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Herpes simplex - oral - Management
What self care advice can I give to someone with cold sores?

  • Reassure the person that the condition is self limiting and that lesions will heal without scarring.
  • Advise paracetamol or ibuprofen to relieve pain if required.
    • Topical anaesthetics or analgesics may relieve symptoms but there is little evidence to support their use.
  • Give advice to minimize transmission:
    • Avoid touching the lesions, other than when applying medication.
    • Wash hands with soap and water immediately after touching lesions.
    • Topical medications:
      • Should be dabbed on rather than rubbed in to minimize mechanical trauma to the lesions.
      • Should not be shared with others as this may spread infection.
    • Avoid kissing until the lesions have completely healed.
    • Do not share items that come into contact with lesion area (e.g. lipstick or lip gloss).
    • Avoid oral sex until all lesions are completely healed.
    • There is a risk of transmission to the eye if contact lenses become contaminated.
  • Inform that children with cold sores do not need to be excluded from nurseries and schools.
  • Advise the individual to seek medical advice if their condition deteriorates (e.g. lesion spreads, new lesions develop after initial outbreak, persistent fever, inability to eat) or no significant improvement is seen after 7 days.
Clarification / Additional information
  • The use of non-antiviral topical preparations to relieve symptoms (e.g. topical anaesthetics or analgesics) may be considered by people with cold sores but there is little evidence to support their use.
Basis for recommendation
  • These recommendations are based on expert opinion and advice issued by the Health Protection Agency (HPA) as most episodes of cold sores are generally mild and self limiting with spontaneous healing occurring over 7–10 days without scarring [Birek, 2000; Barbarash, 2001; Siegel, 2002; Spruance and Kriesel, 2002; HPA North West, 2005; HPA, 2006b; Gonsalves et al, 2007; Woo and Challacombe, 2007]. Treatment is primarily symptomatic [Birek, 2000; Siegel, 2002].
  • Cold sore lesions are generally self-limiting, starting to resolve within 7 days. Extensive or persistent lesions should raise the suspicion of immunosuppression [Birek, 2000; Spruance and Kriesel, 2002]. Expert feedback suggests reviewing the person if the condition deteriorates or no significant improvement is seen after 7 days.
  • Topical preparations for symptomatic relief:
    • A variety of these preparations are widely available to buy. However, CKS could find very little evidence from randomized controlled trials (RCTs) supporting their use.
      • Topical anaesthetics: evidence from a small double-blind placebo-controlled RCT (n = 72) found that topical tetracaine offer short term subjective relief (mainly for itch but not for pain) when initiated within 48 hours of cold sore lesion appearing [Kaminester et al, 1999]. No adverse reactions were reported for both groups. Lidocaine 5% ointment may be considered to relieve pain in oral lesions [BNF 54, 2007].
      • Topical analgesics: CKS found no double-blind RCTs supporting their use. Choline salicylate gel (Bonjela®) is licensed for use in adults and children over 16 years of age to relieve cold sore symptoms and may be sufficient for mildly painful lesions.
    • However, they may be considered by patients if they found them useful. They might help to relieve cold sore symptoms such as dryness, itching and pain [Barbarash, 2001].
    • Indirect evidence from double-blind RCTs have found even inert preparations can relieve symptoms by a direct or placebo effects [Shaw et al, 1985; Bodsworth et al, 2003].

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