Herpes Simplex Virus (Cold Sores)

Herpes simplex virus (HSV) infections are very common worldwide. HSV-1 (often called oral-facial herpes) is transmitted through kissing or sharing drinking utensils, and HSV-2 (often called genital herpes) through sexual contact. Both HSV-1 and HSV-2 can cause infections around the face, mouth, and genitals. The infection may not show symptoms for a long time, and then become activated by exposure to the sun, fever, menstruation, emotional stress, a weakened immune system, or acute illness.

Once you have herpes, it is likely to recur. In between herpes outbreaks, the virus lies dormant (like it is hibernating or sleeping) in nerve cells. Recurrent HSV-1 infections on the lip are often mild and are commonly referred to as cold sores or fever blisters. HSV-2 lesions tend to recur more often and to be more severe than HSV-1 infections.

Herpes infections in infants and in people who have weak immune systems or herpes infections that affect the eyes are serious and potentially life-threatening.

Signs and Symptoms

• Small grouped blisters in the infected area like the genitals (namely, penis scrotum, vagina, cervix, or labia), around the genitals (such as anus or inner thighs) mouth, lips, tongue, gums, or throat; the blisters can then become ulcers (raw sores) and later crust over
• Burning, itching, pain, or tingling sensations often precedes the appearance of the blisters
• Enlarged lymph nodes near the infected area
• Fever, headache, and flu-like symptoms (such as muscle aches and malaise [generally feeling bad]), particularly when you first contract the virus
• Vaginal or penile discharge
• Pain with urination

Causes

HSV-1 is transmitted through saliva; therefore, kissing someone with HSV-1, drinking from the same instrument, or participating in oral-genital sex with someone who has HSV-1 can cause you to contract the virus.

HSV-2 is a sexually transmitted disease meaning that it is transferred from one sexual partner to another through genital secretions.

Herpes simplex may be transmitted even if the infected person does not have active symptoms or visible lesions.

Also, a mother can pass the infection to her baby during vaginal birth, especially if there are active lesions around the vagina at the time of delivery.

Risk Factors

Oral herpes
Everyone is at risk for oral herpes from HSV-1, including children many of whom are already infected by age three. In fact, studies suggest that by adolescence 62% of Americans are infected with HSV-1 and by the time one is in the 40's, 90% have been infected.

Genital herpes
All sexually active people are at risk for acquiring genital herpes. Having multiple sexual partners puts you at even greater risk. Estimates of how many Americans are infected range from 20% to 30%.

Other factors
Immunosuppressed individuals (see Special Populations) are at increased risk for severe cases of herpes.

Diagnosis

In many instances, your doctor is able to make the diagnosis of herpes from physical appearance of the lesions and no tests are required. If your doctor is not 100% certain, however, then fluid from the blisters can be removed and tested for the herpes simplex virus. This can be done through viral cultures which is very accurate but generally takes 2 to 3 days to get the results and make an official diagnosis. Another more immediate, but less accurate, approach is to do a Tzanck test of the skin lesions. This involves taking a sample of fluid from the blisters, staining the fluid with a dye, and examining the stained fluid under the microscope looking for a characteristic appearance of the virus. Finally, there is a blood test that may be helpful for making a diagnosis, especially if herpes simplex is suspected but no symptoms are present or if a distinction between HSV-1 and HSV-2 is needed.

Preventive Care

Prevention of spread from one person to the next is quite difficult since the virus can be transmitted even when there are no visible lesions. Some measures that may help, however, are described below.

If you do not have herpes:

• Avoid direct contact with cold sores or genital herpes lesions on other people. For example, avoid sexual intercourse altogether when your partner has active lesions. At other times, use latex condoms, which can help avoid but not eliminate sexual transmission of genital herpes.
• Wash items that may have saliva or other bodily fluid from someone with oral herpes in boiling water before you use (like razor blades, drinking cups or glasses, etc.)
• Do not share certain items (like a toothbrush, razor, etc.) with an infected person, especially when herpes lesions are active.

