Cold Sores and Herpes Simplex

Craig Kraffert, MD

Herpes simplex virus, or HSV, skin infections are very common. By some estimates, up to 95 percent of adults in the United States tested will demonstrate antibodies indicating past exposure to this virus. The manifestations of herpes simplex virus exposure range from undetected one time infection to recurrent debilitating eruptions.

HSV can cause blisters and sores almost anywhere on a person’s skin. These sores usually occur either around the mouth and nose or in the genital areas. The sores may be painful and unsightly. HSV infections can be very annoying because they can reappear.

HSV-1 and HSV-2

There are two types of HSV: type 1, or HSV-1, and type 2, or HSV-2. The HSV-1 virus causes what are often referred to as cold sores. Most people catch HSV-1 infections during infancy or childhood from close contact with family members or friends who carry the virus. It can be transmitted by kissing or by using the same eating utensils and towels. The sores most commonly affect the lips, mouth, nose, chin or cheeks and occur shortly after exposure. Symptoms may be barely noticeable or require medical attention for pain relief. The cold sores return as a result of reactivation of the HSV infection.

HSV-2 virus is best known for its role in genital herpes, an infection that is usually spread by intimate contact. These infections may be one-time events without recurrence or shedding. In many cases, however, people with this virus experience intermittent outbreaks of cold sore like blisters in genital areas. These blisters are contagious. Additionally, people may harbor the virus at a level that is invisible but allows for shedding of the virus and the chance to spread it to others.

The degree to which HSV-2 causes symptoms once an initial exposure occurs depends largely upon a complex interplay between the virus and the immune system. It is possible to harbor the virus for years without symptoms and then begin developing symptoms at a later date -- sometimes years later. This may result in guilt and confusion when this condition surfaces in a longstanding monogamous relationship.

Both HSV-1 and HSV-2 infections may occur virtually anywhere on the skin, not just on the face or genital areas. Wrestlers, for example, are prone to develop HSV on the body and extremities from contact in the wrestling ring. This is referred to as herpes gladiatorum.

HSV Symptoms

There are two kinds of HSV infections: primary and recurrent. Although most people have been infected with HSV, only 10 percent actually develop sores or cold blisters when the primary infection occurs. The sores of a primary infection last a week or so and appear one to three weeks after contact with an infected person.

The number of blisters varies from one to a cluster. Before the blisters appear, the skin may itch or become very sensitive. The blisters break by themselves or as a result of minor injury, allowing the fluid inside the blisters to ooze and crust. Eventually, crusts fall off, leaving slightly red healing skin.

HSV is most contagious during the phase prior to complete crusting and scabbing, as the blister fluid contains large amounts of contagious viral particles. The sores from primary infection rarely leave a scar. However, the virus causing the infection moves to nearby nerve cells where it remains in a dormant phase with the ability to reactivate and cause recurrent skin eruptions.

Recurrence of HSV

Many people never have a recurrence of HSV. Others will have one or more recurrences, either at the same location as the first infection or at a nearby site. The eruptions may recur every few weeks or less frequently and tend to be milder than the primary infection. Recurrent eruptions can be triggered by a variety of factors including stress, fever, sun exposure and hormonal cycles. For many, however, recurrences are unpredictable and have no recognizable cause.

Treatment of HSV

There is no vaccine to prevent HSV. Safe oral antiviral medications such as Valtrex (valacyclovir) have been developed for severe or frequently recurrent infections. These medicines may be taken at the beginning of each eruption to lessen the duration and severity of the recurrence. Alternatively, low doses of these medicines taken on a regular basis have been shown to be helpful in reducing the number of HSV attacks for people with frequent outbreaks.

In addition to medication, avoidance of common HSV triggers may be helpful. One of the most important manageable triggers is sunlight exposure. Those with history of recurrent HSV often benefit from sun avoidance and regular use of sunscreens for exposed skin and lips. Topical medications that lessen the discomfort associated with these sores are also available.