What are other Names for this Condition? (Also known as/Synonyms)

• Fever Blisters
• Herpes Labialis
• Orolabid Herpes

What is Cold Sores? (Definition/Background Information)

• Cold Sores are fairly common infections caused by the herpes simplex virus (type 1). It typically leads to the formation of painful blisters on the outer lip. The infection is also referred to as Fever Blisters
• Generally young individuals are affected by this highly contagious condition. The risk factors for Cold Sores may include direct contact or sharing materials with infected individuals, oral sex, and individuals who are immune suppressed
• The blisters grow and ulcerate in about 3 weeks after exposure to the virus. The signs and symptoms are worst during the first episode of infection. Subsequent ulcer formation (recurrent Cold Sores) may have less severe presentations. Individuals can be contagious even before the appearance of the ulcers
• The infection may be accompanied by fever, body pain, and swollen lymph nodes. Sometimes, other parts of the body (such as the eye or brain) may be severely affected
• There is no cure for Cold Sores. But, the infection usually disappears within 4 weeks without leaving behind a scar. Antiviral medications and symptomatic treatment are generally adopted to manage the signs and symptoms of the infection
• In most cases, Cold Sores are self-limiting and are not serious conditions. The prognosis is generally good and most individuals make a full recovery. However, in some cases, individuals with poor immune system may be severely affected

Who gets Cold Sores? (Age & Sex Distribution)

• Individuals of all ages can be affected by Cold Sores, but it is more common in adolescents and young adults
• The condition is less frequent as one age into adulthood. However, since the immune system generally weakens in elderly adults, the virus may get reactivated causing Cold Sores in the elderly (a higher occurrence may be observed in them)
• Males and females are affected and no gender preference is observed
• The condition is observed worldwide; there is no racial or ethnic predilection
• Cold Sores are very common; studies indicate that approximately 9 in 10 individuals get infected at some point in their life

What are the Risk Factors for Cold Sores? (Predisposing Factors)

Following are the risk factors associated with Cold Sores:

• Contact with infected individuals; sharing items or materials (such as bed sheets or towels) with such infected members
• Unprotected sex with individuals who are infected, especially oral sex (both giving and receiving)
• A previous episode of Cold Sores; the condition is generally recurrent
• Individuals with eczema have a great risk for the infection
• Having a poor immune system (due to various reasons) and exposed to the virus
• Infection during pregnancy: Pregnant women can transmit the condition to their unborn child
• Healthcare workers administering to infected individuals
• Severe malnutrition

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases ones chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of Cold Sores? (Etiology)

The herpes simplex virus 1 (HSV 1) frequently causes Cold Sores, which is a highly contagious infection.

• The HSV viruses are latently present in most humans after the first episode of infection. After the virus enters the body, it hides in the nerves, especially the facial nerves, even though the individual may not show any signs of infection
• However, the virus remains inactive if the immune system is healthy and robust. In those, who have a susceptible or compromised immune system, the virus can get reactivated and affect many body areas apart from formation of sores on the mouth/lips
• The triggers for the virus to get reactivated may include:
  • Stress
  • High fever
  • Sunburn
  • Food allergies
  • Hormonal imbalance
  • Underlying autoimmune disorders
  • Recurrent Cold Sores also has the same set of triggers
• Transmission of the virus may also occur in various ways including by:
  • Kissing (through saliva)
  • Sharing of materials
  • Oral sex
• Infants may be infected while in the womb or immediately after birth, during breastfeeding, if the mother is infected. Infection spread from the pregnant woman to child can often be a severe and serious condition for the child

Less frequently, Cold Sores can be also caused by the herpes simplex virus 2 (HSV type 2).

What are the Signs and Symptoms of Cold Sores?

Majority of individuals infected with HSV 1 may not have any signs and symptoms. Also, the severity of signs and symptoms of Cold Sores varies from individual to individual. The presentations may include:

• Formation of small blisters that are fluid-filled around the lips (and may be the nose) initially, which are followed by ulceration when the blisters break; the blisters are present in small groups
• A tingling or burning sensation at the site may be felt, which then becomes very painful
• The lesions form more commonly on the border of the outer lip, than the inside of the mouth. From the lips, it can spread to the cheek and around the mouth
• There can be accompanying sore throat, body aches, headaches, swollen lymph nodes, and swallowing difficulties
• The infection may spread to other parts of the body such as the brain, eyes, or to the fingers causing related signs and symptoms
  • When the skin is affected, it can cause skin rashes with blister formation that are often painful
  • The infection is called herpes whitlow, if it spreads to the finger tips with ulcer formation
  • Severe headaches may be present if the condition affects the brain, called herpetic meningitis
  • When the eyes are affected, it can cause pain, irritation, redness, and tearing from the eyes, known as herpes simplex conjunctivitis
• The ulcers ooze and then eventually heal in 7-10 days. The affected individual is infectious until the ulcer completely heals

In general, the signs and symptoms of Cold Sores progress in 8 stages: In some individuals, the infection may be more severe and the time line of the following 8 stages may be shortened.