If you do have herpes:

• Avoid precipitating causes like sun exposure and try to reduce your stress level. (See Mind/Body Medicine.)
• Avoid performing oral sex when you have active herpes lesions on or near your mouth.
• Use latex condoms even when lesions are not present and avoid sexual intercourse altogether when you have active lesions.

Treatment Approach

Herpes cannot be cured, so the goals of treatment include reducing the number of recurrences and lessening your symptoms when you have an outbreak.

Even without any intervention, oral herpes lesions generally subside in no more than 1 to 2 weeks. Using medications may shorten the course and decrease the discomfort.

Some cases of genital herpes may be quite mild and not need any treatment. In severe or prolonged cases, however, as well as herpes infections if you are immunosuppressed (see Special Populations) or if you have frequent recurrences, medications that fight the virus may be needed.

In addition to physical relief of symptoms and reducing frequency of outbreaks, coping with the emotional and social aspects of having genital herpes is part of treatment. See Mind/Body Medicine.

Lifestyle

Taking lukewarm baths or applying ice to herpes lesions may help reduce pain, burning, or other discomfort. It is important to cleanse the infected area with soap and water, which may help avoid local spread of herpes from the active blisters to surrounding areas on your skin. After bathing or washing, it is important to completely dry the affected area.

Wear cotton underwear and avoid tight fitting clothes as they can restrict air circulation and slow the healing of lesions.

Coping with the emotional and social aspects of having genital herpes can be challenging. See Mind/Body Medicine for further discussion.

Medications

Antiviral medicines may help shorten the duration of a herpes outbreak. If you have 6 or more recurrences of genital herpes per year, your doctor may recommend use of antiviral medicines at all times to prevent such frequent outbreaks.

Medications that your doctor may prescribe include:

• Acyclovir
• Famciclovir
• Pancyclovir
• Valacyclovir

For maximum benefit during recurrences, medication should be started as soon as you experience the tingling, burning, itching, or other sensations that often precede the appearance of the herpes lesions.

Acyclovir given intravenously (through a vein) in the hospital is sometimes needed if you have an infection involving the brain, eyes, or lungs or if you are in a group at high risk for complications (see Special Populations).

Foscarnet, another antiviral agent that is quite powerful and also delivered intravenously, may be nececessary if your herpes lesions are resistent to acyclovir or the other medications listed.

Nutrition and Dietary Supplements

Because supplements may have side effects or interact with medications, they should be taken only under the supervision of a knowledgeable healthcare provider.

Lysine
Although the research to date is not entirely conclusive, lysine supplements have been used to help treat or prevent mouth and genital lesions caused by herpes. Taking lysine supplements or increasing lysine in your diet (from foods like fish, chicken, eggs, and potatoes) may speed recovery time and reduce the chance of recurrent breakouts of the herpes infection. If you have high cholesterol, heart disease, or high triglycerides (type of fatty material in the blood, generally measured when you have your cholesterol checked), it is best, at this point, not to use lysine because animal studies suggest that this supplement may raise cholesterol and triglyceride levels.

Propolis
Propolis, a resin from tree bark and leaves, is loaded with flavonoids (antioxidants that help fight infection and boost immune function). A study of a small number of people with genital herpes compared an ointment made from propolis to acyclovir ointment (a medication commonly used for herpes). In this research trial, the lesions of those using the propolis healed more quickly than those using acyclovir. Research on larger numbers of people would be helpful. In the interim, it may be worth trying propolis ointment for genital herpes lesions if your doctor approves.

Spirulina
Test tube studies suggest that spirulina, also known as blue green algae, has activity against certain viruses including herpes. Whether this laboratory finding will prove beneficial for people in treating herpes infections is not known. More research is needed before a recommendation can be made.

Zinc Topical preparations of zinc have shown benefit in relieving symptoms and preventing recurrences of oral herpes lesions.

Herbs

The use of herbs is a time-honored approach to strengthen the body and treat disease. Herbs, however, contain active substances that can trigger side effects and interact with other herbs, supplements, or medications. For these reasons, herbs should be taken with care and only under the supervision of a practitioner knowledgeable in the field of herbal medicine.

