Oral Herpes
Oral herpes is a very common viral infection that affects the mouth and lips, causing small blisters known as cold sores. About half of adults in the United States have this infection, often contracted during childhood through everyday contact like kissing. While there is no cure, the condition can be effectively managed with treatment.
Table of contents
- What is oral herpes?
- How oral herpes spreads
- Signs and symptoms
- The first outbreak
- Recurrent outbreaks
- Diagnosis
- Treatment options
- Prevention
- Living with oral herpes
- Possible complications
What is oral herpes?
Oral herpes is an infection that affects the mouth area, causing small, painful blisters commonly called cold sores or fever blisters[1]. The infection is caused by the herpes simplex virus, usually type 1 (HSV-1), though type 2 (HSV-2) can also cause oral herpes[2].
cold sores, fever blisters, oral-facial herpes, herpes labialis
This is an extremely common condition. Approximately 50 percent of the adult population in the United States has oral herpes, and an estimated 3.8 billion people under age 50 globally have HSV-1 infection[3][4]. Most people become infected with HSV-1 during childhood or young adulthood[5].
Once you have an oral herpes infection, the virus stays in your body for life. It remains dormant (inactive) in nerve cells and can reactivate from time to time, causing new outbreaks of cold sores[1]. However, the virus doesn’t cause symptoms all the time, and many people go for long periods without any cold sores.
How oral herpes spreads
Oral herpes spreads through direct contact between the infected area and broken skin or mucous membrane tissue, such as the mouth[3]. The virus is highly contagious and can be transmitted in several ways:
- Kissing someone who has a cold sore
- Sharing eating utensils, cups, towels, or razors with an infected person
- Touching an open herpes sore or something that has been in contact with the virus
- Through oral sex
Most people contract oral herpes when they are children by receiving a kiss from a friend or relative[3]. Parents may spread the virus to their children during regular daily activities[2].
An important fact to understand is that herpes can be transmitted even when there are no visible symptoms present. This is called asymptomatic shedding, when the virus reactivates yet causes no symptoms but can still be passed to others[3]. During one study, the median duration of HSV-1 shedding was 60 hours, with peak viral load occurring at 48 hours[14].
Signs and symptoms
The most common sign of oral herpes is the appearance of cold sores. These are small, fluid-filled blisters that typically form on or around the lips, especially along the outer edge where the lip meets the surrounding skin[1]. Cold sores can also appear on the cheeks, chin, nose, or inside the mouth[1][6].
Many people experience warning symptoms before the blisters appear. This early stage is called the prodromal stage and may include[1]:
- Tingling near the lips or mouth area
- Itching of the lips or surrounding skin
- Burning sensation near the lips or mouth
- Numbness or pain on the lip or surrounding skin
The blisters themselves look like tiny bumps filled with clear or slightly yellowish fluid. The skin around them may be red, swollen, and painful[1]. After a couple of days, the blisters break open and ooze fluid. Then a golden-brown crust forms on top of the sores, which may occasionally crack open or bleed[1]. Within about two weeks from the start of the outbreak, the crust falls off and the skin underneath may look slightly pink for a short time[1].
Some people get infected but don’t have symptoms, making it possible to carry HSV for a while without realizing it[1].
The first outbreak
When a person is infected with herpes for the first time, this is called the primary infection. The first outbreak may occur within one to three weeks after contact with the virus, though it may not occur for months or even years later[1][2].
During the first episode, symptoms can be more severe than during later outbreaks[3]. The primary infection may include[1][2]:
- Fever
- Swollen lymph nodes in the neck
- Sore throat
- Headaches
- Body aches
- Redness and swelling in the throat
- Painful sores inside the mouth, including on the gums, tongue, and roof of the mouth
- Sores along the back of the throat
In children, this condition is commonly called herpetic gingivostomatitis and can cause painful sores affecting the mouth, gums, throat, and lips, which may last for more than 14 days if left untreated[6]. Oral acyclovir suspension is an effective treatment for children with this primary infection[14].