Stage 1: Latent remission period

• It can last from weeks to months; the individual is usually asymptomatic during this period
• However, the individual may be contagious in spite of no signs and symptoms

Stage 2: Prodromal stage

• This stage usually lasts 1-2 days
• The affected individual may have tingling sensation and redness at the infection site
• The condition at this stage is contagious
• A prompt recognition can help in early treatment, which can shorten the duration and severity of infection

Stage 3: Inflammation stage (Days 1-2)

• This stage usually lasts 1-2 days
• The individual has redness and tingling sensation at infection site
• The affected individual is contagious
• Treatment at this stage can help decrease the severity and duration of the infection

Stage 4: Pre-sore stage (Days 2-4)

• This stage usually lasts 2 days
• There is a formation of small blisters that are painful
• This stage is contagious

Stage 5: Open sore stage (Days 3-5)

• This stage usually lasts 2 days
• The sores are very painful
• The vesicles break to form ulcers with fluid oozing from them
• It is a very contagious stage
• Stage 5 may be associated with fever/body aches

Stage 6: Crusting stage (Days 5-8)

• This stage usually lasts 3 days
• The ulcers crust and start to heal; there may still be significant pain
• Oozing may be present
• The individual is contagious

Stage 7: Healing stage (Days 8-15)

• This stage usually lasts 7 days
• The ulcers begin to heal and the pain is usually decreased
• Affected individuals are still infectious, but less so
• Fever and body aches decrease

Stage 8: Post scab stage (Days 12-16)

• This stage usually lasts 4 days
• The ulcers are healed; there may be some redness
• Mild pain may be present
• Individuals can be infectious in stage 8 too, but less so

How is Cold Sores Diagnosed?

• Diagnosis of Cold Sores is made based on the complete evaluation of medical history and thorough clinical examination (including visual examination of the mouth sores)
• An oral examination may be performed
• Blood tests or blood culture to rule out other infectious causes
• Examination of lesion scrapings: The cells from the scrapings are examined under a microscope to detect viral changes

In majority of cases, additional laboratory tests are generally unnecessary to diagnose the infection. Nevertheless, it may be undertaken to help rule out other causes of infection.

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

What are the possible Complications of Cold Sores?

The possible complications of Cold Sores may include:

• If the eyes are severely affected, then it may result in corneal ulcer or scarring; severe damage to the eye can also lead to loss of vision
• If it spreads to brain, it can cause meningitis or encephalitis
• There can be serious complications, if there is underlying immunosuppression such as AIDS
• Recurrence of Cold Sores
• Untreated Cold Sores may give rise to superimposed bacterial or fungal infections

How is Cold Sores Treated?

Currently, there is no cure for Cold Sores. However, medications can help improve the signs and symptoms, alleviate the discomfort, and ensure an earlier recovery, if prompt treatment is provided. Many individuals with mild symptoms get better on their own without treatment.

Nevertheless, the following situations warrant consultation with a healthcare provider:

• The Cold Sores are not healing within 2-4 weeks
• If there are severe signs and symptoms due to the infection
• If one has a weakened immune system (due to autoimmune disorder, HIV infection, organ transplant, underlying treatment for cancers)
• If there are frequent occurrence of Cold Sores
• If there is pain or irritation of the eyes, which could indicate early signs of herpes simplex conjunctivitis
• If there are severe headaches, which may indicate herpetic meningitis
• If the affected individual already has eczema

The treatment measures for Cold Sores may include:

• Antiviral therapy, which can make the condition better and heal faster
• Use of anti-inflammatory pain medication
• Symptomatic treatment with medications and self-care to improve the signs and symptoms
• Treat underlying associated conditions, if any

Individuals with eczema who develop signs and symptoms of Cold Sores should seek immediate medical attention; since, this can be a life-threatening emergency.

How can Cold Sores be Prevented?

The herpes simplex viral infection causing Cold Sores is an opportunistic infection. The virus affects a large proportion of the population. Maintaining basic hygiene and following simple practices (such as regular hand washing) can reduce the risk of HSV transmission through direct contact.

The preventive measures for Cold Sores may include:

• Avoiding physically interacting with infected individuals, such as kissing, sharing of items, etc.
• Practicing safe sex
• Washing hands at regular intervals
• Avoiding picking, touching, or scratching the mouth ulcers
• Avoiding touching one’s eyes frequently
• Individuals with poor immune system should avoid any behavior that places them at risk for infection

What is the Prognosis of Cold Sores? (Outcomes/Resolutions)

• Cold Sores are usually not life-threatening infections
• The prognosis is generally very good. In a majority of the individuals, the infection resolves spontaneously within 3-4 weeks. Also, there is no scarring of the skin associated with the condition
• However, the infection can come and go, and the infection remains in the body lifelong
• Individuals with weak immune systems may be affected severely by Cold Sores, if early treatment is not provided

Additional and Relevant Useful Information for Cold Sores:

• In many cases, Cold Sores are often confused with herpetiform canker sores. In herpetiform canker sores, ulcer formation precedes blister appearance. Whereas in Cold Sores, small blisters appear initially, which then ulcerate and heal
• Generally, HSV 1 affects the head and neck area, while HSV 2 affects the genitalia. However, it can be the other way too