Cold sore

Definition

A cold sore is a fluid-filled blister that 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 cold sores are fever blisters, oral herpes, labial herpes, herpes labialis, and herpes febrilis. Cold sores most often occur on the lips, distinguishing them from the common canker sore that is usually located 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, herpes virus can infect a cell and instead of making the cell

produce new viruses, it hides inside the cell and waits. 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 thousands of new viruses which causes 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 present. 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 a latent virus to activate, several conditions seem to bring on infections. These include stress, illness, fatigue, exposure to sunlight, menstruation, fever, and diet.

Causes & 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 fatigue, headache, fever, and swollen lymph nodes in the neck.

Typically, 50–80% 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 or two days. The herpes infection prodrome occurs in both the primary infection and recurrent infections.

In 95% of 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 which 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 10 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, which 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 others have more frequent occurrences. 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 is taken for viral culture. A sterile cotton swab is wiped over open sores and the sample used to infect human cells in culture. Cells which are killed by 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, doctors 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 cold sores but many alternative treatments can reduce outbreaks and shorten healing time. 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 a warm, saline solution and pat gently to dry. Application of ice or a cold wet teabag for 10 minutes four or five times a day can relieve the itching and burning.

Supplements

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, chocolate, nuts, and sugar should be avoided.

An imbalance in the amino acids lysine and arginine is thought to be a contributing factor in herpes virus outbreaks. A diet that is rich in the amino acid lysine may help prevent recurrences of cold sores. Foods that 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. The effectiveness of lysine supplementation in treating herpes infections is controversial. 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 herpes viruses are dormant. B complex vitamins also can help manage stress, an important contributing factor to the outbreak of herpes viruses. Some studies have shown that correcting iron, folate, vitamin C, or vitamin B₁₂ deficiencies improves cold sores. Vitamin E speeds healing and reduces pain. Squeeze the oil from a vitamin E capsule onto a cotton ball and apply to the sore for 30 minutes to one hour.

Herbals

Mints are effective antivirals. Lemon balm or Melissa (Melissa officinalis) is comparable to the antiviral acyclovir in the treatment of cold sores. Apply lemon balm cream to the sore several times a day. Alternatively, prepare lemon balm tea, drink the tea and apply the dregs to the sore for one or two hours. The patient may also drink several strong cups of teas prepared from hyssop, oregano, rosemary, thyme, and sage. Licorice may be added to the tea.

Licorice (Glycyrrhiza glabra) is an antiviral and immune system stimulant. Licorice is available as a capsule or an ointment. Gradually take up to 300 mg a day. Apply ointment that contains glycyrrhetinic or glycyrrhizic acid directly to the sore as necessary. Ingestion of licorice may cause loose stools and high blood pressure.

Chinese medicine

Treatment with Qing Dai San (Natural Indigo Powder) mixed with cold boiled water and applied to the sore is generally all that is needed. For recurrent cold sores, the following oral preparations can be taken:

• Yin Huang Kou Fu Yi (Honeysuckle and Scutellaria Fluid): one ampule three times daily
• Yin Qiao Jie Du Pian (Honeysuckle and Forsythia Tablet to Resolve Toxin): two to four tablets three times daily
• Huang Lian Shang Qing Wan (Coptis Pill to Clear Heat of Upper Jiao): 5 g, two to three times daily

Other treatments for cold sores include:

• Pepto-Bismol. Rub liquid into cold sore.
• Laser therapy. Ten daily treatments with low-intensity laser significantly lowered the incidence of oral herpes outbreaks as compared to placebo.
• Mild electric current. Preliminary studies of a small device that delivers a mild electric current to the cold sore site have shown shorter duration of pain and blisters.

Allopathic treatment

There is no cure for herpes virus infections. There are antiviral drugs available which have some effect in lessening the symptoms and decreasing the length of herpes outbreaks. There is evidence that some may also prevent future outbreaks. These antiviral drugs 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.

Acyclovir (Zovirax) has been 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. In 2001, a report showed that use of high-dose acyclovir during primary infection will reduce the extent of latent infection. The use of penciclovir (Denavir) cream as soon as the prodrome symptoms appear speeds healing.

Over-the-counter lip products which contain the chemical phenol (such as Blistex Medicated Lip Ointment) and numbing ointments (Anbesol) help to relieve cold sores. Pharmacists also recommend the over-thecounter medicine Abreva, the only cold sore medicine approved by the U.S. Food and Drug Administration (FDA) to shorten healing time. Acetaminophen (Tylenol) or ibuprofen (Motrin, Advil) may be taken if necessary to reduce pain and fever.

Expected results

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. Alternative medicines can reduce the pain, prevent outbreaks, and shorten the course of cold sores. The spread of herpes virus to the eyes is very serious. 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. As of 2001 there were no known herpes vaccines available, although 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 which helps to keep the virus in check and prevent outbreaks.
• Participate in a stress reduction program. Yoga, massage, aromatherapy, meditation, hypnosis, or biofeedback can relieve stress which may reduce outbreaks.

Copyright 2008 The Gale Group, Inc. All rights reserved.