Good Medicine: Coping with Cold Sores

Everyone calls them cold sores or fever blisters because that sounds nicer than what they are: oral herpes. There’s nothing nice about periodic and painful sores on our lips and in our nose and mouth that are caused by an infection with Herpes Simplex Virus I, or HSV1. At least half of the people in the United States carry HSV1. While it doesn’t produce symptoms in all carriers, the virus does stay in the body forever, meaning it can be transmitted to others.  

Kissing, touching or sharing utensils and personal items such as razors, toothbrushes, makeup and lip balm can spread the disease from person to person. And carriers of HSV1 aren’t just contagious when they’re suffering an outbreak, but up to 24 hours before. 

Once someone is infected, the virus lies dormant in the trigeminal ganglion, a cluster of nerves located in front of the ear and just above the jaw joint. When triggered, HSV1 travels down the nerve endings and causes blisters in the trigeminal distribution: lips, mouth and nose. When the outbreak is over, the virus returns to the ganglion until the next flare-up, when the process begins again.  

Oral herpes always recurs in the same place. The frequency of outbreaks ranges from once or twice in a lifetime to multiple times annually. (Infections tend to become milder and less frequent for those over 35.) Symptoms start with tingling in the spot where the sore will develop one to two days later. The affected area then becomes red, swollen and painful. Over the next two to three weeks, it will ulcerate and scab. An initial HSV1 infection can be quite severe, accompanied by fever, a sore throat and swollen glands.  

The triggers for recurrence include stressors like anxiety or depression, temperature extremes, chapped lips, sunburn, illness, fever and hormonal changes, such as menstruation. Your medical provider or dentist can detect an HSV1 infection by examining the sore and taking a thorough history. In rare cases a blood test or a culture of the blister fluid is required. Because oral herpes is so predictable, most sufferers diagnose their own recurrences.   

Although there is no cure for HSV1, cold sores can be effectively managed with over-the-counter treatments. Antiviral ointments, such as Abreva, limit the duration and severity of the outbreak, and hydrocortisone 1% cream helps reduce swelling and redness. Acetominophen (Tylenol) or ibuprofen (Advil) can help minimize pain, as do topical anesthetics like lidocaine or benzocaine. Cool compresses are effective for swelling and discomfort. If your painful blisters don’t respond to these treatments, your medical provider can prescribe valacyclovir or acyclovir, which come in tablets or creams. The pills, taken daily, can prevent frequent outbreaks. People often take the herbal supplement lysine, an essential amino acid, but there is no evidence that it effectively blocks recurrence. 

Most cold sores can be treated at home. But there are some instances where you should contact your primary care provider: if symptoms last longer than two to three weeks or are severe; if the infection is in your eye, which can lead to blindness; if you are receiving chemotherapy or are otherwise immunocompromised; if you have eczema, which can cause HSV1 spreads easily; or if you have sores on your body, not just your face. 

There are currently no available vaccines for oral herpes. Wearing lip balm with SPF, getting adequate sleep, avoiding stress and practicing good self-care are your best tools to help prevent frequent recurrences. 

Mary Jenkins is recently retired after nearly 40 years as a family practice physician in New York state.