By Gary M. White, MD
Recurrent infection in an adult.
Herpes labialis is a herpes simplex infection of the lip.
Initial tingling, burning, or pain, followed by erythema, edema and possibly vesicles in one area of the lips. Onset may be precipitated by sun, menstruation, or dental work.
Patients should be told that the condition is contagious and is spread by contact. A patient with a cold sore can pass the virus to another through kissing. This often occurs from mother to child and is a way for the virus to pass from one generation to the next. So advise patients that when they have an active cold sore, they should abstain from kissing.
Regardless of the location, herpes infection responds well to oral antiviral therapy. The key to success is starting the oral medication as early as possible. If started 72 hours or more after onset, therapy is often not effective. Patients should be told to start taking the medication the moment they sense an outbreak (e.g., tingling and pain), even when no skin changes have yet occurred.
Any of the following are appropriate therapy for primary infection.
Any of the following are appropriate for treating symptomatic herpes simplex virus (HSV) recurrence in normal hosts. They should be started as soon as possible.
One can add clobetasol TID for 3 days topically to any of these.
Some patients have outbreaks so frequently (e.g., 6 or more per year) that daily suppressive therapy, as follows, is appropriate.
Patients with more frequent recurrences tend to require the higher doses.
For patients with herpes labialis that is provoked by the sun, sunscreen use is recommended.
Herpotherm is a new treatment for herpes labialis and herpes genitalis. It is a device that applies heat (50°-51°C) for 4 seconds to the lesion. As usual, the patient should start the treatment the moment the onset is noticed.
Sitavig is a new formulation of acyclovir, in a tablet, that contains 50 mg acyclovir in a milk protein formulation. It is applied to the gum above the incisor tooth on the side of the lip that is infected with the cold sore. The tablet releases the acyclovir over 12-15 hours providing a very high blood level. In clinical studies, the mean duration of the recurrent herpes labialis episode was approximately half a day shorter in patients treated with Sitavig compared with placebo.
Various topical antiviral agents are available but these are much less effective compared to the oral agents. For example, penciclovir 1% cream (Denavir in the US) is FDA approved for the treatment of herpes labialis. It is applied every 2 hours while awake for 4 days. Therapy should begin as soon as any signs or symptoms appear. In a large study, penciclovir sped healing by 30%.
Docosanol applied 5 times daily until healing occurs reduced healing time by 18 hours in one study [JAAD 2001;45;222].
Primary infection. The initial infection as shown here is often more severe.
Infection may occur anywhere about the lip.
Photograph courtesy Michael O. Murphy, MD
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