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Herpes_BlisterCopyright 2006 Martin S. Spiller, D.M.D. courtesy of Dr. Ed Cataldo

Herpes Labialis (Cold Sore)

These sores can be brutally painful.  They are caused by the Herpes Simplex virus, (HSV) and when they occur, they are often accompanied by the symptoms one associates with the flu; nausea, fever, chills, muscle aches and malaise. Once a person is infected with the virus, generally early in life, he or she will suffer recurrences on a fairly regular basis, depending on the state of their mental or physical health.

The virus is an opportunistic invader, taking advantage of a depressed immune responses in a patient who is under psychological or physical distress. They are called “cold sores” or “fever blisters” because they tend to happen when the patient is physically burdened with another viral infection such as rhinovirus (the cold virus). The image above is unusual because it was taken before the blister actually broke. All cold sores start as blisters, but the blister rarely survives for long enough to actually get a picture of it.

Herpes Labialis starts with prodromal symptoms such as burning, tingling, soreness or swelling on the lip and is followed by the formation of tiny blisters, called vesicles, which coalesce and break forming a crusty sore. In healthy people, these will heal without scaring in seven to fourteen days.

New antibiotics like acyclovir (Zovirax®), famciclovir (Famvir®) or valacyclovir (Valtrex®) are effective in suppressing the Herpes virus and will generally alleviate the symptoms within a fairly short time.  Systemic drugs like these are generally used in very severe cases in immunocompromised patients, or in herpes infections of the eye. In patients exposed to a lot of sun who are prone to outbreaks of recurrent herpes labialis, a prophylactic regimen of 400 mg of acyclovir twice a day may prevent the outbreaks  Unfortunately, the antibiotics do not often “cure” the disease since the virus continues to remain in an inactive form inside a nerve root waiting for another chance to cause an outbreak.

Recently, the Food and Drug Administration has approved penciclovir 1% topical cream for the treatment of herpes labialis. This is applied every two hours while awake, and will help to shorten the duration and severity of the cold sore. Acyclovir cream (Zovirax®) is less effective

Lysine (available at most drug stores) has been reported to reduce the severity of recurrent outbreaks if taken in high enough doses (2-3 gm) at the first prodromal signs (burning, tingling)

Laser treatments are really quite an effective way to treat cold sores. These devices have only recently become widely available because of the development of inexpensive diode lasers which can now be found in many dental offices. The treatment takes about ten or fifteen minutes and is totally painless. The pain associated with these sores is relieved immediately, and the lesion itself heals within 24 to 48 hours. Furthermore, once an area of the lip is treated with a laser, that area is less likely to ever again be the focus of another cold sore.

Unfortunately, Laser treatments do not treat the underlying viral infection. The virus still “hangs out” in the trigeminal nerve root and may cause another sore in a different area of the lip at a later date. Furthermore, treating the soreness of the lip does not treat the other flue-like symptoms of the viral infection. These symptoms generally disappear within 7 to 10 days on their own, and can be relieved to a certain extent using acetaminophen and drinking plenty of fluids. The course of the infection can be shortened substantially with a course of acyclovir or another viral antibiotic.

ColdSore2Copyright 2006 Martin S. Spiller, D.M.D. courtesy of Dr. Ed Cataldo

The image above is a more typical presentation of recurrent herpes simplex (a cold sore).

ColdSore3Copyright 2006 Martin S. Spiller, D.M.D. courtesy of Dr. Ed Cataldo

The herpes virus remains inactive in a branch of the local nerve trunk throughout life. Whenever the patient’s immune system is depressed due to physical or psychological stresses, disease states, or even a common cold, the virus erupts into activity. This can happen numerous times throughout the patient’s life, which is why cold sores are often called “Recurrent” herpes simplex. The above image shows a severe outbreak. During these outbreaks, the patient may also suffer numerous generalized flu-like symptoms such as fever, malaise, headache and body aches. This virus responds quite well to acyclovir or other anti-herpetic antibiotics.

herpeslabialisCopyright 2006 Martin S. Spiller, D.M.D. courtesy of Dr. Ed Cataldo

The images above show an acute pair of herpes blisters that have coalesced to form one large lesion. The image on the right shows what it looks like 7 days later when healing is almost complete

The image below shows a case of primary herpes stomatitis in a child. The first herpes infection in a person of any age can be quite aggressive and cover quite a bit of the skin around the mouth as well as any of the tissues in the mouth. After the primary infection, which generally disappears without treatment in about two weeks, the virus “hides out” in the trigeminal nerves and manifests as a cold sore when the patient’s immune system is at a low ebb such as when he or she is sick or under a lot of stress.

PrimaryHerpesPatients who develop recurring cold sores are actually continuously infected with the virus, even when the lesions are not present. Patients are generally infected when they are quite young.

HerpesWhitlowCopyright 2006 Martin S. Spiller, D.M.D. courtesy of Dr. Ed Cataldo

Herpes can also be transferred from the mouth to other parts of the body simply by touching the blister with the fingers and then touching other areas. When the virus is transferred to the eye, ocular herpes may result. Ocular herpes can be very painful and dangerous. When a herpes blister forms on the fingers or the hand, the lesion is called a herpes whitlow (pictured above).

A Note on Genital Herpes

Herpes Simplex type I (HSV-1)prefers to infect the face and oral cavity. It is the virus most responsible for traditional cold sores and primary herpes stomatitis. There is, however a second variety of Herpes that prefers to infect the genital areas. Herpes Simplex Type II (HSV-2) is called “genital Herpes” because of its venereal (sexually transmitted) qualities. Both varieties produce similar lesions, the difference between them being their site specific preferences. Both establish latency (take up permanent residence) in nerve roots and once established, tend to cause occasional outbreaks with active lesions (sores) in areas of the body serviced by that particular nerve root. HSV-1 prefers to live in the trigeminal nerve root where it causes lesions in the oral cavity and on the face. HSV-2 takes up residence in the sacral ganglion at the base of the spine where it may cause genital lesions (see the dermatome chart on the Herpes zoster page).

Even though each type has site specific preferences, the viruses are genetically similar and can take up residence in nerve roots in other parts of the body, including in each other’s territory. Outside of their own home territories, however, neither virus is especially virulent, and rarely cause recurrent outbreaks.  Although HSV-1 can infect the genital regions, HSV-2 causes approximately 90% of all cases of genital herpes. Genital herpes caused by HSV-1 is generally much milder than that caused by HSV-2. HSV-1 is usually transferred to the genital area by direct oral/genital contact, because the virus is present in the saliva of infected individuals. Thus the use of saliva as a lubricant can, in fact, transfer HSV-1 to the genital area. HSV-1 is found in only about 10% of all cases of genital herpes, however most people infected with HSV-1 in the genital area have few, if any, outbreaks after the initial episode. HSV-2 prefers to live in this area and causes a much more virulent infection there.
On the other hand, HSV-1 causes almost all cases of oral and facial herpes. Oral herpes caused by HSV-2 almost never reoccurs, except in immunocompromised patients.

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