Cold sores - causes, treatment and when to see a Dr

What Is a Cold Sore?

A cold sore, also known as oral herpes or a fever blister, is a skin condition caused by the herpes simplex virus (HSV-1). Commonly affecting the upper lip, a cold sore can appear anywhere on the face.

The condition starts with tiny, painful, fluid-filled blisters on or around the lips. These blisters burst and crust over, before usually healing on their own after about 10 days.

Due to where they appear, cold sores can have a psychological impact, leading many to seek treatment to clear up the unsightly blisters. Here at Quick Meds, we provide antiviral creams and tablets, designed to target the causating virus.

To be effective, treatment for cold sores should start as soon as you notice the first symptoms. Get your treatment today from a GPhC-registered online pharmacy by completing a quick online questionnaire.

The Herpes Simplex Virus (HSV-1) Explained

The herpes simplex virus (HSV) is a very contagious and common virus that affects the majority of the population.
Once a person is infected, HSV stays in the body for life, resting until an outbreak occurs.

HSV is classified into two different types, based on where it presents in the body:

• HSV-1 - affects the lips, mouth and face. According to WHO, roughly 64% of people under the age of 50 have HSV-1.

• HSV-2 - affects genital or anal areas. Roughly 13% of people ages 15 to 49 live with an HSV-2 infection.

The virus enters the body through breaks in the skin (like in the lips or genitals). The first encounter is usually the worst, accompanied by systemic illness, a longer duration of symptoms and higher rate of complications.

Following the initial exposure, the virus hides in the body until a trigger wakes it up, leading to a recurrent infection. Recurrent episodes are milder and don't last as long. These recurrent infections are the ones many aim to seek treatment for through pharmacies.

How Do Cold Sores Spread

HSV-1 is a highly contagious virus, which mainly spreads through direct skin-to-skin contact:

• Intimate contact and kissing - the leading cause of oral herpes transmission.

• Oral Sex and Genital Herpes - where oral herpes spreads to the genitals

Whilst skin-to-skin contact is the main way the virus spreads, the virus can spread through contaminated objects such as:

• Eating utensils

• Lip balms, lipsticks or shared cosmetics

• Towels or pillowcases.

The most contagious phase is when the blisters are open and weeping, however, cold sores can spread at any stage of the viral cycle, due to asymptomatic shedding.

1. Prodrome Stage - the tingle. The moment you feel tingling or itching is when the virus has reactivated. You are contagious from this point onward.

2. Asymptomatic shedding - This is when patients shed and spread the virus without any symptoms. Data from studies show up to 70% of patients with HSV shed asymptomatically at least once a month.

The cold sores are contagious from the moment you feel tingling until the moment it has completely healed.

Recognising Cold Sore Symptoms

Cold Sore stages

A cold sore begins with tingling or itching, on or near the lips. Known as the prodromal stage, this is a sign HSV has reactivated and a sign cold sores are about to form. This is usually the best time to start cold sore treatments, to stop the virus from multiplying.

Within 24 hours, bumps form on the lip, which eventually turn into fluid-filled blisters. The area becomes red, swollen and painful.

On days 2-3, the blisters rupture, during the weeping phase, releasing a clear/yellow fluid. Continuing into days 3 and 4, a crust forms, turning the area into a golden-brown scab, covering the sore.

By days 6-14, the scab falls off, leaving the skin behind pink before fully healing.

The severity of symptoms depends significantly on whether this is your very first cold sore or if it is a repeat outbreak.

The very first time HSV infects you, known as the primary infection, is usually the worst. Also known as herpes gingivostomatitis, this is most common in young children.

Alongside the cold sores, you may also experience:

• Fever

• Sore throat

• Swelling/redness in your throat

• Painful sores inside the mouth

Following the initial infection, HSV travels to the nerve cells, where it stays ‘asleep’. Recurrent infections occur when the virus is reactivated and usually tend to be milder and don't last as long.

Cold Sore Treatments: Creams vs. Tablets

The right treatment could mean the difference between a slight inconvenience and 10 days of painful blisters. Here in the UK, there are various treatments available, ranging from over-the-counter to prescription-strength designed to fight HSV-1.

Depending on the severity of your outbreaks, and how often you get them, you can obtain creams, tablets and even daily prevention relief.

Topical Antiviral Creams

For those who experience mild outbreaks occasionally, the standard treatment to start with is a cream, applied directly to the sore.

These creams are available over-the-counter, meaning you don’t need a prescription and are relatively easy to use.

Aciclovir, or the branded Zovirax creams, both contain 5% of aciclovir, an antiviral ingredient which stops the HSV-1 virus replicating on the skin surface.

The cream is applied five times daily to the affected area. Treatment should be started as soon as tingling starts, and should be continued for at least 5 days. In some cases, patients may need to keep on using the cream for up to 10 days.

Prescription Oral Tablets

If creams do not work, or if outbreaks are painful, oral tablets offer a more effective solution. These are prescription-only (POM) and can be accessed from registered online pharmacies such as Quick Meds.

Aciclovir tablets are taken at a dose of 200mg five times daily for 5 days. As they are swallowed, the tablets work internally, attacking the virus from the inside out. As with the cream, the tablets should be started as soon as the first symptoms appear, for maximum effectiveness.

