cold sore

Cold Sore 

Definition

A cold sore is a fluid-filled blister which usually appears at the edge of the lips. Cold sores are caused by a herpes simplex virus infection.

Description

A cold sore is a fluid-filled, painful blister that is usually on or around the lips. Other names for a cold sore are fever blister, oral herpes, labial herpes, herpes labialis, and herpes febrilis. Cold sores most often occur on the lips which distinguishes them from the common canker sore which is usually inside the mouth. Cold sores do not usually occur inside the mouth except during the initial episode. Canker sores usually form either on the tongue or inside the cheeks.

Cold sores are caused by a herpes virus. There are eight different kinds of human herpes viruses. Only two of these, herpes simplex types 1 and 2, can cause cold sores. It is commonly believed that herpes simplex virus type 1 infects above the waist and herpes simplex virus type 2 infects below the waist. This is not completely true. Both herpes virus type 1 and type 2 can cause herpes lesions on the lips or genitals, but recurrent cold sores are almost always type 1.

Oral herpes is very common. More than 60% of Americans have had a cold sore, and almost 25% of those infected experience recurrent outbreaks. Most of these persons became infected before age 10. Anyone can become infected by herpes virus and, once infected, the virus remains latent for life. Herpes viruses are spread from person to person by direct skin-to-skin contact. The highest risk for spreading the virus is the time period beginning with the appearance of blisters and ending with scab formation. However, infected persons need not have visible blisters to spread the infection to others since the virus may be present in the saliva without obvious oral lesions.

Viruses are different from bacteria. While bacteria are independent and can reproduce on their own, viruses enter human cells and force them to make more virus. The infected human cell is usually killed and releases thousands of new viruses. The cell death and resulting tissue damage causes the actual cold sores. In addition, the herpes virus can infect a cell and, instead of making the cell produce new viruses, it hides inside the cell and waits. The herpes virus hides in the nervous system. This is called "latency." A latent virus can wait inside the nervous system for days, months, or even years. At some future time, the virus "awakens" and causes the cell to produce thou sands of new viruses that cause an active infection.

This process of latency and active infection is best understood by considering the cold sore cycle. An active infection is obvious because cold sores are pre sent. The first infection is called the "primary" infection. This active infection is then controlled by the body's immune system and the sores heal. In between active infections, the virus is latent. At some point in the future, latent viruses become activated and once again cause sores. These are called "recurrent" infections. Although it is unknown what triggers latent virus to activate, several conditions seem to bring on infections. These include stress, illness, tiredness, exposure to sunlight, menstruation, fever, and diet.

Causes and symptoms

While anyone can be infected by herpes virus, not everyone will show symptoms. The first symptoms of herpes occur within two to 20 days after contact with an infected person. Symptoms of the primary infection are usually more severe than those of recurrent infections. The primary infection can cause symptoms like other viral infections including tiredness, headache, fever, and swollen lymph nodes in the neck.

Typically, 50 to 80% of persons with oral herpes experience a prodrome (symptoms of oncoming disease) of pain, burning, itching, or tingling at the site where blisters will form. This prodrome stage may last anywhere from a few hours to one to two days. The herpes infection prodrome occurs in both the primary infection and recurrent infections.

In 95% of the patients with cold sores, the blisters occur at the outer edge of the lips which is called the "vermilion border." Less often, blisters form on the nose, chin, or cheek. Following the prodrome, the disease process is rapid. First, small red bumps appear that quickly form fluid-filled blisters. The painful blisters may either burst and form a scab or dry up and form a scab. Within two days of the first red bumps, all the blisters have formed scabs. The skin heals completely and without scarring within six to ten days.

Some children have a very serious primary (first episode) herpes infection called "gingivostomatitis." This causes fever, swollen lymph glands, and numerous blisters inside the mouth and on the lips and tongue that may form large, open sores. These painful sores may last up to three weeks and can make eating and drinking difficult. Because of this, young children with gingivostomatitis are at risk for dehydration (excessive loss of water from the body).

Most people experience fewer than two recurrent outbreaks of cold sores each year. Some people never experience outbreaks, while some have very frequent outbreaks. In most people, the blisters form in the same area each time and are triggered by the same factors (such as stress, sun exposure, etc).

