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About cold sores There are two types of HSV – HSV-1 and HSV-2. A hemangioma, also called a strawberry nevus, is an abnormal buildup of blood vessels from an unknown cause. Hemangiomas of the oral cavity are not common pathologic entities, but, among hemangiomas, the head and the neck are common sites. Cavernous hemangiomas are composed of large, irregular, deep dermal and subcutaneous blood-filled channels that impart a purplish discoloration to the overlying skin. Superficial hemangiomas do not normally present serious medical complications, though understanding this has required medical research and patient observation. Medical research has revealed different medical treatments are appropriate for different hemangiomas, though not all doctors agree on the appropriate course of action. Injections of steroids in the superficial lesion itself (with or without liquid nitrogen cryosurgery) can be used for fairly small hemangiomas that are not on the face. Hemangiomas that cause deformities, grow rapidly or obstruct body or organ functions may require early aggressive treatment, like surgery. Geographic tongue is a condition in which the surface of the tongue shows reddish patches in which the upper layer of the tongue surface is eroded. High-grade T1 (formerly T1G3) bladder cancer (BCa) has a high propensity to recur and progress. To review the current literature on the management of T1G3 BCa and to provide recommendations for its treatment. The diagnosis of T1G3 disease is difficult because pathologic staging is often unreliable and because of the risk of significant understaging at initial transurethral resection (TUR) of bladder tumour. The incidence of transitional cell carcinoma (TCC) of the bladder worldwide is in excess of 336000 [1]. T1G3 tumours have a high propensity to recur and progress to muscle invasion and are associated with a significant risk of metastasis and death. The mainstay of diagnosis and initial treatment of T1G3 BCa is transurethral resection (TUR). Interobserver variability in pathology interpretation is another source of error in properly assigning a T1G3 diagnosis. The ability to correctly assign stage and grade to T1G3 tumours depends on adequate TUR technique. For all cases of newly diagnosed T1G3 TCC, a secondary TUR 4–6 wk after the primary TUR is strongly recommended.
In addition to the diagnostic benefit, repeat TUR has the ability to detect and potentially clear residual TCC. Adjuvant intravesical bacillus Calmette-Guérin (BCG) immunotherapy is the treatment of choice for bladder preservation with T1G3 TCC.
Five-year survival; all other survival rates are those reported at last follow-up for the respective study. Recurrence rates have ranged from 23% to 74%, and progression rates have ranged from 5% to 49%.
Based on these data and consensus within the urologic community, BCG is the preferred intravesical treatment for high-risk bladder TCC.
Patients experiencing severe side-effects from full-dose BCG can be considered for dose reduction, which may, however, compromise efficacy. Herr recently reviewed the data supporting maintenance BCG for high-risk non–muscle-invasive TCC and questioned, based upon methodologic limitations in the cited trials and a paucity of positive studies, the routine use of maintenance BCG for the prevention of tumour progression [37]. Compliance with therapy is also an issue, as only 16% of the SWOG trial participants completed all seven planned cycles. Late BCG failures are defined as patients with an initial complete response (CR) to BCG treatment (no tumour 6 mo after TUR) but with a subsequent recurrence [39]. BCG for late BCG failure patients as a salvage treatment for T1 cancers has been studied only to a limited extent. A third cycle of BCG is definitely not indicated because of success rates as low as 6% [44]. Thus, for patients with an initial T1G3 diagnosis and recurrence after BCG therapy, salvage treatment with a second course of BCG should be reserved for patients with pTa or CIS recurrences.
Device-assisted therapy has also been investigated as a means of increasing the efficacy of intravesical chemotherapy. The relatively high recurrence and progression rates associated with conservatively treated T1G3 TCC (Table 1) make cystectomy an option for these patients. Rates reported are those reported at study completion and not necessarily 5-yr actuarial values.
Risk stratification involves assessing the probability of progression and local failure with conservative treatment. Noncompliance or intolerance to adjuvant intravesical therapy or tumours in a location difficult to access transurethrally are indications for immediate or early cystectomy. A limited number of reports assessing the role of radiation therapy (RT) with or without chemotherapy for the treatment of T1G3 TCC are available. The excellent CSS and OS rates achieved with cystectomy for stage T1 TCC (Table 2) must be weighed against the understandable wish of the patient to preserve his or her own bladder along with the risks and morbidity of cystectomy. Kulkarni et al performed decision analysis that enabled comparisons of cystectomy and BCG while accounting for detriments in QoL related to either treatment (level 2b) [54].
