Please educate me about cold sores

December 28, 2005 6:39 PM

This thread about cold sores has prompted me to ask some long-standing questions about them.

My girlfriend has had cold sores (2-3 episodes per year) since she was a toddler. I've never had cold sores. Since we've been together she's had a couple, and when she does get one we are careful not to kiss and so far that's been successful. Barring any further knowledge, this strategy of avoidance during her outbreaks will continue to be our gold standard prophylaxis.

However, the things I've read about Herpes Simplex virus 1 (HSV1) have made me wonder whether there's any point. From reputable sources, I've read that as many as 60% of the population have antibodies to the virus, but only a number of them ever show clinical disease. Also, I've read that virus is shed into saliva even during non-symptomatic phases.

I can't help but think that on a long enough timeline I'm going to get it, or that I even have it now but am lucky enough to not be symptomatic. Could either of those be correct? Is there some test I can take that could reliably tell me whether I've already been exposed? Supposing I have, does that mean that we no longer have to be so cautious during episodes? I once tried to ask my doctor these questions, but he didn't know and was kinda pissed that I would waste his time just to ask some questions. He's not the best.

I can avoid kissing her for 10 days, 3 times a year. But if it's a pointless strategy, I'd want to know. And speaking of avoiding kissing her, once the sore has backed down and started the healing process, is it safe then? Or do I have to wait until the area has completely healed?

Finally, can someone with a cold sore give themselves genital herpes (I know HSV2 is typically responsible, but genital HSV1 infection can happen)?

Thanks in advance. There's a lot I don't know, and failing my other reasonably extensive attempts to find out, I put it you you guys. And don't worry, I will take responses with the appropriate-sized grain of salt before acting. So, supporting articles, credentials, or even just where you heard it, would be much appreciated.

posted by anonymous to health & fitness (12 comments total)

Keep kissing. I'm a carrier of HSV1, as is my mom and my sister, and my wife and I don't have any problems with outbreaks. I might get 1 or 2 cold sores per annum, and my wife might pick up one... maybe. They're really not that big of a deal though. Pick up some medicated oral gel and get your freak on!
posted by bjork24 at 6:56 PM on December 28, 2005

According to wikipedia: "he presence of antibodies indicate that a person has been exposed to the virus because the immune system only creates antibodies in response to the presence of that virus. About one third of those exposed to the HSV1 (see below for differences between HSV1 & 2) will experience recurrent outbreaks or cold sores. This means that most persons infected with HSV may not know they are infected."

They also mention that 80% of the population has antibodies at age of 50. So dollars to doughnuts you're already infected, but also a good chance you'll never show symptoms. Just like my gf of ten years.
posted by furtive at 7:07 PM on December 28, 2005

I don't know anything about the herpes virus, but I do know you should get a new doctor. It's your doctor's job to answer these kinds of questions or any other question you care to ask them.
posted by duck at 7:10 PM on December 28, 2005

It is possible for a person to contract genital herpes if the partner with oral herpes performs oral sex.

HSV-1 can cause genital herpes through transmission during oral-genital sex, thus both strains of the virus may be transmitted by sexual contact. Initial oral herpes infection, however, usually occurs in childhood. It is therefore not classified as a sexually transmitted disease. [from herpes.com]

I get 4-6 HSV-1 outbreaks a year. My wife never had it until she met me, and now gets an outbreak every other year or so. We play by the no-oral-sex-with-a-cold-sore rule, which sucks (or doesn't, I suppose).
posted by F Mackenzie at 7:29 PM on December 28, 2005

I get cold sores. My dad gets cold sores. My mom doesn't. They've been married for 36 years. I'm not sure if they have a particular avoidance system, but I know my dad's sores are usually really ferocious (lysine and other treatments be damned) so I imagine they probably hurt too much for the majority of the outbreak for kissing or anything else. Mine are more easily controlled with lysine, though, and so are my husband's (which he had prior to being with me).

According to everything I've ever read, simplex 1 can mutate into simplex 2 if it's introduced into the genital area via contact with an active outbreak. So, none of that. I don't know so much about giving yourself genital herpes, but my high school health teacher just said to be sure to wash your hands a lot during an outbreak, so either it can be or she didn't want anyone finding out the hard way.
posted by Medieval Maven at 8:06 PM on December 28, 2005

Short answer:

You will likely get oral herpes, but don't kiss her when she has an outbreak. There are tests to find out if you have herpetic antibodies, and thus herpes. People can give themselves herpes.

Long answer:

Ignore the distinction between HSV-1 and HSV-2. Yes, HSV-1 is more common as oral herpes, and HSV-2 is more common as genital, but both can infect either locus and behave almost identically (HSV-2 is usually linked to higher frequency, more severe recurrent outbreaks).

It is possible you've contracted oral HSV and not expressed the virus. There are tests that can detect HSV antibodies to determine this. On a long enough timeline, you likely will get it. I've seen some studies peg the number of Americans over the age of 15 with Oral Herpes as over 80% of the population. But if you do get it. So what?

