Cold Sores (Orofacial Herpes)

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Images of Herpes Simplex Virus (HSV), Orofacial


Orofacial herpes simplex virus is the medical name for herpes simplex infection of the mouth and face, also known as cold sores or fever blisters. These are common, contagious sores that usually occur on the inner and outer lips but can also be spread to the fingers and other body parts. There are 2 major strains of herpes simplex virus (HSV): herpes simplex type 1 (HSV-1) and herpes simplex virus type 2 (HSV-2). In general, cold sores and fever blisters are caused by HSV-1, and genital herpes is caused by HSV-2. HSV-1 is not a sexually transmitted disease, though HSV-2 is. There is no cure for either strain of the virus, and once a person is infected, he/she is contagious for life.

Fever blisters and cold sores look like small open sores, usually appearing on the corners of the mouth or inside the lips. They are often painful when the sores are open, and before they appear, some people experience a tingling sensation that indicates that the cold sore is on its way. Once a person has a cold sore at one location, he/she is more likely to get another in the same location at another time. Cold sores and fever blisters can be spread by kissing or sharing intimate objects such as toothbrushes, lip balms, utensils, or towels.

Both HSV-1 and HSV-2 are very contagious. However, only about 20% of people exposed to either virus will experience the associated sores. This means that the majority of people carrying the virus do not know it. For this reason, it is important to protect yourself by knowing your sexual partners and by avoiding contact with others' intimate items. There is no cure for either strain of HSV. People who struggle with frequent outbreaks of sores often learn specific triggers that bring the sores on and can take medicines or use treatments to help lessen the attacks.

Who's at risk?

Anyone of any age can get either HSV-1 or HSV-2. HSV -1 is more common, and almost all adults in the United States are carriers of the virus, though only some people develop the associated sores.

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. These blisters may be yellow to gray and are fragile, so that many people never notice blisters but instead see tiny 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) HSV outbreak typically lasts 1–3 weeks.

In mild cases of primary orofacial HSV infection, an individual may develop 1 or 2 cold sores, or the newly infected person may notice no symptoms at all. The lymph nodes in the neck may or may not be swollen. In severe cases of HSV infections, the infection may involve the entire lining of the mouth and both lips. These severe HSV 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
  • Injury, 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 associated with the cold sores. Try to drink as many fluids as possible to prevent dehydration. Applying ice packs may relieve some of the swelling and discomfort. Avoid citrus fruits and juices or spicy foods as they may cause increased pain.

Because HSV infections are 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:
  • 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.

Trusted Links

Clinical Information and Differential Diagnosis of Herpes Simplex Virus (HSV), Orofacial


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.