Analysis and interpretation of data: Kulkarni, Hakenberg, Gschwend, Thalmann, Kamat, Kassouf, Zlotta. Drafting of the manuscript: Kulkarni, Hakenberg, Gschwend, Thalmann, Kamat, Kassouf, Zlotta.
Critical revision of the manuscript for important intellectual content: Kulkarni, Hakenberg, Gschwend, Thalmann, Kamat, Kassouf, Zlotta. Most cold sores are caused by HSV-1, whereas most genital sores (genital herpes) are caused by HSV-2. These can occur in the skin or the internal organs and are usually present at birth, although they also can show themselves a few months later. Most true hemangiomas involute with time, but a certain small percentage do not, which may present with complications that require treatment. Capillary hemangiomas are on the surface layers of the skin and, as the name would indicate, involve capillaries. There is an initial rapid growth phase, followed by a rest period, after which the hemangioma begins to involute, or recede. Internal hemangiomas can cause severe problems, such as bleeding, and need to be treated immediately and aggressively.
These can treated with lasers, such as the flash-lamp pulse dye, pump dye, diode and sclero-laser, when caught early.
Girls are five times more likely than boys to have hemangiomas and Caucasians are more likely than any other race to be born with them. The surface of the tongue appears uneven in this condition, and the patches change position over hours or days. Risk stratification of patients based on pathologic features at initial TUR or at recurrence can select those most appropriate for bladder preservation compared to those for whom cystectomy should be strongly considered. Risk stratification based on pathologic features at initial transurethral resection or at recurrence can select those most appropriate for bladder preservation compared to those for whom cystectomy should be strongly considered.
Long-term progression and death rates as high as 53% and 34%, respectively, have been reported [3]. Each article's title and abstract were reviewed for their appropriateness regarding clinical management of T1G3 TCC of the bladder. The resection must include the muscular layer and should be as complete as possible without bladder perforation. In a study of 1400 patients pooled from five European Organisation for Research and Treatment of Cancer (EORTC) randomised, controlled studies of adjuvant intravesical therapy for Ta and T1 BCa, agreement on lamina propria invasion was only 42.9% (level 2b) [10].
Excessive cautery artefacts can make pathologic interpretation difficult and should be avoided.
A meta-analysis performed by Sylvester et al analysed 1476 patients from seven randomised, controlled trials of prophylactic chemotherapy versus no prophylaxis after TUR (level 1a) [17].
Contraindications to its use include very deep resections, bladder perforation, and prior documented allergic reaction. Because at least 27% of patients harbour residual tumour (with the highest reported rates of 62%) [9], repeat resections may have a therapeutic benefit.
Although upstaging of T1G3 lesions to pT2 disease or higher automatically selects patients for radical therapy, Herr and colleagues demonstrated that evidence of T1 disease on repeat TUR portends future muscle invasion (level 2b) [24]. Standard induction therapy comprises six weekly instillations after diagnosis of T1G3 disease after complete resection, although this regimen is largely non–evidence based. For studies in which data for T1G3 tumours are not reported separately, combined data with the proportion of cases made up of T1G3 lesions are provided.
Where available, the reported disease-specific survival (DSS) and overall survival (OS) estimates also ranged widely. Shelley and colleagues published a Cochrane Review, updated in 2008, assessing the impact of BCG therapy on medium- and high-risk TCC compared to TUR alone (level 1a) [25].
MMC is a reasonable alternative only in situations where adjuvant BCG is contraindicated (allergy, intolerance to BCG, or immunosuppressed states) and immediate cystectomy is refused [30].
Although these provocative arguments should be considered prior to prescribing maintenance BCG, until strong evidence suggests otherwise, the data nevertheless support maintenance BCG for all cases of T1G3 TCC treated with a bladder-sparing approach. In fact, less than half of the patients completed more than three cycles, suggesting that the noted significant impact of maintenance therapy was achieved up front during therapy.