Aloe (Aloe vera)
Preliminary evidence suggests that aloe gel used topically may improve the symptoms of genital herpes. Whether this same use of aloe will apply to oral herpes lesions is not known, but it may be worth trying in order to reduce the length and severity of your symptoms. Talk to your doctor about the possibility of using topical aloe vera for herpes lesions.

Lemon Balm (Melissa officianalis)
Some studies suggest that topical ointments containing lemon balm may help heal herpes cold sores. In one study of 116 people with HSV, for example, those who applied lemon balm cream to their lip sores experienced significant improvement in redness and swelling after only two days. Although other symptoms (such as pain and scabbing) did not improve, both the participants and their physicians reported that the lemon balm ointment was highly effective. Several animal studies also support the value of topical lemon balm for oral herpes lesions.

Peppermint Oil (Mentha x piperita)
In test tubes, peppermint oil has exhibited antiviral properties against a number of infectious agents, including herpes. Whether this would translate into help for relieving herpes lesions is not known at this point.

Sage-Rhubarb Cream
In one Swiss study, a cream made from sage (Salvia officinialis) and rhubarb (Rheum palmatum) lessened the length of time that herpes lesions were present to the same extent as the medication acyclovir. More research on this topic would be helpful.

Siberian Ginseng (Eleutherococcus senticosus/Acanthopanax senticosus)
Although not all studies agree, one 6-month study of 93 people with HSV-2 (which, again, generally causes genital herpes lesions) found that Siberian ginseng reduced the frequency, severity, and duration of outbreaks. This herb should not be given to children and should not be taken if you have high blood pressure, obstructive sleep apnea (repeated, prolonged periods when breathing stops while sleeping), narcolepsy (frequent day time sleeping), are pregnant or breastfeeding.

Tea Tree Oil (Melaleuca alternifolia)
Use of tea tree oil, applied topically in gel form, has some popularity for herpes lesions on the lips. Although more research is needed before definitive conclusions can be drawn, there is some scientific basis for this use. First, in test tubes, tea tree oil has the ability to fight both strains of herpes viruses (HSV 1 and HSV 2). Secondly, there has been one small study comparing use of tea tree oil gel to placebo in those with recurrent oral herpes. The herpes lesions of those who used the tea tree oil healed more quickly than those who used placebo. Studies of larger numbers of people are necessary, however, along with studies that compare tea tree oil to medications used for herpes.

Others
Additional herbs that may be recommended by an herbal specialist for the treatment of either oral or genital herpes include:

• Pau d'Arco (Tabebuia avellaneda)

Although Echinacea (coneflower) has gained some popularity for the prevention of herpes, there is no scientific evidence that it works for this purpose. In fact, despite test tube studies suggesting that Echinacea has the ability to fight the herpes virus, one study of people with herpes did not show any reduction in the number of their outbreaks.

To try to prevent herpes outbreaks, herbalists may also consider remedies that help strengthen your immune system or act as adaptogens (substances that help relieve stress).

Acupuncture

Case reports in the scientific literature suggest that acupuncture may help reduce the length of time of a herpes outbreak and decrease your chances for recurrent lesions. Additional research would be helpful.

Massage and Physical Therapy

Regular massage can help alleviate chronic stress; therefore, in theory, receiving massage on a regular basis may help avoid recurrent outbreaks. Aromatherapy, a massage method using essential oils, is one that has been evaluated for these purposes and results thus far suggest that this is a useful technique.

Homeopathy

Although few studies have examined the effectiveness of specific homeopathic therapies, professional homeopaths may consider the remedies described below for the treatment of herpes based on their knowledge and experience. One study of 53 people with genital herpes did show that the majority experienced improvement in their symptoms and were less likely to have recurrent outbreaks when treated with homeopathy. Participants in this study were followed for up to 4 years.

Before prescribing a remedy, homeopaths take into account a person's constitutional type. A constitutional type is defined as a person's physical, emotional, and psychological makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for each individual.