Once a recurrence starts up, slap some Abreva (OTC antiviral cream) on it, and your two-week outbreak changes to a less severe four day ordeal. That said:

Don't kiss her during outbreaks. Two reasons:
1) They're cold sores. They hurt when things touch them.
2) HSV is most infectious right after the scabs are shed, leaving an open wound. Let her heal completely.

Viral shedding is more of a problem with genital herpes, as a person can transmit the disease with no indication that they're infectious, and genital herpes can affect fertility. Oral herpes is just a minor cosmetic inconvenience. Viral shedding happens in people that are on daily suppressant therapy less frequently than those who are not, but a person on a steady Valtrex regimen will still shed.

That said, self-innoculation is also very possible with Herpes, but reasonably rare. It doesn't hurt to take precautions and wash your hands with soap before using the restroom, though. Women are more likely to contract genital herpes than men, thanks to genital design. I have one female friend who self-innoculated.

Here's a fun fact: 20% of the American adult population has genital herpes. More than 80% of those that do have genital herpes aren't aware of it.

Credentials: I'm a sophomore in college with no formal medical education. But I am a huge infectious disease nerd. Herpes is one of my favorite viruses. It's interesting both in terms of viral efficiency, and social impact. Cold sores are fine to talk about, so long as you don't call them herpes. And nearly a quarter of the population has genital herpes, but it's still quite hush-hush.

In terms of the info, Valtrex and shedding are covered pretty well in:
Once-Daily Valacyclovir to Reduce the Risk of Transmission of Genital Herpes. Lawrence Corey, Anna Wald, Raj Patel, Stephen L Sacks, et al. The New England Journal of Medicine. Boston: Jan 1, 2004.Vol. 350, Iss. 1; pg. 11
Reducing the risk of transmitting genital herpes: advances in understanding and therapy. Leone P. Current Medical Research and Opinon. 21 (10): 1577-1582. Oct 2005.

The second article in particular should be useful. It's a review, so it cites a ton of additional articles on the general subject of transmission risk reduction.

Feel free to email me if you'd like me to try to dig up more specific articles on any of the other facets of your question, or if you have any other general questions. I'm not a doctor or an expert, of course.

On Preview:

HSV-1 can't turn into HSV-2 when it's introduced into a genital environment. You just get a genital case of HSV-1. The number designates a strain of the virus, not a location of infection. And oral-genital transmission is very real, and very possible.
posted by SemiSophos at 8:13 PM on December 28, 2005

I almost said the review article was useful because it "links to," not "cites," other articles. And I wrote all of that off the top of my head and two articles lying around my hard drive. And I'm going to be a Geology major.
posted by SemiSophos at 8:17 PM on December 28, 2005

I don't have the papers with me at the moment, but that 80% of people having it at 50 sounds about right; I don't remember exactly what the percentage of people at 20, 30, and so on is but it is high enough to make me disgusted by the lot of you people. :) I honestly wouldn't worry so much about getting an infection as you are right about the shedding during latentcy and that you probably already have it.

Yes, you can get a genital HSV-1 infection -- it is harder for HSV-1 to infect the genitalia than the lips/face but it can happen (and the other way around for HSV-2). Avoiding oral sex during an outbreak is probably a good idea. If I remember right, it takes some work to infect the genitals with HSV-1, which is to say you have to tear the skin (rip, rub raw, scratch, etc...) but if it was me, I wouldn't chance it. The real complication to worry about is spreading the infection to your eye as this will cause scaring of the cornea and lead to blindness.

On preview: SemiSophos is pretty much spot on. As for the HSV-1/-2 distinction, they are different viruses which are separate but related -- they share about 50 percent identical genome sequence and off the top of my head I can't remember what that 50% codes for and how much of it is homologus.

Credentials -- I'm a molecular biology graduate student that has so far just done a rotation is a lab researching HSV-1 and may go on to do my doctorate work in it. I've read a slew of papers, know more than the average bear, but am not an expert yet.
posted by The Bishop of Turkey at 9:06 PM on December 28, 2005

My parents are like MM's; married for 20 years, father gets really, really bad outbreaks, valtrex be damned, and mother has never had an outbreak. They do avoid kissing during outbreaks, but still.
SemiSophos, oral herpes can be more than a "minor cosmetic inconvenience". My father gets them near his eyes and nose as well as his mouth. If they ever spread into his eyes, he could go blind. If they spread into his nose, they might get into his brain, which, you know, could kill him. This is only what I understand; it may not be as serious as I've heard, but oral herpes can be more than an "inconvenience".
posted by MadamM at 9:56 PM on December 28, 2005

SemiSophos: The following is what I posted in the thread linked to from this one. Do you have any further information on Abreva, or even Valtrex?

Copied-and-pasted post follows:

I strongly argue against using Abreva.

