4.05 Oral Herpes Simplex (Cold Sore)
=======================================

agk's Library of Common Simple Emergencies


Presentation
------------
Patients have swelling, burning or soreness at 
an intra- or extra-oral lesion consisting of 
clusters of small vesicles on an erythematous 
base, which then rupture to produce red 
irregular ulcerations with swollen borders and 
possibly crusting or superinfection. These 
lesions occur on the hard palate or gingiva or, 
more commonly, at the vermilion border of the 
lip.

What to do:
-----------
- When there is any doubt of the diagnosis, 
   scrape the base of a vesicle (warn the 
   patient this hurts) smear on a slide, stain 
   with Wright's or Giemsa, and examine for 
   multinucleate giant cells (look for nuclear 
   molding). This is called a Tzanck Prep, and 
   establishes the diagnosis of herpes. 
   Alternatively, this swab can be sent for 
   viral cultures, which may take days to grow.
- An equal mixture of Kaopectate and Benadryl 
   elixir will coat and dry the area and reduce 
   pain. Topical Orabase, or Xylocaine 2% 
   Viscous Solution will also relieve the pain. 
   Consider oral analgesics for continuous pain 
   relief. Narcotic analgesics and mild 
   sedation may be required to manage the most 
   severe pain.
- Instruct the patient to keep lesions clean, 
   and avoid touching lesions (so as not to 
   spread the virus to eyes, unaffected skin, 
   and other people).
- Inform the patient that oral herpes need not 
   be related to genital herpes; that the 
   vesicles and pain should resolve over about 
   two weeks (barring superinfection); that 
   they are infectious during this period (and 
   perhaps other times as well); and that the 
   herpes simplex virus, residing in sensory 
   ganglia, can be expected to cause 
   recurrences from time to time (especially 
   during illness or stress).

What not to do:
---------------
- Do not prescribe topical or systemic 
   acyclovir (Zovirax) unless the patient or 
   household contacts are immunocompromised. It 
   reduces viral shedding, but has not been 
   shown to benefit oral herpes simplex.
- Do not use topical anesthetics on keratinized 
   skin. They are only effective on oral 
   mucosa.

Discussion
----------

Herpes simplex infection may be either primary 
or recurrent. Possible causes of herpes 
reactivation include stress, fever, menstrua- 
tion, gastrointestinal distubance, infection, 
cold, fatigue and sunlight. Primary herpes 
usually appears as gingivostomatitis, pharyng- 
itis, or a combination of the two, while 
recurrent infections usually occur as intraoral 
or labial ulcers. Primary infection tends to be 
a disease of children or young adults, more 
severe than recurring episodes, preceded by 
fever to 105 degrees, sore throat and headache, 
and followed by red, swollen gums that bleed 
easily. This gingivostomatitis may need to be 
differentiated from herpangina, acute 
necrotizing ulcerative gingivitis, 
Stevens-Johnson syndrome, Beh¨et's syndrome 
and hand, foot and mouth disease.

Herpangina is caused by Coxsackie A virus and 
involves the posterior pharynx. Acute 
necrotizing ulcerative gingivitis, also known 
as Vincent's angina or trench mouth, is 
bacterial in origin, has characteristic 
blunting of the interdental gingival papillae, 
and responds rapidly to penicillin. Steven- 
Johnson sundrome is a severe form of erythema 
multiforme. There are characteristic lip 
lesions, the gingiva is only rarely affected, 
and there may be bull's-eye skin lesions on the 
hands and feet. Beh¨et's syndrome is thought 
to be an autoimmune response and is associated 
with genital ulcers and inflammatory ocular 
lesions. Hand, foot and mouth disease is also 
caused by the Coxsackie A virus and is 
associated with concurrent lesions of the palms 
and soles.

Home remedies for cold sores include ether, 
lecithin, lysine, and vitamin E. Because herpes 
is a self-limiting affliction, all of these 
work, but, in controlled studies, none have 
outperformed placebos (which also do very 
well).

References:
-----------
- Raborn GW, Dip MS, McGaw WT, Grace M, Percy 
   J: Treatment of herpes labialis with 
   acyclovir. *Am J Med* 1988;85(suppl 2A): 
   39-42.

 ----------------------------------------------------
 from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES
 Longwood Information LLC 4822 Quebec St NW Wash DC
 1.202.237.0971 fax 1.202.244.8393 electra@clark.net
 ----------------------------------------------------