Grouped, crusted blisters on the lips and chin are typical of herpes simplex infection. This image displays a blister with a central depression, typical of herpes simplex. This image displays severe inflammation with skin ulcers and bloody crusts as seen on the right upper lip of this immunocompromised person. This image displays an ulcer from a herpes infection, which is typical of an immunocompromised person. The first time a person contracts a herpes infection, there is often severe blistering, pain, and sometimes fever. This image displays an unusual area for the herpes simplex infection. A slightly bloody crust has formed at the center of this herpes blister. This image displays a mucosal blister caused by a herpes simplex infection. This image displays a herpes infection in a patient with a weak immune system, causing a severe, large oral or ulcer. This image displays a herpes simplex infection on the face. This image displays the fluid-filled blister typical of herpes. This image displays early crusting and swelling typical of recurrent herpes. This image displays multiple grouped herpes lesions that are starting to crust and dry. Small fluid-filled blisters typical of a herpes infection are present at the lateral lip.
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Cold Sores (Orofacial Herpes)  Information for adults

Picture of Cold Sores (Orofacial Herpes): Grouped, crusted blisters on the lips and chin are typical of herpes simplex infection. Divider line
Grouped, crusted blisters on the lips and chin are typical of herpes simplex infection.
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Overview
Herpes simplex infection of the mouth and face, known as orofacial herpes simplex, herpes labialis, cold sores, or fever blisters, is a common, recurrent skin condition associated with infection by the herpes simplex virus (HSV). Orofacial HSV usually appears as small blisters or sores around the mouth, nose, genitals, and buttocks, though infections can develop almost anywhere on the skin. Furthermore, these cold sores may periodically come back in the same sites.

Infections with HSV are very contagious and are spread by direct contact with the skin lesions. There are 2 types of HSV: herpes simplex virus type 1 (HSV-1) and herpes simplex virus type 2 (HSV-2). HSV-1 infections usually occur around the mouth, lips, nose, or face, while HSV-2 infections usually involve the genitals or buttocks. However, HSV-1 can sometimes cause infections in the genitals or buttocks, while HSV-2 can occasionally cause infections around the mouth, lips, nose, or face.

Both types of virus produce 2 kinds of infections: primary and recurrent. Because it so contagious, HSV causes a primary infection in most people who are exposed to the virus. However, only about 20% of people who are infected with HSV actually develop visible blisters or sores. Appearing 2–12 days after a person's first exposure to HSV, the sores of a primary infection last about 1–3 weeks. These sores heal completely, rarely leaving a scar. Nevertheless, the virus remains in the body, hibernating in nerve cells.

Certain triggers can cause the hibernating (latent) virus to wake up, become active, and travel back to the skin. These recurrent HSV infections may develop frequently (every few weeks), or they may never develop. Recurrent infections tend to be milder than primary infections and generally occur in the same location as the primary infection.

Most people get cold sores as children, through contact with a friend or family member who is already infected with HSV. It can be spread (transmitted) by kissing, sharing eating utensils or drinking vessels, or by using the same towel.
Who's At Risk
HSV infections occur in people of all races, of all ages, and of both sexes.

Increasing age is associated with increased likelihood of infection. Up to 80% of Americans are infected with HSV-1 by the time they are 30 years old.

Only 20% of people who are infected with HSV actually develop visible blisters or sores. That means that approximately 80% of people with HSV infections have not been diagnosed and are unaware of their condition. Nevertheless, they can still transmit the infection to others.
Signs and Symptoms
The most common locations for HSV-1 infections include:
  • Lips
  • Mouth (including gums, tongue, roof of mouth, and inside the cheeks)
  • Nose
  • Chin
  • Cheeks
Shortly after exposure to the virus, a newly infected person may develop fluid-filled blisters, occurring singly or in a cluster of several blisters. These blisters may be yellow to gray and are fragile, so that many people never notice blisters but instead see tiny open sores (ulcers). These ulcers subsequently become scabbed over and may appear dry and yellow. The scabs eventually fall off, leaving a red area that fades. The first (primary) outbreak of HSV typically lasts 1–3 weeks.

