Cold Sores

Cold sores are small, blister-like lesions which usually appear around the mouth. They're caused by the herpes simplex viruses. The strain that usually causes them around the mouth is herpes simplex type 1 (HSV-1).

 In most cases, the virus is passed on in early childhood when a child is kissed by a person with a cold sore, such as a family member. The virus goes through your skin and travels up your nerves, where it lies dormant (inactive) until it is triggered at a later date.

There are several different factors that are thought to trigger outbreaks of cold sores, which can be different for each person.

The triggers may include:
- Emotional upset, or psychological stress
- Fatigue and tiredness
- An injury to the affected area
- Menstruation
- Strong sunlight

In rare cases, cold sores can also be caused by the herpes simplex type 2 virus (HSV-2). This can happen as a result of having oral sex with a man or woman who has genital herpes.

Cold sores usually clear up without treatment in seven to 10 days. Creams and treatments are available over-the-counter (OTC) that can help ease the symptoms of cold sores and to speed up the healing time. To be effective, they must be applied as soon as you have any signs of a cold sore, e.g. pain, burning, tingling, itching or a numb sensation (paraesthesia).

In the majority of cases, cold sores are mild. In rare cases they can cause a number of complications. It isn't possible to prevent cold sores, but there are ways to prevent them from recurring.

Symptoms
Symptoms of the primary infection
In most cases of primary infection of the cold sore virus, there will not be any noticeable signs or symptoms. However, if there are symptoms, they are most likely to occur in children under the age of five, and they can be quite severe.

They include:
- Swollen and irritated gums, with small painful sores in and around your mouth (known as herpes simplex gingivostomatitis)
- Sore throat and swollen glands
- Excess salivation (producing more saliva than normal)
- Fever
- Dehydration (a lack of water in the body)
- Nausea
- Headaches

If you or your child develops herpes simplex gingivostomatitis, it can last between 7-14 days, and it may take up to three weeks for the sores to heal. However, gingivostomatitis does not often recur after the primary infection. It is usually young children who get gingivostomatitis, although it is possible for adults to get it as part of a primary infection.

However, if an adult has a primary infection it usually presents itself as pharyngotonsillitis (a sore throat and swollen tonsils), or a glandular fever-like illness. The symptoms will usually be a sore throat, with or without swollen glands. You may also have halitosis (foul-smelling breath) and painful sores in and around your mouth, which can develop into ulcers with grey or yellow centres.

If someone has been infected with the herpes simplex virus at an early age, it may be triggered periodically in later life which can cause recurring bouts of cold sores. After the primary infection, the symptoms are usually reduced to just the cold sores themselves.

Symptoms of the recurrent infection (outbreaks of cold sores)
Recurrent infections are usually shorter and less severe than the primary infection. The only symptom is usually the outbreak of cold sores themselves, although in some cases you may also have swollen glands.

An outbreak of cold sores usually starts with a tingling, itching or burning sensation around your mouth. Small fluid-filled sores then appear, most commonly on the edges of your lower lip.

If you have frequent recurrent infections, you may find that your cold sores occur in the same place every time. Your cold sores may grow in size and cause irritation and pain. They may weep and eventually grow a crust or scab within 48 hours of the initial tingling sensation.

Treating cold sores
Antiviral treatments for cold sores
If used correctly, antiviral cold sore creams may help speed up the healing time of a recurrent infection. They usually contain medication known as aciclovir or penciclovir. Typical brand names include Zovirax, and Soothelip.

These creams are widely available over-the-counter (OTC) from pharmacies without a prescription. However, it is important to remember that they are only effective if you apply them as soon as the first signs of a cold sore appear, when the herpes simplex virus is spreading and replicating itself. Using an antiviral cream after this initial period is unlikely to have much effect.

If you have frequently recurring bouts of cold sores, you should apply an antiviral cream as soon as you feel the tingling sensation which indicates that a cold sore is about to develop. You will need to apply the cream up to five times a day, for 4-5 days, in order for it to work. However, antiviral creams can only help to heal a current outbreak of cold sores. They do not get rid of the virus that causes cold sores, or prevent future outbreaks from occurring.

If your cold sores are particularly severe, or you have a damaged immune system (which can be caused by factors such as undergoing chemotherapy, or having HIV), you may be at risk of further complications, including encephalitis (swelling of the brain) or a spread of your infection to other parts of your body, such as your eyes.

If this is the case, you should see your GP, who may prescribe antiviral tablets and refer you for specialist treatment. The kind of treatment that you will receive will depend on the severity of your cold sores, or the particular complication that is causing problems. For example, if you develop herpetic keratoconjunctivitis (a secondary infection that affects the eyes), you may need to see an ophthalmologist (specialist eye doctor). For more information about this, see the 'complications' section.

