• Scenario: Cold sores: covers the management of herpes simplex cold sores.
• Scenario: Gingivostomatitis: covers the management of gingivostomatitis caused by herpes simplex infection.

• 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.

In depth

• 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. They should not be shared with others.
• 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.

In depth

• Advise that the benefits of topical antivirals (aciclovir 5% or penciclovir 1% cream) are small and that the cold sores will usually resolve within 7–10 days even without treatment.
• If topical antiviral therapy is desired, remind the individual that:
• Topical antivirals only affect the course of the current episode. They do not cure the individual or prevent future episodes of cold sores.
• Treatment needs to be initiated at the onset of symptoms before vesicles appear.
• Compliance is important, as topical antivirals need to be applied frequently for a minimum of 4–5 days.
• Topical antivirals are widely available (without prescription). This can help to minimize the delay to starting treatment in future recurrences.
• Seek specialist advice when managing neonates and people who are immunocompromised (including people with HIV) with cold sores.

In depth

• For immunocompetent individuals, oral antivirals are not routinely indicated for the treatment of cold sores but may be indicated in severe episodes. However, the optimum timing and dose of oral antiviral treatment are uncertain. Consider seeking specialist advice (particularly for pregnant women — unlicensed use).
• Seek specialist advice for people who are immunocompromised (including people with HIV).

In depth

• Offer self-care advice on how to manage future episodes symptomatically.
• If treatment with a topical antiviral is desired, advise the individual that these should be applied at the onset of symptoms before vesicles appear. Inform the individual that the benefits might be small.
• Seek specialist advice for immunocompromised individuals (including people with HIV).

In depth

• If sunlight is a trigger, consider the use of sunblock lip balm (SPF 15 or greater).
• Prophylactic use of topical antivirals is ineffective.
• For most immunocompetent people, the benefits of suppressive (continuous) treatment with oral antivirals are small and do not justify the routine use of long-term treatment. Episodic treatment might be preferred and be more convenient (e.g. for those with 1–2 mild episodes per year).
• For people with frequent or severe episodes, or for immunocompromised individuals (e.g. with HIV), prophylactic oral antiviral treatment may be helpful. Specialist advice should be sought.

In depth

• Reassure the individual or parent that gingivostomatitis (inflammation of the gums and mucous membranes of the mouth) is self limiting.
• Treat symptomatically:
• Offer paracetamol or ibuprofen to relieve pain and fever.
• Encourage adequate fluid intake to avoid dehydration.
• Consider offering topical benzydamine for additional pain relief.
• Offer chlorhexidine mouthwash to help control secondary infections and to control plaque accumulation if brushing of teeth is painful.
• The use of a lip barrier preparation (e.g. Vaseline^®, Lypsyl^®) may be useful to prevent lip adhesion.
• Provide advice to minimize transmission:
• Avoid touching the lesions, other than when applying medication.
• Wash hands with soap and water immediately after touching lesions.
• 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.
• Children with gingivostomatitis who are generally well do not need to be excluded from nurseries and schools.
• Consider oral antivirals for immunocompetent individuals with severe gingivostomatitis. The optimum timing and dose of oral antiviral treatment are uncertain. Consider seeking specialist advice before prescribing.
• Seek specialist advice if:
• Symptoms are not improving after 5 days.
• The affected person is pregnant, a neonate, or is immunocompromised.
• Admit the person if they have difficulty drinking and are at risk of becoming dehydrated. Intravenous fluids may be required.

In depth