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Herpes simplex - oral - Management
When should I seek specialist advice for cold sores?

  • Seek specialist advice for managing immunocompromised individuals with cold sores.
  • Consider seeking specialist advice for pregnant women (particularly near term). Expert opinion differs as to whether this is necessary.
  • Neonatal herpes simplex infection is rare and may present with skin, eye and/or mouth symptoms. Seek specialist advice if this is suspected.
Basis for recommendation
  • CKS recommends seeking specialist advice on the management of immunocompromised people with cold sores and neonates with oral herpes simplex infection because of the increased risk of severe disease and complications in these groups [Arduino and Porter, 2006; BNF 54, 2007; Kimberlin, 2007; RCOG, 2007; Woo and Challacombe, 2007].
    • In immunocompromised individuals, recurrent herpes simplex virus (HSV) type 1 infection may be 'atypical', usually more extensive and aggressive than that of immunocompetent individuals, slow healing and extremely painful [Arduino and Porter, 2006]. Oral recrudescent HSV may lead to HSV viraemia and life-threatening disseminated disease [Woo and Challacombe, 2007].
    • In neonates, HSV infection is rare with a high morbidity (particularly if the central nervous system or multiple organs are affected) [RCOG, 2007]. Most cases occur as a result of direct contact with infected maternal secretions. Neonatal herpes can be localized to the skin, eye and/or mouth (SEM) which can progress to more severe disseminated disease. Treatment with intravenous aciclovir may be required for SEM infection [Kimberlin, 2007].
  • Pregnant women
    • There is a risk of HSV transmission to the neonate, particularly at child birth if the mother with cold sores is actively shedding the herpes simplex virus [RCOG, 2007].
    • Feedback from experts is divided whether specialist advice should be sought.

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