Most people with the primary infection have no symptoms, some have mild symptoms, and some experience more discomfort[6]. Symptoms may last up to three weeks[2].
Recurrent outbreaks
After the primary infection clears up, HSV stays dormant in nerve cells in the head. The virus travels from the skin to the trigeminal ganglion, a bundle of nerves close to the inner ear, where it remains hidden[6][14].
From time to time, the virus “wakes up” and causes a new outbreak of cold sores. At least a quarter of people with oral herpes experience recurrences[3]. Approximately 90 percent of recurrent HSV-1 infections cause the orofacial lesions known as herpes labialis[14]. Oral HSV-1 usually recurs one to six times per year[14].
Recurrent infections tend to be much milder than the first outbreak. The symptoms are less severe, and outbreaks typically last about 8 to 10 days on average[3]. Signs and symptoms of a recurrent episode tend to last about a week to 10 days[5][6].
Various factors can trigger the virus to reactivate, including[1][6][14]:
- Stress (emotional or physical)
- Fever or illness
- Long or intense exposure to sunlight or UV radiation
- Extreme weather conditions
- Menstruation or hormonal changes
- Fatigue or extreme tiredness
- Weakened immune system
- Surgery or trauma to the skin
The number of recurrences varies from person to person and tends to decrease over time[3]. Some people have few or no outbreaks, while others have regular recurrences that seem to become less frequent with age[6].
Diagnosis
Your healthcare provider can often diagnose oral herpes by looking at your mouth area and examining the cold sores[2]. The diagnosis is usually made by the appearance of the lesions, which are typically grouped vesicles or ulcers on a red base, and by taking your medical history[14].
If the diagnosis is uncertain, several laboratory tests can confirm herpes infection[2][14]:
- Viral culture: A sample from the sore is sent to a laboratory for testing. However, the sensitivity of viral culture is low, especially for recurrent lesions, and decreases rapidly as lesions begin to heal.
- Polymerase chain reaction (PCR) or viral DNA test: These are the most sensitive tests for detecting HSV from genital ulcers or other skin lesions.
- Direct fluorescent antibody testing: This test detects HSV antigen from samples.
- Tzanck test: This checks for HSV by examining cells from a sore.
- Type-specific serologic tests: Blood tests that can detect antibodies to herpes viruses and determine whether you have HSV-1 or HSV-2.
Type-specific serologic tests can be used when there are no visible lesions. These blood tests can show if you have herpes and which type, but they cannot tell you what part of your body the virus will affect[9].
Treatment options
While there is no cure for herpes, several treatments can help manage symptoms and reduce the frequency and severity of outbreaks[1].
Symptoms will go away on their own without treatment in one to two weeks[2]. However, antiviral medications can help reduce pain and make symptoms go away sooner. These medicines work best if taken at the first sign of symptoms, before blisters fully develop[2][12].
Three antiviral medications are FDA-approved for treating oral herpes[12]:
- Acyclovir: The oldest antiviral medication for herpes, available since 1982. It has been shown to be safe in people who have used it continuously for as long as 10 years.
- Valacyclovir: A newer drug that uses acyclovir as its active ingredient but delivers it more efficiently, allowing for less frequent dosing.
- Famciclovir: Uses penciclovir as its active ingredient and can be taken less frequently than acyclovir.
There are two main approaches to taking antiviral medication[12]:
Episodic therapy: Taking medication at the first sign of an outbreak (ideally at the first signs of tingling or itching) and continuing for several days. This can help shorten the duration of symptoms by a day or two on average. Treatment typically ranges from one to five pills daily for three to five days during an outbreak.
Suppressive therapy: Taking antiviral medication daily to prevent outbreaks. For people who have frequent recurrences (six or more per year), studies show that suppressive therapy can reduce the number of outbreaks by at least 75 percent[12]. Daily suppressive therapy also reduces asymptomatic shedding by about 94 percent[12]. Treatment typically ranges from one to two pills every day.