Of 126 patients with an initial pT1 lesion, Brake et al reported that 89 (71%) had a lasting response to a single course of BCG [40].
To avoid cystectomy, other intravesical salvage options for BCG failures have been studied. Patients with a pT1 recurrence are at high risk of progression and should definitely be offered cystectomy. Intravesical gemcitabine has been used for the treatment of high-risk BCa after BCG failure. Local hyperthermia coupled with MMC has been shown to have improved efficacy over MMC alone in the treatment of high-risk superficial TCC.
Although restaging TUR refines local cancer staging, thereby decreasing the risk of understaging T1 lesions, approximately 13% of patients will still be understaged even after re-TUR (level 3b) [51]. First, the perioperative mortality and morbidity rate following cystectomy is not trivial at 1–6% (level 2c) [52] and 30% (level 2b) [53], respectively. This is particularly important because a number of series have demonstrated that delays in cystectomy can lead to worse outcomes. Identifying candidates at high risk for progression would help to identify clearly patients who should undergo early cystectomy. 1 illustrates a possible treatment algorithm for newly diagnosed T1G3 tumours based on the information we have presented in this review.
Weiss and colleagues retrospectively evaluated the impact of radiochemotherapy for high-risk T1 BCa in 141 patients followed for a median of 62 mo (level 3b) [62]. Intravesical treatment may result in bladder preservation but not without risk and morbidity. Not surprisingly, they found that the treatment associated with the highest gain in quality-adjusted life expectancy (QALE) was dependent on patient age and comorbidity.
Bladder preservation with BCG and RC are the current standard treatment modalities of choice for these tumours. Kulkarni had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. An estimated 10-20% of true hemangiomas incompletely involute and require postadolescent ablative treatment.
In the rapid growth phase, which can last up to 18 months, the volume and size of the lesion increases dramatically.
The lesion may expand and darken with crying, when agitated, or when placed in a dependent position. Alfa-interferon can be used for hemangiomas unresponsive to steroids, or that are problematic or life-threatening. Treatment with bacillus Calmette-Guérin (BCG) risks progression and metastases but may preserve the bladder. Nevertheless, many of these tumours can be treated successfully with bladder-preservation approaches.
Although a wide variety of chemotherapeutic agents were used in the pooled trials (mitomycin C [MMC], doxorubicin, epirubicin, and thiotepa), the majority of centres use MMC (40mg in 40cm3 of saline) as the prophylactic chemotherapeutic agent of choice. First, a repeat resection of the previously resected site 2–6 wk after the initial resection (along with any other cystoscopically suspicious areas) will provide more accurate staging information. Divrik and colleagues provided randomised, controlled evidence supporting this notion (level 1b) [23]. Of 92 T1 patients with residual T1 disease at second resection, 82% progressed to muscle invasion by 5 yr.
The heterogeneity in outcomes is likely related to a combination of factors, including differences in patient selection (eg, differing rates of concomitant CIS), in the quality of TUR (eg, differing rates of muscularis propria sampling), in the use of secondary TUR, in the use of maintenance instillation regimens and agents, as well as variable times of follow-up.
Six randomised trials involving 585 patients, of which more than half were pT1, were included. Undoubtedly, patients experience significantly fewer local and systemic side-effects with adjuvant MMC compared to BCG [27], but the potentially aggressive nature of T1G3 TCC necessitates the use of the most effective treatment.
The maintenance protocol consisted of three weekly BCG instillations at 3 and 6 mo post-TUR and semiannually thereafter for 3 yr.
This notion is supported by a report from Decobert and colleagues [38] in which 111 patients at high risk for recurrence (32% pT1) received BCG as per the SWOG maintenance protocol (level 2b). Many urologists also consider cystectomy as the appropriate treatment for late BCG failures. Of the 37 recurrences, 13 were muscle invasive, and the remaining 24 were treated with repeat resection and a second course of BCG. In a phase 2 trial involving 467 unselected superficial BCa patients with at least one BCG failure, the combination of BCG plus interferon-α resulted in a disease-free rate of 45% at 24-mo median follow-up [45].
