Overview

Cold sores — also called fever blisters — are a common viral infection. They are tiny, fluid-filled blisters on and around your lips. These blisters are often grouped together in patches. After the blisters break, a crust forms over the resulting sore. Cold sores usually heal in two to four weeks without leaving a scar.

Cold sores spread from person to person by close contact, such as kissing. They're caused by a herpes simplex virus (HSV-1) closely related to the one that causes genital herpes (HSV-2). Both of these viruses can affect your mouth or genitals and can be spread by oral sex. Cold sores are contagious even if you don't see the sores.

There's no cure for HSV infection, and the blisters may return. Antiviral medications can help cold sores heal more quickly and may reduce how often they return.

Symptoms

A cold sore usually passes through several stages:

  • Tingling and itching. Many people feel an itching, burning or tingling sensation around their lips for a day or so before a small, hard, painful spot appears and blisters erupt.
  • Blisters. Small fluid-filled blisters typically break out along the border where the outside edge of the lips meets the skin of the face. Cold sores can also occur around the nose or on the cheeks.
  • Oozing and crusting. The small blisters may merge and then burst, leaving shallow open sores that will ooze fluid and then crust over.

Signs and symptoms vary, depending on whether this is your first outbreak or a recurrence. They can last several days, and the blisters can take two to four weeks to heal completely. Recurrences typically appear at the same spot each time and tend to be less severe than the first outbreak.

During first-time outbreaks, some people also experience:

  • Fever
  • Painful eroded gums
  • Sore throat
  • Headache
  • Muscle aches
  • Swollen lymph nodes

Children under 5 years old may have cold sores inside their mouths and the lesions are commonly mistaken for canker sores. Canker sores involve only the mucous membrane and aren't caused by the herpes simplex virus.

When to see a doctor

Cold sores generally clear up without treatment. See your doctor if:

  • You have a weakened immune system
  • The cold sores don't heal within two weeks
  • Symptoms are severe
  • You have frequent recurrences of cold sores
  • You experience irritation in your eyes

Causes

Cold sores are caused by certain strains of the herpes simplex virus (HSV). HSV-1 usually causes cold sores. HSV-2 is usually responsible for genital herpes. However, either type can cause sores in the facial area or on the genitals. Most people who are infected with the virus that causes cold sores never develop signs and symptoms.

Cold sores are most contagious when oozing blisters are present. But you can transmit the virus to others even if you don't have blisters. Shared eating utensils, razors and towels, as well as kissing, may spread HSV-1. Oral sex can spread HSV-1 to the genitals and HSV-2 to the lips.

Once you've had an episode of herpes infection, the virus lies dormant in nerve cells in your skin and may emerge as another cold sore at the same place as before. Recurrence may be triggered by:

  • Viral infection or fever
  • Hormonal changes, such as those related to menstruation
  • Stress
  • Fatigue
  • Exposure to sunlight and wind
  • Changes in the immune system

Risk factors

About 90 percent of adults worldwide — even those who've never had symptoms of an infection — test positive for evidence of the virus that causes cold sores.

People who have weakened immune systems are at higher risk of complications from the virus. Medical conditions and treatments that increase your risk of complications include:

  • HIV/AIDS
  • Severe burns
  • Eczema
  • Cancer chemotherapy
  • Anti-rejection drugs for organ transplants

Complications

In some people, the virus that causes cold sores can cause problems in other areas of the body, including:

  • Fingertips. Both HSV-1 and HSV-2 can be spread to the fingers. This type of infection is often referred to as herpes whitlow. Children who suck their thumbs may transfer the infection from their mouths to their thumbs.
  • Eyes. The virus can sometimes cause eye infection. Repeated infections can cause scarring and injury, which may lead to vision problems or blindness.
  • Widespread areas of skin. People who have a skin condition called eczema are at higher risk of cold sores spreading all across their bodies. This can become a medical emergency.
  • Other organs. In people with weakened immune systems, the virus can also affect organs such as the spinal cord and brain.

Prevention

Your doctor may prescribe an antiviral medication for you to take on a regular basis, if you develop cold sores frequently or if you're at high risk of serious complications. If sunlight seems to trigger your recurrences, apply sunblock to the spot where the cold sore tends to erupt.

To help avoid spreading cold sores to other people or to other parts of your body, you might try some of the following precautions:

  • Avoid skin-to-skin contact with others while blisters are present. The virus spreads most easily when there are moist secretions from the blisters.
  • Avoid sharing items. Utensils, towels, lip balm and other items can spread the virus when blisters are present.
  • Keep your hands clean. When you have a cold sore, wash your hands carefully before touching yourself and other people, especially babies.
May 15, 2015
References
  1. AskMayoExpert. Cold sores. Rochester, Minn.: Mayo Foundation for Medical Education and Research; 2014.
  2. Habif TP. Warts, herpes simplex, and other viral infections. In: Clinical Dermatology: A Color Guide to Diagnosis and Therapy. 5th ed. Edinburgh, U.K.; New York, N.Y.: Mosby Elsevier; 2010. http://www.clinicalkey.com. Accessed March 23, 2015.
  3. Herpes simplex. American Academy of Dermatology. https://www.aad.org/dermatology-a-to-z/diseases-and-treatments/e---h/herpes-simplex. Accessed March 23, 2015.
  4. Ferri FF. Herpes simplex. In: Ferri's Clinical Advisor 2015: 5 Books in 1. Philadelphia, Pa.: Mosby Elsevier; 2015. www.clinicalkey.com. Accessed March 23, 2015.
  5. Herpes simplex virus (HSV) infections. The Merck Manual Professional Edition. www.merckmanuals.com. Accessed March 23, 2015.
  6. Cold sores. Natural Medicines Comprehensive Database. http://www.naturaldatabase.com. Accessed March 23, 2015.
  7. Wolff K, et al. Viral diseases of skin and mucosa. In: Fitzpatrick's Color Atlas and Synopsis of Clinical Dermatology. 7th ed. New York, N.Y.: The McGraw-Hill Companies; 2013. http://www.accessmedicine.com.  Accessed March 23, 2015.
  8. Rakel RE. Dermatology. In: Textbook of Family Medicine. 8th ed. Philadelphia, Pa.: Saunders Elsevier; 2011. http://www.clinicalkey.com. Accessed March 23, 2015.
  9. Kliegman RM, et al. Herpes simplex virus. In: Nelson Textbook of Pediatrics. 19th ed. Philadelphia, Pa.: Saunders Elsevier; 2011. http://www.clinicalkey.com. Accessed March 23, 2015.
  10. Klein RS. Treatment of herpes simplex virus type 1 infection in immunocompetent patients. http://www.uptodate.com/home. Accessed March 23, 2015.
  11. Gibson LE (expert opinion). Mayo Clinic, Rochester, Minn. April 6, 2015.
  12. Dorland's Illustrated Medical Dictionary. 32nd ed. Philadelphia, Pa.: W.B. Saunders; 2011. http://dorlands.com/index.jsp. Accessed March 25, 2015.