“Ouch”, it hurts when I smile.

Those darn cold sores!

Author: Mark Parkinson RPh:  President  AFC CE

Credit Hours 1- Approximate time required: 60 min. 

Educational Goal

To give an instructional overview of cold sores

Educational Objectives:

1.  Give a description of what is a cold sore.

2. Tell how to treat cold sores.

3. Tell when care giver should respond to a cold sour outbreak


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  Disclaimer  -    The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.


“Ouch” it hurts when I smile.

Those darn cold sores!


Those darn cold sores!

     Cold sores, fever blisters, or recurrent herpes labialis are those annoyingly painful blisters that form around the lips. They break out, leak fluid, and crust over.  Before they go away, scabs form that are none too flexible. They often crack when you move your lips, adding to the painful annoyance.  Just what are cold sores? Where do they come from? Can I get rid of them? Can I prevent them from happening in the first place? As a care provider, should I even care?

What are cold sores?

     Cold sores are lesions that are the result of a reoccurring infection of the Herpes Simplex Virus (HSV). That’s right, herpes. You might have heard that name before associated with a sexually transmitted disease. You’d be wrong to worry, though, because there are two types of HSV.  Simply named HSV-1 and HVS-2.  HSV-2 is the bad one; HSV-1 is the more common form that causes most of the cold sores.

Where do they come from?

     Unfortunately, HSV is a very common, very contagious virus. It has been estimated that by age 50, 80-90 percent of adults carry the virus. More than 50 million people in the U.S. will have at least one outbreak this year. Everyone who has an outbreak can potentially spread the virus to anyone they come in contact with.

     It can be spread by direct contact, like kissing, or indirect contact. It can be passed along by sharing a drink or lip balm, or if the patient rubs the sore with his hands then spreads it by touch.  The virus can even spread through air-borne droplets of saliva from a sneeze. It is pretty safe to answer the question, “Where do they come from” by answering “from anywhere and anyone.”

How does the infection progress?

     Most people get their first exposure as a child or adolescent. It manifests itself as a fever with a severe sore throat, possibly with lesions that on the cheeks or gums. The body quickly develops antibodies to the virus and the symptoms fade. But the virus never completely goes away. There are places where it can hide and go dormant, waiting for optimal conditions to multiply and spread again. Its primary hiding place is the sensory facial nerves around the mouth.

     When a virus invades a cell, it will start to take over and make the cell produce more viruses. Eventually the cell dies or bursts, releasing thousands of new viruses. For the most part, the body’s defenses will swoop in and take care of things. That is why we are symptom-free, although we all carry the virus. But there are times when our defenses are down or busy elsewhere and a local outbreak happens and symptoms reoccur.

Cycle of an outbreak

Symptoms typically follow an eight-stage cycle.

  1. Latent or remission period: There are no symptoms. It can last weeks to months
  2. Prodromal: (day 0-1): Symptoms start to appear before the lesion does. Typically it starts with a tingling or itching along with redness around the infection site. This can last a few hours to a few days
  3. Inflammation (day 1): The virus tries to attack new cells. The body tries to defend itself with the inflammation response, essentially walling off the area and calling in the clean-up crew.
  4. Pre-sore (day 2-3): When the inflammation response starts to take care of all those new viruses, things get pretty crowded. Tiny, hard, inflamed vesicles start to form. They may itch and become painful. Soon, fluid-filled blisters form in a cluster, usually at the border of the lip and skin, but they can form on the nose, chin, or cheeks. (In case you’re wondering, only about 10 percent of cold sores develop away from the lips.) 
  5. Open lesion (day 4): The tiny blisters break open and become one large, irregular-shaped one. An all-out battle is occurring between the infection and the body. The discharge weeping from the sore is full of active viral particles that are highly contagious
  6. Crusting (day 5-8): The body is starting to win the battle and a hard scab starts to appear. But the scab cracks and breaks with lip movement causing more pain and virus-filled fluid to leak out.
  7. Healing (day 9-14): New skin is formed under the scab as the infection starts to resolve itself. Most, but never all, of the viral particles are killed off.
  8. Post-scab (12-14 days): The battle is all most over. A reddish area may linger as new cells are regenerated and the inflammation response is turned off.

What triggers an outbreak?

   In about one-third of those who carry the virus, a reoccurrence of cold sores can happen. In most people, the blisters form in the same area each time and are triggered by the same factors.  Common trigger factors or “stressors” include overexposure to the sun and other UV radiation sources; mouth surgeries; facial procedures like laser treatments, tattoos, and chemical peels; psychological stress; menstrual cycles; and immunosuppression.  Cold sores that are sun-induced tend to be more severe in pain and duration.

What can you do for cold sores?

     There is no known cure for HSV-1, but since patients are largely symptom-free, it just doesn’t matter.  But what do you do about those annoying cold sores when they pop out?

Cold sore treatment options

A. Do nothing. Cold sores are self-limiting and they resolve themselves after about 14 days.

B. Treat yourself. There are several OTC medications you can use to feel better. There is no “one-drug-does-all” medicine, so you must know what each one does and chose your therapy wisely.  Here is a list of the different kinds of OTC medication by group.