Non-antiviral treatments for cold sores
There are several non-antiviral creams that are available over-the-counter (OTC) without a prescription, from pharmacies, which may help to ease the irritation of your cold sores. However, these creams are not made specifically to treat cold sores, and they will not help them to heal faster, but you may want to try them if your cold sores are painful, dry or itchy. Brand names include Bonjela, Blistex and Cymex.

When applying antiviral or non-antiviral creams to cold sores, you should dab them on rather than rubbing, as this may damage your skin further. Before and after applying cold sore creams, you should wash your hands using soap and water. You should also avoid touching your cold sores, other than to apply cream. Do not share your cold sore cream with others.

Pain can be treated with painkillers, such as ibuprofen or paracetamol (both are available in liquid form for young children). However, you should not take ibuprofen if you are asthmatic or you have, or have had, stomach ulcers. Children under the age of 16 should not take aspirin.

You should speak to your GP if you have cold sores and you are pregnant.

Complications of cold sores
Infections caused by the cold sore virus are often mild and usually heal without the need for treatment. However, in rare cases they can cause complications, particularly in people with damaged immune systems, such as those undergoing chemotherapy and those who are HIV positive.

The possible complications of the cold sore virus are detailed below.

Dehydration is a lack of water in the body, and it may occur as a result of the pain caused by an infection of the cold sore virus. Cold sores, or herpes simplex gingivostomatitis, can be painful, and it's easy to neglect your need to drink plenty of fluids. Young children are particularly at risk of becoming dehydrated.

It is possible for the cold sore virus to spread to other parts of your body. This is known as a secondary infection. Herpetic whitlow is a secondary infection of the cold sore virus, which causes painful sores and blisters on your fingers. It can occur when the cold sore virus comes into contact with a cut or graze on your hand, and enters your skin. However, it can be easily treated using antiviral medication.

Herpetic keratoconjunctivitis is a secondary infection of the cold sore virus which affects your eyes. If the virus comes into contact with your eyes, it can cause inflammation (swelling and irritation) of your eye area, and sores to appear on your eyelids. However, it can usually be easily treated using antiviral medication available from a specialist eye doctor.

If left untreated, herpetic keratoconjunctivitis can cause your cornea (the transparent layer over your eye) to become infected, which can eventually lead to blindness. It is very important not to touch your eyes when you have an active cold sore. However, if you must touch your eyes, for example to remove contact lenses, make sure you wash your hands thoroughly first.

Encephalitis is a serious condition in which the brain becomes swollen, possibly causing brain damage and even death. In severe cases it is caused by the cold sore virus spreading to the brain, but this is very rare. Encephalitis can be treated by injecting antiviral drugs such as aciclovir into the veins

It is not possible to completely prevent primary infections, or outbreaks of cold sores. Cold sores are at their most contagious when they burst (rupture), but they remain contagious until they are completely healed. Therefore, it is important for others to avoid direct contact with your affected area until your cold sore has completely healed and disappeared.

However, if you or your child have a cold sore, there is no need for you to stay away from work, or for your child to miss school. Similarly, if you or your child have a primary infection, you do not need to keep yourselves away from work, nursery or school, unless you're feeling unwell.

Minimising the spread of the infection
Measures that you can take to help minimise the spread and recurrence of the cold sore virus are detailed below.

- Try to avoid touching your cold sores, unless you are applying a cream. Creams should be dabbed on gently rather than rubbed in, as this can damage your skin further.
- Always wash your hands before and after applying cream, and after touching the affected area.
- Do not share creams or medications with others because this can cause the infection to spread.
- Do not share items that come into contact with the affected area, such as lipsticks or cutlery.
- Avoid kissing and oral sex until your cold sores have completely healed.
- If you have a cold sore, be particularly careful around newborn babies, pregnant women and people with a low immune system, such as those who have been undergoing chemotherapy, or those with HIV.

Preventing recurrent outbreaks of cold sores
If you know what usually triggers your cold sores, try to avoid these triggers if possible. For example, a sun block lip balm (SPF 15 or higher) may help to prevent cold sores triggered by bright sunlight.

Use an antiviral cold sore cream, such as Zovirax, as soon as you feel the tingling sensation that indicates a coming cold sore. However, there is no benefit in using an antiviral cream continuously to try and prevent future cold sores. They cannot cure the virus, and will only be effective once the virus has been triggered.

Nicki Wakeman - Almeria Angels