Diagnosis

Because oral herpes is so common, it is diagnosed primarily by symptoms. It can be diagnosed and treated by the family doctor, dermatologists (doctors who specialize in skin diseases) and infectious disease specialists. Laboratory tests may be performed to look for the virus. Because healing sores do not shed much virus, a sample from an open sore would be taken for viral culture. A sterile cotton swab would be wiped over open sores and the sample used to infect human cells in culture. Cells that are killed by the herpes virus have a certain appearance under microscopic examination. The results of this test are available within two to 10 days.

Oral herpes may resemble a bacterial infection called impetigo. This skin infection is most commonly seen in children and causes herpes-like blisters around the mouth and nose. Also, because oral herpes can occur inside the mouth, the blisters could be mistaken for common canker sores. Therefore, the doctor would need to determine whether the blisters are oral herpes, canker sores, or impetigo. The diagnosis and treatment of herpes infections should be covered by most insurance providers.

Treatment

There is no cure for herpes virus infections. There are antiviral drugs available that have some effect on lessening the symptoms and decreasing the length of herpes outbreaks. There is evidence that some may also prevent future outbreaks. These antiviral drugs work by interfering with the replication of the viruses, and are most effective when taken as early in the infection process as possible. For the best results, drug treatment should begin during the prodrome stage before blisters are visible. Depending on the length of the outbreak, drug treatment could continue for up to 10 days.

Acyclovir (Zovirax) is the drug of choice for herpes infection and can be given intravenously or taken by mouth. It can be applied directly to sores as an ointment, but is not very useful in this form. A liquid form for children is also available. Acyclovir is effective in treating both the primary infection and recurrent outbreaks. When taken by mouth to prevent an outbreak, acyclovir reduces the frequency of herpes outbreaks.

During an outbreak of cold sores, salty foods, citrus foods (oranges etc.), and other foods that irritate the sores should be avoided. Wash the sores once or twice a day with warm, soapy water and pat gently to dry. Over-the-counter lip products that contain the chemical phenol (such as Blistex Medicated Lip Ointment) and numbing ointments (Anbesol) help to relieve cold sores. A bandage may be placed over the sores to protect them and prevent spreading the virus to other sites on the lips or face. Acetaminophen (Tylenol) or ibuprofen (Motrin, Advil) may be taken if necessary to reduce pain and fever.

Alternative treatment

Vitamin and mineral supplements and diet may have an effect on the recurrence and duration of cold sores. In general, cold sore sufferers should eat a healthy diet of unprocessed foods such as vegetables, fruits, and whole grains. Alcohol, caffeine, and sugar should be avoided.

An imbalance in the amino acids lysine and arginine is thought to be one contributing factor in herpes virus outbreaks. A diet that is rich in the amino acid lysine may help prevent recurrences of cold sores. Foods which contain high levels of lysine include most vegetables, legumes, fish, turkey, and chicken. In one study, patients taking lysine supplements had milder symptoms during an outbreak, a shorter healing time, and had fewer outbreaks than patients who did not take lysine. Patients should take 1,000 mg of lysine three times a day during a cold sore outbreak and 500 mg daily on an ongoing basis to prevent recurrences. Intake of the amino acid arginine should be reduced. Foods rich in arginine that should be avoided are chocolate, peanuts, almonds, and other nuts and seeds.

Vitamin C and bioflavonoids (a substance in fruits that helps the body to absorb and use vitamin C) have been shown to reduce the duration of a cold sore outbreak and reduce the number of sores. The vitamin B complex includes important vitamins that support the nervous system where viruses can hide out. B complex vitamins can also help manage stress, an important contributing factor to the outbreak of herpes viruses. Applying the oil in vitamin E capsules directly to cold sores may provide relief. Zinc lozenges appear to affect the reproduction of viruses and also enhance the immune system. Ointments containing lemon balm (Melissa officinalis) or licorice (Glycyrrhiza glabra) and peppermint (Mentha piperita) have been shown to help cold sores heal.