My personal experience is that it made my cold sores worse. Because of using Abreva (according to directions) I'm pretty damn sure I have two new sites for cold sores to erupt. They used to only come in at one, small site, now that site is larger and I have two new sites, one on the same lip and one on the other lip.

Being hyperaware of my own body, my opinion is that Abreva either "pissed off" my virus/cold sore infection, or somehow possibly caused it to mutate. My cold sore is decidedly not the same as it was before briefly trying Abreva.

I wouldn't be surprised if there was a class action lawsuit occuring or occuring over Abreva in the near future, or other related herpes simplex medications.

Beside, the crap is expensive, and you're better off just eating right and managing stress and all that in the first place.

I combat my cold sores by staying hydrated, eating well and managing stress.

AFAIK L-Lysine is readily available in dairy products. I drink a lot of (hormone free) milk and eat a lot of yogurt when I feel an outbreak coming on. Along with the above management tools, it seems to work well. I also have noted that when I elimate diary/L-Lysine from my diet I get cold sores more often.

posted by loquacious at 11:57 PM on December 28, 2005

Loquacious: I'm off campus for break, so I can't get in to any of the databases we subscribe to. If you'd like, I could look for things once I get back (the 31st). However, searching for docosanol efficacy at Google Scholar brings you to this article from the Journal of the American Academy of Dermatology. With a sample size of 737 folks the abstract indicates:

Adverse experiences with docosanol were mild and similar to those with placebo. CONCLUSION: Docosanol applied 5 times daily is safe and effective in the treatment of recurrent HSL. Differences in healing time compared favorably with those reported for the only treatment of HSL that has been approved by the Food and Drug Administration.

The article was published in 2001. It would be useful to pop into the Web of Knowledge database and do a search for studies that have cited it. Just to see if the findings about adverse effects are corroborated.

As far as Valtrex, the first study I mentioned above is pretty awesome. Proquest has its fulltext. Its abstract:

BACKGROUND
Nucleoside analogues against herpes simplex virus (HSV) have been shown to suppress shedding of HSV type 2 (HSV-2) on genital mucosal surfaces and may prevent sexual transmission of HSV.
METHODS
We followed 1484 immunocompetent, heterosexual, monogamous couples: one with clinically symptomatic genital HSV-2 and one susceptible to HSV-2. The partners with HSV-2 infection were randomly assigned to receive either 500 mg of valacyclovir once daily or placebo for eight months. The susceptible partner was evaluated monthly for clinical signs and symptoms of genital herpes. Source partners were followed for recurrences of genital herpes; 89 were enrolled in a substudy of HSV-2 mucosal shedding. Both partners were counseled on safer sex and were offered condoms at each visit. The predefined primary end point was the reduction in transmission of symptomatic genital herpes.
RESULTS
Clinically symptomatic HSV-2 infection developed in 4 of 743 susceptible partners who were given valacyclovir, as compared with 16 of 741 who were given placebo (hazard ratio, 0.25; 95 percent confidence interval, 0.08 to 0.75; P=0.008). Overall, acquisition of HSV-2 was observed in 14 of the susceptible partners who received valacyclovir (1.9 percent), as compared with 27 (3.6 percent) who received placebo (hazard ratio, 0.52; 95 percent confidence interval, 0.27 to 0.99; P=0.04). HSV DNA was detected in samples of genital secretions on 2.9 percent of the days among the HSV-2-infected (source) partners who received valacyclovir, as compared with 10.8 percent of the days among those who received placebo (P<0 .001). the mean rates of recurrence were 0.11 per month and 0.40 per month, respectively (p0.001). br> CONCLUSIONS
Once-daily suppressive therapy with valacyclovir significantly reduces the risk of transmission of genital herpes among heterosexual, HSV-2-discordant couples.

MadamM: Apologies if I sounded dismissive of oral herpes. There are atypical cases that result in more severe outbreaks, and outbreaks are not always confined to the oral/genital areas. Dentists, for instance, have been known to have herpetic lesions appear on their fingers (Herpes whitlow), and an infection of the eye can damage sight if it produces corneal scarring (Herpes keratitis). Wrestlers are at higher risk for skin infections (Herpes gladiatorum).

Herpes encephalitis, an infection of the brain, is also an issue, but such infections are extremely rare (to the tune of ~0.003% of Americans experiencing it yearly).

Like everything, herpes expresses itself differently in different people, and there's no way for Anonymous to know how his body will react when he contracts it. Of course, chances are he will acquire herpes. The question is when and how he'll react.
posted by SemiSophos at 12:23 AM on December 29, 2005

loquacious - FWIW, my experience with Abreva was not as bad as what you describe, but it really didn't help me at all, and seemed to make mine more painful/tender. I just OD on the lysine and leave it at that, but now that you mention it, since I've been drinking Organic milk, I don't think I've had one. Hm. Food for thought.
posted by Medieval Maven at 2:34 PM on December 29, 2005