After recovery from primary HSV infection, the virus is not cleared from the body but is transported to the trigeminal ganglion, a cluster of sensory nerve cells near the brain stem. Periodically, the virus reactivates from dormant (latent) infection in these cells and is transported back down the nerves to skin or mucous membranes, where it may cause a recurrent infection to present either as viral shedding in the saliva and/or a cold sore. Replicating virus is usually recognised promptly by the immune system and therefore recurrent infections are short-lived.
Diagnosis
The blistered appearance of cold sores on the vermilion border of the lip and their recurrent history is characteristic. If there is any doubt lesions can be cultured.
Management
Cold sores are unsightly and uncomfortable and therefore there is great interest in finding effective remedies. At present, there is no way of eradicating the latent infection and treatments are directed solely at control of each outbreak. There are two types of treatments—topical and oral medications.
Topical medication (over the counter)
There are numerous aciclovir creams currently available, including Zovirax, Lovir, Acihexal, Blistex, Acivir and pharmacy-owned brands. The greatest benefit of topical agents is likely to be achieved if the medications are used during the prodromal (ie tingling) stage of the sore.
Prescribed oral medication
Oral antivirals, including aciclovir, famciclovir and valaciclovir have been shown to be effective in the management of cold sores. These are currently available on prescription but they are not funded by the PBS. Prophylaxis and episodic therapy with antiviral medication for frequent or troublesome recurrences is effective. For people with advanced HIV infection, famciclovir tablets are available both for suppressive and episodic treatment in patients with moderate to severe oral or labial herpes. For further prescribing details, see the product information.
The response varies between episodes and between individuals. Prophylaxis and episodic therapy with antiviral medications for frequent or troublesome recurrences is effective. Oral medication is currently available, but famciclovir tablets are only funded by the PBS for people with advanced HIV infection. For all other patients famciclovir is available on prescription but is not PBS funded. For further prescribing details, see product information and PBS guidelines.
Gingivostomatitis
Primary infection (gingivostomatitis) responds well to oral aciclovir. For infants and children, aciclovir tablets can be given as a suspension. Aciclovir tablets can easily be dispersed in water or crushed tablets may be mixed with jam.
Bibliography
Cunningham AL, Taylor R, Taylor J, Marks C, Shaw J and Mindel A. Prevalence of infection with herpes simplex virus types 1 and 2 in Australia: a nationwide population based survey. Sexually Transmitted Infections 2006:82(2):164-8
Esmann J. The many challenges of facial herpes simplex virus infection. Journal of Antimicriobiological Chemotherapy 2001;47(1):17-27
Emmert DH. Treatment of common cutaneous herpes simplex virus infections. American Family Physician 2000;61(6):1679-1706
Stanberry LR, Cunningham AL, Mindel A, Scott LL, Spruance SL, et al. Prospects for control of herpes simplex virus disease through immunization. Clinical Infectious Diseases 2000;30(3):549-566
Whitely R. Herpes simplex virus infection. Seminars on Pediatric Infectious Diseases 2002;13(1):6-11.
Disclaimer
The AHMF have made considerable efforts to ensure the information upon which this guideline is based reproduces the evidence as accurately as possible. Users of this guideline are strongly recommended to confirm that the information contained within it, especially drug indications, is correct by way of independent sources, as this guideline does not indicate an exclusive course of action or serve as a standard of medical care. The AHMF accepts no responsibility for any inaccuracies, information perceived as misleading, or success of any treatment regime detailed in this guideline.
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| Document Information |
Date: December 1998 Revised: |
Australian Herpes Management Forum
c/- STIRC
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Westmead NSW 2145
Australia
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