Prognosis

Oral herpes can be painful and embarrassing but, it is not a serious infection. There is no cure for oral herpes, but outbreaks usually occur less frequently after age 35. The spread of the herpes virus to the eyes is very serious. The herpes virus can infect the cells in the cornea and cause scarring that may impair vision.

Prevention

The only way to prevent oral herpes is to avoid contact with infected persons. This is not an easy solution because many people are not aware that they are infected and can easily infect others. Currently there are no herpes vaccines available, although herpes vaccines are being tested.

Several practices can reduce the occurrence of cold sores and the spread of virus to other body locations or people. These practices are:

• Avoidance of sun exposure to the face. Before getting prolonged exposure to the sun, apply sunscreen to the face and especially to the lips. Wearing a hat with a large brim is also helpful.
• Avoid touching cold sores. Squeezing, picking, or pinching blisters can allow the virus to spread to other parts of the lips or face and infect those sites.
• Wash hands frequently. Persons with oral herpes should wash their hands carefully before touching others. An infected person can spread the virus to others even when he or she has no obvious blisters.
• Avoid contact with others during active infection. Infected persons should avoid kissing or sexual contact with others until after the cold sores have healed.
• Wear gloves when applying ointment to a child's sore.
• Be especially careful with infants. Never kiss the eyes or lips of a baby who is under six months old.
• Be watchful of infected children. Do not allow infected children to share toys that may be put into the mouth. Toys that have been mouthed should be disinfected before other children play with them.
• Maintain good general health. A healthy diet, plenty of sleep, and exercise help to minimize the chance of getting a cold or the flu, which are known to bring on cold sores. Also, good general health keeps the immune system strong; this helps to keep the virus in check and prevents outbreaks.

Key terms

Latent — A nonactive virus which is in a dormant state within a cell. The herpes virus is latent in the nervous system.

Prodrome — Symptoms that warn of the beginning of disease. The herpes prodrome consists of pain, burning, tingling, or itching at a site before blisters are visible.

Recurrence — The return of an active infection following a period of latency.

Resources

Other

Mayo Clinic Online. March 5, 1998. http://www.mayohealth.org.

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sore (sor)

1. popularly, almost any lesion of the skin or mucous membranes.

2. painful.

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bed sore  decubitus ulcer.

canker sore  recurrent aphthous stomatitis.

cold sore  see herpes simplex.

desert sore  a form of tropical ulcer occurring in desert areas of Africa, Australia, and the Near East.

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cold sore

n.

A small blister occurring on the lips and face and caused by a herpes simplex virus.

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cold sore.

See herpes simplex.

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cold sore,

n See herpes labialis.

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cold sore

Dermatology A popular term for a perioral infection by HSV 1, resulting in a blister and a weeping ulcer; Pts should avoid direct–oral, orogenital mucosal contact with others, to prevent spread of infection; herpes labialis may recur, exacerbated by stress, sunlight, fever or illness Management Antiviral creams, oral–acyclovir; pre-treatment with acyclovir before certain exposures may ↓ exacerbations. Cf Canker sore.

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Patient discussion about cold sore.

Q. Are cold sores contagious? My boyfriend has cold sores on his mouth. Can I catch it from him? If so, how can I prevent catching it?

A. The virus that causes cold sores is known as the herpes simplex virus (HSV). There are two types of HSV, type I and type II. Cold sores are usually caused by type I. Herpes simplex infections are contagious. You can catch the virus by kissing your boyfriend or having other close contact with his sores or even from having contact with other parts of his skin that appear normal but are in fact shedding the virus. People are most contagious when they have active blister-like sores. Once the blisters have dried and crusted over (within a few days), the risk of contagion is significantly lessened. Therefore, it is best that you don't come in physical contact while he has the cold sores, since he is contagious. However, a person infected with HSV can pass it on to another person even when a cold sore is not present. This is because the virus is sometimes shed in saliva even when sores are not present.

Q. i just got over a cold sore using abreva is this best remedy to use? i didnt get a cold sore for while but i think problems lately have caused them to appear?

A. Yes, Abreva is a good choice for a cold sore. It usually helps with the itching and dryness. Next time, you should apply an acyclovir cream (Zovirax) straight from the beginning - when you get that itching or tingling even before the cold sore appears. It will make it go away faster.