  1. Docosanol (Abreva). This is the only OTC medication approved for the healing of cold sores. It works by blocking the virus from entering cells. It heals about as well as prescriptions and costs about $15. It cuts the severity of the outbreak but only lessens the duration by about a day or two. You must apply it five times daily for no more than 10 days. It does nothing for the pain, but the cream base might help the scab from cracking.
  2. Pain relieving pills. We all have our favorites - no use in listing all the benefits and side effects. The idea is to use them to reduce the pain. One note, though: acetaminophen (Tylenol) does not reduce inflammation.
  3. Topical agents. There are plenty of creams, ointments, and solutions with medicines that numb, dry up the sores, or keep the scab pliable to prevent cracking.  I really don’t have a preference myself, though I can tell you that 20-percent benzocaine is probably the most potent numbing agent.  The following is an incomplete list of the products I know about. Anbesol cold sore remedy, Blistex medicated lip balm, Campho-Phenique with drying action, Carmex, Chap Stick cold sore therapy, Herpecin L, Lip Clear Lysine +, Neosporin LT, Orabase, Zilactin,
  4. Moisturizers. Pharmacists recommend keeping the area moist as the lesion begins to form a crust. If the lesion cracks, it may be more susceptible to secondary bacterial infection that can slow   healing. Common skin protectants, such as petrolatum and cocoa butter, can be used to keep the area moist.
  5. Other treatments.  Tooth-numbing agents would probably do in a pinch, although all numbing agents wear off fairly quickly. Lysine has been used for a long time on cold sores but scientific studies done with it just does prove it actually does anything. Zinc can prevent viruses from multiplying, but here again, there isn’t much proof that it works on cold sores. For herbals and homeopathic agents, you’ll have to decide for yourself because there isn’t much scientific evidence one way or another.

C. Prescription antivirals. Topical (acyclovir cream, penciclovir cream) and oral (valacyclovir, famciclovir) antiviral agents are effective in reducing the viral load of an outbreak and reducing the severity of the infection. But for maximum effect, therapy should start within the first two days of infection. A quick response becomes problematic when doctor appointments are involved. Because the of self-limiting nature of cold sores, there are those who say that doctors should only be called when there are serious complications or reoccurrence is very frequent.

Can you prevent cold sores?

The answer is yes and no.

Yes: By avoiding “stressors,” it is conceivable that you could avoid some cold sores. Of course that would mean that you have to know what events trigger your individual outbreaks. You’ll need to pay attention and keep good records. If you have frequent outbreaks, it might be worth the effort.

No: Sometimes bad things just happen and you have no control. Certainly, a healthy lifestyle goes a long way, but who can completely control everything that happens to them?

As a caregiver, should I even care?

     From a caregiver’s point of view, the real question is, when should I care? A cold sore can be painful and embarrassing, but it’s not a serious infection. From my perspective, I take care of those who are under my charge. Their condition is a direct reflection on my caring skills. The way a client looks and feels is the most potent advertisement of my skills. Beside, that’s what I do - care for people.

     Still, there are those times when even a cold sore can be a serious infection.

  1. Frequency of cold sores. Outbreaks usually occur less frequently after age 35. If you see an increase in frequency, it could be a warning sign. A more serious health event might be happening. It would be a good idea to I would notify the doctor.
  2. Patients who are immunocompromised may suffer from severe complications such as encephalitis. For those who are at greater risk the wise saying is “When in doubt-send them out” to the doctor that is.
  3. It is possible that every cold sore infection could be spread to the eye where serious problems could rise. Be aggressive in therapy if the eye starts to get red or goopy.
  4. There are some other infections that may look like a cold sore infections. It would be important to know how to tell them apart. Two possibilities are canker sores and impetigo. Canker sores happen exclusively in the mouth and are really a mouth ulcer. Cold sores are rare in the mouth and happen in the same location over and over again. Impetigo is a skin infection most commonly seen in children. It causes blisters around the nose and mouth. If a blister happens around the nose I would send the patient to the doctor.

     One Final note to the care giver. The main cold sore battle happens in the first two days. It’s a priority that therapies should start then. Since the site of the cold sore and the symptoms are predictable it shouldn’t be too difficult to be prompt with therapy. To cover bases, if cold sores happen often I would get some standing doctors in the records on what to do.  


     HSV-1 infections are not usually serious but often painful and annoying. The infection will usually resolve itself in about 14 days. There are several things a patient or a caregiver could do to lessen the severity of an outbreak. Prompt action within the first two days of a cold sore is the most effect therapy. Rare but serious complications and look alike conditions should be handled by a doctor.



1. Elena Beyzarov, PharmD,,Addressing Common Oral Ailments: Current and Emerging Treatments for Herpes Labialis, Aphthous Ulcers, and Xerostomia. Pharmacy Times ACPE Program 0290-0000-12-86-HO1-P


2.The Free Dictionary by Farlex


3. Wm Opstelten MD, Arie Neven  MD, Just Eekhof MD, Treatment and prevention of herpes labialis, Canadian FamilyPhysican 2012                                                                 


4.  Herpes labialis. Wikipedia The Free encyclopedia


5.Cold Sores: Patient Education Series, Brown University Health Services


6. Barbara Sax, Cold sores and canker sores? What is the difference?,Pharmacy Times.Nov.1 2004


7. Mohamad El Mortada  MD, MaryAnn Tran  MD, Corrine Young  PharmD, Mary Nettleman, MD, Cold Sores.EMedicineHealth.com


8.Melanie Cupp,PharmD. PL Detail-Document, Treatment of Cold Sores. Pharmacist’s Letter/Prescriber’s Letter. May 2011. Melanie Cupp, Pharm.D.,


“Ouch”, it hurts when I smile.

Those darn cold sores!

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