In mild cases of primary orofacial HSV infection, an individual may develop 1–2 cold sores or may notice no symptoms at all. The lymph nodes in the neck may or may not be swollen. In severe cases of HSV infection, cold sores may involve the entire lining of the mouth and both lips. These severe infections may be accompanied by fever, sore throat, foul breath, and difficulty eating.

Repeat (recurrent) HSV infections are often milder than the primary infection, though they look alike. However, some people never develop the symptoms of a primary HSV infection and may mistake a recurrent infection for a primary infection. A recurrent infection typically lasts 7–10 days. People who are prone to recurrent outbreaks tend to get them 3–4 times per year.

Many people with recurrent HSV infections report that the skin lesions are preceded by sensations of burning, itching, or tingling (prodrome). About 24 hours after the prodrome symptoms begin, the actual lesions appear as one or more small blisters or open sores, which eventually become scabbed over.

Triggers of recurrent HSV infections include:
  • Fever or illness
  • Sun exposure
  • Hormonal changes, such as those due to menstruation or pregnancy
  • Stress
  • Trauma, such as that caused by dental work or cuts from shaving
  • Surgery
Self-Care Guidelines
Acetaminophen or ibuprofen may help reduce fever, muscle aches, and pain caused by cold sores. Try to drink as many fluids as possible to prevent dehydration. Applying ice packs may relieve some of the swelling and discomfort.

Because HSV is very contagious, it is important to take the following steps to prevent spread (transmission) of the virus during the prodromal phase (burning, tingling, or itching) and active phase (presence of blisters or sores) of HSV infections:
  • Avoid sharing cups or eating utensils.
  • Avoid kissing or performing oral sex.
  • Avoid sharing lip balm or lipstick.
  • Avoid sharing razors, towels, and other personal care items.
  • Wash your hands with soap and water if you touch an active lesion.
Unfortunately, the virus can still be transmitted even when someone does not have active lesions.
When to Seek Medical Care
If you develop tender, painful sores in the mouth or on the lips or nose, see a physician.

Contact your doctor immediately if an HSV outbreak has not gone away in 2 weeks, if you are not eating or drinking because of the pain, or if you develop blisters or sores near your eye.

If you have an underlying medical condition such as cancer or HIV, or if you have undergone organ transplantation, you are at higher risk for more serious complications. Seek medical advice as soon as possible, especially if you are at risk for more serious complications.
Treatments Your Physician May Prescribe
Most HSV infections are easy for physicians to diagnose. On occasion, however, a swab from the infected skin may be sent to the laboratory for viral culture, which takes a few days to grow. Blood tests may also be performed.

Untreated HSV infections will go away on their own, but medications can reduce the symptoms and shorten the duration of outbreaks. There is no cure for HSV infection.

Treatment for primary HSV infection includes the following oral antiviral medications:
  • Acyclovir pills
  • Valacyclovir pills
  • Famciclovir pills
These medications are usually taken for 5–14 days.

More severe primary HSV infections may require additional medications:
  • Oral antibiotic pills if the areas are also infected with bacteria
  • Topical anesthetic, such as viscous lidocaine, if the areas inside the mouth are very painful
In addition, very severe infections may require intravenous fluids (and even intravenous antiviral medications) or painkillers if the pain prevents you from drinking fluids.

Treatment for recurrent HSV infection includes the same oral antiviral medications used to treat primary infection:
  • Acyclovir pills
  • Valacyclovir pills
  • Famciclovir pills
People who experience early signs (prodromes) before recurrent infections may benefit from episodic treatment, by starting to take medication after the onset of tingling and burning but before the appearance of blisters and sores.

Other people have recurrent infections that are frequent enough or severe enough to justify suppressive therapy, in which medications are taken every day in order to decrease the frequency and severity of attacks.



References

Bolognia, Jean L., ed. Dermatology, pp.1235-1241. New York: Mosby, 2003.

Freedberg, Irwin M., ed. Fitzpatrick's Dermatology in General Medicine. 6th ed, pp.1252. New York: McGraw-Hill, 2003.
Last Updated: 22 Dec 2008