Valaciclovir tablets are taken twice daily. When swallowed, the body converts these into aciclovir, absorbing it much more effectively. These tablets stay in the body for longer, so they don't need to be taken as often as aciclovir, making it easier to manage doses.

Daily Preventative Treatment for Frequent Outbreaks

Some patients suffer from frequent outbreaks. For these patients, taking treatment long-term to prevent an attack is preferred over treating each individual attack.

The NHS defines a frequent sufferer as one who experiences six or more outbreaks per year, or for those in whom outbreaks are severe, affecting daily life.

For suppressive therapy, whichever therapy you take, this is taken everyday, regardless of symptoms. This helps keep HSV ‘asleep’, preventing an outbreak.

If you are taking preventative therapy, this cannot be taken indefinitely. A clinical break every 6-12 months allows your healthcare provider to see how often you get outbreaks and determine if you still need preventative therapy.

*except valaciclovir - taken twice daily

When Is It Safe to Treat Cold Sores Yourself Online?

GPhC-registered online pharmacies, such as Quick Meds offer a safe, convenient and discreet access to cold sore treatments without having to wait for a GP appointment.

When requesting prescription-strength tablets, you will be asked to complete an online consultation that asks about your symptoms, medical history and if you take other medication.

Online pharmacies can supply treatment to those who:

• Are over 18 years old

• Have a confirmed history of cold sores

• Have localised symptoms only.

• Do not have major underlying medical conditions.

An online clinic cannot treat all patients. Due to the reasons below, some patients need to see a GP or dermatologist to rule out other severe conditions - this is to make sure you receive the correct advice and treatment:

• It is your first ever cold sore outbreak - First time infections require a face-to-face evaluation to rule out other severe conditions such as impetigo

• The sores are not on your lips - sores on the eyes are a medical emergency. Sores inside the mouth, on the genitals, hands, torso or beard area requires specialist advice.

• You are pregnant or breastfeeding

• You are showing signs of serious complications - if you have eczema and develop a painful rash in clusters or experience symptoms like a severe headache, stiff neck, confusion or difficulty swallowing.

Simple Self-Care Tips to Speed Up Healing at Home

Whether you are using creams or prescription strength tablets, using the correct home-care advice can ease discomfort, prevent viral spreading and help the skin recover.

• Dab, and never rub creams. Rubbing can irritate the skin, break blisters and spread the virus.

• Moisturise the sore. When the cold sore starts to dry out, apply a moisturiser to soften the scab, preventing cracking or bleeding.

• Use cool compresses. An ice pack wrapped in a towel can help reduce inflammation over the scab.

• Avoid trigger foods. Acidic, salty or spicy foods can cause intense burning and irritation.

• Wash your hands constantly. Always wash your hands before and after touching your face and applying treatments to avoid spreading the virus.

Severe Symptoms: When You Must See a Doctor

For most, a cold sore outbreak is a minor irritation that resolves within 10 days. However, due to the contagious nature of HSV-1, the infection can quickly become a serious clinical complication.

High-Risk Groups

Some patients face a much higher risk of the virus spreading past the lip, causing deeper tissue damage.

• Weakened immune system (immunocompromised). If your immune system is suppressed due to HIV, chemotherapy, an organ transplant or long-term immunosuppressant medications, the virus can easily lead to serious complications.

• Pregnant or breastfeeding individuals. Pregnancy alters the immune response, with many antiviral treatments restricted in pregnancy.

• Those with severe chronic skin conditions - such as eczema, dermatitis or psoriasis, your natural skin barrier is broken down, making it easier for the virus to trigger dangerous infections.

In these circumstances, assessment and treatment must be initiated by a GP or specialist dermatologist, optimally placed to assess the risks and benefits.

Warning Signs of Complications

If you notice the cold sore is unusual in any way, it may be a sign that an infection or dangerous viral complication has taken place. Look out for:

Ocular herpes (herpetic keratitis)

If the virus accidentally gets transferred to the eyes, it can cause an ocular infection. This is a medical emergency that can lead to blindness.

You should seek immediate medical attention if you notice:

• Blisters on the eyelids or near the eyes

• Blurred vision, eye pain or watery discharge

• Severe redness and a gritty feeing

• Extreme light sensitivity (photophobia)

Eczema Herpeticum

When HSV infects large skin areas that are already damaged by eczema, it can cause a life-threatening complication called Eczema Herpeticum.

Look out for:

• A sudden breakout of intensely painful clusters of blisters that spread across the face, neck or body

• A high fever

• Feeling very unwell

This requires same-day emergency hospital treatment.

Impetigo

If bacteria enter the open, weeping cold sore, an infection can develop.

Look out for:

• Oozing thick, yellow pus

• A spreading golden-brown crust

• An increasing area of hot, red and swollen skin around your mouth.

Severe Red Flags

In very rare cases, HSV can enter the bloodstream or travel to the central nervous system, causing life-threatening complications.

If a cold sore outbreak occurs alongside any of the following, you should go to A&E or call 999 immediately:

• A sudden, severe headache, worse than anything you’ve felt before

• A stiff neck, making it impossible to touch your chin to your chest

• Extreme confusion, slurred speech or drowsiness

• Unable to swallow liquids

• A high fever

• Sores, ulcers or lumps inside the mouth