Cold Sores

Question 1

What virus causes cold sores

Answer 1

HPV (herpes simplex virus)

Question 2

What are other names for cold sores

Answer 2

herpes labialis or fever blisters

Question 3

What other viruses are in the Human Herpesvirus family

Answer 3

varicella zoster virus (e.g., chickenpox & shingles) & Epstein-Barr virus (e.g., mononucleosis)

Question 4

What are the 2 types of HSV

Answer 4

HSV-1

HSV-2

Question 5

Which HSV causes mucocutaneous oral infections

Answer 5

HSV-1

Question 6

Which HSV usually causes genital infections

Answer 6

HSV-2

Question 7

What do both HSV-1 and HSV-2 cause

Answer 7

can cause ocular, CNS, or disseminated disease, but these are not common in immunocompetent people

Question 8

What is the % of the world infected by HSV-1

Answer 8

65%

Question 9

T/F: transmission requires direct contact

Answer 9

True

Question 10

T/F: The virus can be transmitted from normal skin

Answer 10

T: “asymptomatic shedding”

Virus present, no cold sore

Question 11

How are young children likely to get HSV-1

Answer 11

Adults transmit through kissing

Question 12

What are the most common ways to transmit HSV-1

Answer 12

Oral-oral, oral-genital, genital-genital

Question 13

T/F: HSV-1 seropositive patients are at risk of reinfection in a different area

Answer 13

False; have antibodies in blood that prevent auto-inoculation
- can get HSV-2 infection

Question 14

What are the types of primary oral HSV infection

Answer 14

• Asymptomatic
  * Majority of seropositive patients do not recall previous symptoms
• Symptomatic (~20 to 25%)
  * Gingivostomatitis (most common in young children)
  * Pharyngitis (most common in older children, teens, & adults)

Question 15

What are the types of reactivation/recurrence oral HSV infections

Answer 15

• Asymptomatic (e.g., asymptomatic shedding)

• Symptomatic (~20 to 40%)
• Herpes labialis (minor ailment in Ontario & other provinces)

Question 16

What is gingivostomatitis

Answer 16

Painful vesicles with fever & pharyngitis

Question 17

Where do lesions of gingivostomatitis occur

Answer 17

Lesions develop anywhere on pharyngeal or oral mucosa -> progress over several days to soft palate, buccal mucosa, tongue, & floor of mouth -> quickly ulcerate & crust over

Question 18

What are symptoms of gingivostomatitis

Answer 18

local lymphadenopathy, malaise, myalgia, difficulty eating/ drinking/ swallowing

Question 19

How long does it to take for gingivostomatitis to resolve

Answer 19

Resolves spontaneously in 7 to 18 days

Question 20

What are symptoms of pharyngitis

Answer 20

Severe sore throat

May also demonstrate pharyngeal edema, tonsillar exudate, oral exudative & ulcerative lesions

May also experience local lymphadenopathy, malaise, myalgia, difficulty eating/ drinking/ swallowing

Question 21

How long does it take for pharyngitis to resolve

Answer 21

Resolves spontaneously in 2 to 8 days, although lymphadenopathy may last for weeks

Question 22

T/F: Herpes labilis will cause fever, malaise, etc

Answer 22

False; no systemic features

Question 23

What prodromal symptoms will occur with herpes labialis

Answer 23

Pain, burning, tingling, pruritus at site within 24 hrs of lesions

Question 24

What is the progression of the lesion (herpes labialis)

Answer 24

Vesicles develop unilaterally at vermillion border of lip -> rupture & ooze -> crust -> heal without scarring

Question 25

How long does it take for lesion to heal in herpes labialis

Answer 25

Pain lasts ~24 hrs, lesions heal in 7 to 10 days

Question 26

How often does herpes labialis reoccur

Answer 26

Frequency, location, & severity variable between patients but may be consistent within patients • Frequency can range from 1 to 12 episodes per year, or none