For lesions around the lips and mouth:

• Natrum Muriaticum — for eruptions at the corners of the mouth that occur during periods of emotional stress and tend to worsen in the daytime
• Rhus toxicodendron — for eruptions consisting of many small blisters that itch intensely at night
• Mercurius — for children who drool and may have a fever
• Sepia — for outbreaks that do not improve with other homeopathic remedies; this remedy is most appropriate for individuals who tend to have a lack of energy and don't tolerate cold weather

For genital lesions:

• Graphites — for large, itchy lesions in individuals who are overweight
• Natrum Muriaticum — for eruptions that occur during periods of emotional stress and symptoms that tend to worsen in the daytime
• Petroleum — for lesions that spread to anus and thighs; symptoms tend to worsen in winter and improve in summer
• Sepia — for outbreaks that do not improve with other homeopathic remedies; this remedy is most appropriate for individuals who tend to have a lack of energy and don't tolerate cold weather

Mind/Body Medicine

Support Groups
Having genital herpes can impact your social and emotional life and many find it quite difficult to cope with this. In fact, if you have herpes, it is quite common to feel depressed, angry, and even guilty. Worrying about possible rejection by someone with whom you are hoping to become intimate is also typical. Joining a support group in which members share common experiences and problems can help alleviate these stresses associated with having genital herpes. Seeing a couples' therapist with a committed partner may also be helpful for working through some of these issues.

Relaxation Techniques
Using relaxation techniques, such as yoga, guided imagery, and meditation, on a daily basis may help you feel better overall and cope with your stresses related to having herpes.

Self-Hypnosis
In a 6-week training program to learn how to hypnotize oneself using guided imagery, participants with frequently recurring genital herpes were able to reduce their outbreaks by nearly 50% and improve their mood, including reducing feelings of depression and anxiety.

Other
Individual therapy with a psychiatrist, psychologist, or social worker as well as biofeedback are other therapeutic approaches that can help reduce symptoms associated with herpes and reduce one's tendency to withdraw from social situations if you have genital herpes.

Traditional Chinese Medicine

A traditional Chinese physician would likely prescribe topical herbal remedies consisting of a combination of herbal extracts to treat oral or genital herpes.

Other Considerations

Pregnancy

Herpes viruses can be transmitted to a newborn during vaginal delivery in mothers infected with herpes viruses, especially if the mother has active lesions in the vagina at the time of delivery. If you do have active lesions at that time, delivery by cesarean section (often called C-section) will be recommended to avoid infecting your baby.

Special Populations

Newborn baby – herpes infections contracted during delivery from the mother can lead to meningitis, herpes infection in the blood, chronic skin infection, and may even be fatal.

If your immune system is suppressed (from, for example, human immunodeficiency virus [HIV], receipt of chemotherapy for cancer, long term use of high doses of steroids, or use of medications that intentionally suppress the immune system such as following organ transplant) are more likely to suffer from complications of herpes and are more likely to have severe, frequent outbreaks.

Warnings and Precautions

If you are diagnosed with genital herpes, you should be tested for other sexually transmitted diseases like chlamydia and gonorrhea.

Prognosis and Complications

Herpes is a chronic, recurrent infection. The initial symptoms usually appear within 1 to 3 weeks of exposure to the virus and last 7 to 10 days (for oral lesions), 7 to 14 days (for genital lesions). Usually the number of outbreaks is greatest in the first year and higher for HSV-2 genital lesions than HSV-1 oral lesions. Each year after that, the number of outbreaks typically diminishes and they become progressively less severe. But, you can never completely get rid of the virus.

Complications of herpes include:

• Herpetic keratitis – herpes infection of the eye leading to scaring within the cornea and possible blindness
• Persistent herpes infection, without lesion-free periods
• Herpes infection in the esophagus
• Herpes infection of the liver which can lead to cirrhosis (liver failure)
• Encephalitis and/or meningitis – serious brain infections
• Lung infection
• Eczema herpetiform – widespread herpes across the skin

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