Topical antiviral creams are also available, including acyclovir, penciclovir, and docosanol[12][14]. However, these are less effective than oral medications and often only shorten the outbreak by a few hours to a day[2].
Other measures that can help make you feel better include[2][13]:
- Applying ice wrapped in a washcloth or a cold, damp cloth to soothe pain and inflammation
- Using over-the-counter pain relievers such as acetaminophen or ibuprofen
- Washing the blisters gently with antiseptic soap and water
- Avoiding hot beverages, spicy and salty foods, and citrus
- Applying sunscreen to protect lips from sun exposure
- Gargling with cool water or eating fruit-flavored ice pops
- Rinsing with salt water
Prevention
While you cannot completely prevent oral herpes once you’re infected, you can take steps to reduce the risk of spreading it to others and to minimize the frequency of your own outbreaks[1].
To avoid spreading oral herpes to others[3][15]:
- Avoid kissing or oral sex when you have any visible sores or during the prodromal stage (tingling, itching)
- Don’t share cups, eating utensils, towels, razors, or toothbrushes
- Wash your hands frequently, especially after touching your mouth or applying cream
- Avoid touching the cold sores; if you do, wash your hands immediately
- Don’t pick at or pop the sores, as this can spread the virus to other parts of your body
People are most contagious from the start of tingling sensations through the healing of the last ulcer. During this time, avoid close contact that could spread the virus[6].
To help prevent outbreaks[1][13]:
- Use sunscreen on your lips when out in the sun, as sunburn may trigger a cold sore
- Manage stress through meditation or deep breathing exercises
- Maintain a balanced diet to support your immune system
- Get adequate rest and avoid extreme fatigue
- Protect your lips from harsh weather (wind and cold)
- Consider daily suppressive antiviral therapy if you have frequent outbreaks
Living with oral herpes
Finding out you have herpes can bring up strong emotions. It’s normal to feel anxious, embarrassed, or upset at first. However, it’s important to remember that oral herpes is extremely common, and millions of people live normal, healthy lives with this condition[16].
Most people get at least one sexually transmitted infection in their lifetime, and having herpes doesn’t mean you’re “dirty” or a bad person—it means you’re a normal human who got a very common infection[16]. Herpes isn’t deadly and usually doesn’t cause any serious health problems[16].
The best thing to do when you find out you have herpes is to follow your doctor’s directions for treating it. If you’re having a hard time dealing with the news, talking with a close friend or joining a support group for people living with herpes may help[16].
People with herpes have romantic and sexual relationships. Because most adults have oral herpes, it’s not suggested that a person should stop giving or receiving affection altogether between outbreaks simply because they have oral herpes[3]. However, it’s important to be honest with partners about your condition and to take precautions during outbreaks.
Over time, most people find that outbreaks become less frequent and less bothersome. For many people, the first outbreak is the worst, and subsequent outbreaks lessen in frequency and severity as the body builds antibodies to the virus[1].
Possible complications
Oral herpes doesn’t cause complications in most people. However, certain groups are at higher risk for serious problems[1][2]:
Eye infections: Herpes can spread to the eye region and may cause herpes keratitis, herpes conjunctivitis, or herpes stromal keratitis. Eye infection with HSV is a leading cause of blindness in the United States because it causes scarring of the cornea[2][6].
Newborn babies: Herpes can be severe and dangerous in newborns. Pregnant women with herpes should discuss their condition with their healthcare provider.
People with weakened immune systems: Those with weakened immune systems due to certain diseases (such as HIV) or medicines (such as cancer treatment) may have more severe oral herpes outbreaks, including painful sores inside the mouth or throat[1][2].
Increased HIV risk: Studies suggest that having genital herpes may increase the risk of contracting HIV twofold to threefold because herpes causes open sores that make it easier for the HIV virus to enter the body[9].
If you experience severe symptoms, signs of eye infection, or if you have a weakened immune system, contact your healthcare provider promptly.