Question 27

What factors risk reactivation of herpes labialis

Answer 27

Immunodeficiency, stress, sun exposure, fever or other infection, menstruation, trauma to area (e.g., dental work)

Question 28

Red flags for referral

Answer 28

* Suggestion of alternative diagnosis: * Lesions have been present > 14 days * Lesions follow dermatomal distribution * Lesions present beyond lips & perioral area * Lesions excessively red or swollen, or contain pus * Frequent recurrences (e.g., > 6 per year) * Immunocompromised (due to disease or therapy) * Primary infection (e.g., first ever cold sore, any systemic features, gingivostomatitis or pharyngitis)

Question 29

What are goals of therapy for herpes labialis

Answer 29

1. Prevent complications 2. Reduce spread to others (& self?) 3. Reduce intensity & duration of symptoms 4. Prevent recurrence

Question 30

T/F: HSV infection can be cured

Answer 30

False

Question 31

What are Non-Pharmacological Strategies to Prevent Complications

Answer 31

* Lip adhesions: * Barrier use (e.g., petroleum jelly, cocoa butter, zinc oxide, etc.) * Secondary bacterial infection: * Avoid touching lesions * Wash hands before touching lesions * Keep lesions clean with mild soap & water

Question 32

What are Non-Pharmacological Strategies to Prevent Spread

Answer 32

* Apply products with a disposable cotton swab * Avoid kissing & barrier-free oral-genital contact * Avoid touching lesions & wash hands frequently * Do not share cups, utensils, cosmetics, towels, etc. * Consider keeping young children who cannot yet control saliva out of daycare until lesions are crusted

Question 33

What are 3 ways to manage symptoms

Answer 33

- cool compresses (reduce pain and swelling) - systemic analgesics (acetaminophen, NSAIDS; max 3 days) - topical analgesics

Question 34

Camphor/ menthol/ phenol (e.g., Blistex®, Lypsyl®)

Answer 34

Camphor, menthol – counterirritant Phenol – anesthetic Apply TID to QID Mild tingling, cool sensation, white residue Camphor >3% or menthol >1% can cause irritation or inflammation

Question 35

Benzocaine (e.g., Anbesol®, Zilactin-B®, Orajel®)

Answer 35

Anesthetic Apply for 1 to 5 hrs then remove Numbness, tingling Allergic contact dermatitis (more likely)

Question 36

Lidocaine (e.g., Maxilene®, Lidodan®)

Answer 36

Anesthetic Apply for 1 to 5 hrs then remove Numbness, tingling Allergic contact dermatitis (less likely)

Question 37

Lidocaine/ prilocaine (EMLA®)

Answer 37

Anesthetic Apply for 1 to 5 hrs then remove Numbness, tingling Allergic contact dermatitis (less likely)

Question 38

Pramoxine (e.g., Gold Bond Anti-Itch®, Polysporin Itch Relief®)

Answer 38

Anesthetic Apply for 1 to 5 hrs then remove Burning, stinging Allergic contact dermatitis (least likely)

Question 39

What is the OTC treatment for herpes labialis

Answer 39

Docosanol 10% (Abreva® cream) - results in faster healing time - may have mild burning or stinging upon application

Question 40

What topical treatment (Rx) can be used

Answer 40

Topical acyclovir - inhibits viral DNA synthesis - >12 years - 5% cream, ointment, or combined with hydrocortisone (cream has best penetration) - Use 5x/day x 4 days - less effective than oral antivirals

Question 41

What are the oral antivirals (Rx) available

Answer 41

Acyclovir 400 mg po 5x/day x 5 days Famciclovir 750 mg po BID x 1 day (or 1500 mg po x 1) Valacyclovir 2 g po BID x 1 day

Question 42

Which is the most convenient oral antiviral

Answer 42

Valacyclovir 2 g po BID x 1 day | > 12 years

Question 43

What triggers to avoid to prevent recurrence

Answer 43

Emotional stress, fatigue, sun exposure