In a phase 2 trial of intravesical gemcitabine for BCG-refractory BCa where cystectomy was recommended but refused, Dalbagni and colleagues noted a CR, defined as negative cystoscopy, cytology, and biopsy at first surveillance of 50% (15 of 30; level 3b) [46]. Second, cystectomy may have a detrimental impact on quality of life (QoL) secondary to long-term changes in sexual, gastrointestinal, and genitourinary function (although it should be remembered that BCG therapy can also impair QoL because of frequent follow-up, surveillance cystoscopy, lower urinary tract symptoms, and the risk of disseminated BCG infection [54]). The need for such a strategy has been recognised by a recent international consensus panel on T1 BCa that subclassified T1 tumours into high-risk and low-risk variants based on multifocality, associated CIS, tumour location (dome or anterior bladder wall), or residual T1 disease on restaging TUR [44].
It supports a bladder-preservation regimen in patients without identifiable risk factors while helping to identify those individuals at risk for progression in whom immediate or early cystectomy should be performed. Of the 84 patients with T1G3 disease, 89% achieved a CR (no tumour on restaging TUR 6 wk after completion of radiochemotherapy). As a result of cost, inconvenience, potential for toxicity, and a lack of benefit over conventional intravesical therapies, the authors concluded that RT cannot be recommended for routine use as a bladder-preservation strategy. Although CSS remains of paramount importance, QoL considerations, which are difficult to assess, cannot be ignored. Younger, healthier patients had higher QALE when treated with cystectomy, but after age 65, a higher QALE was noted with BCG treatment.
The decision to pursue bladder preservation versus cystectomy depends on a number of tumour factors, which can indicate the risk of progression. They tend to be most alarming to parents when they are present on the face or head of infants.
Often, a capillary component overlies a cavernous component, and it may be difficult to distinguish these components histologically. Hemangiomas on the eyelid, for instance, can impede normal vision development in young children. However, severe complications can occur with walking in 10 to 12 percent of patients taking this medication, so it is not the first course of treatment.
Cystectomy may offer the best opportunity for cure but is associated with morbidity and a risk of mortality, and it may constitute potential overtreatment for many cases of T1G3 tumours.
For a bladder-sparing approach, intravesical BCG should be given as induction with maintenance dosing. The dilemma facing the urologist is how best to treat these tumours in a timely manner so that the chances of bladder preservation and cancer control are maximised while the risks of overtreatment with radical therapy are minimised. Tumour visibility and completeness of resection can be aided by fluorescence cystoscopy (or photodynamic diagnosis), although this diagnostic modality is not available in all jurisdictions [6]. Discrepancies in grade were also noted in this study, with grade 3 agreement only observed in 61.3% of cases. The importance of the quality of TUR was shown by Brausi et al in their assessment of 2410 EORTC patients from seven phase 3 adjuvant intravesical therapy trials (level 2b) [16]. This is particularly important because the probability of understaging a T1G3 tumour ranges from 20–70%, depending on the presence of muscularis propria in the sample. In their study, T1 patients (11% T1G3) were randomised to TUR plus adjuvant intravesical MMC versus TUR plus MMC followed by re-TUR 2–6 wk later. In contrast, of 260 T1 patients without lamina propria invasion on re-TUR (stage distribution on re-TUR: 149 T0, 87 carcinoma in situ [CIS], 24 Ta), only 19% progressed at 5 yr.
Despite these discrepancies, these studies point to the need for long-term surveillance of patients with T1G3 BCa. At 12 mo, the recurrence rate was 26% for patients treated with adjuvant BCG compared to 51% in patients treated by TUR alone. In a subgroup analysis of high-risk patients receiving maintenance BCG, the risk reduction compared to MMC was 49%. In a number of cases, efficacy and safety did not appear to be compromised for T1G3 tumours [32] and [33], but recent reports by Martinez-Pineiro et al [34] and Yoneyama et al [35] have suggested worse outcomes with low-dose regimens in T1G3 patients, with trends towards reduced DSS and RFS (level 2b). The durable response rate, however, was much lower, with a 1-yr RFS in responders of only 21%.
Table 2 lists the contemporary series in which T1 tumours were treated immediately or early with radical cystectomy (RC; level 2b). Because up to 18% (Table 2) of T1 patients have positive lymph nodes, cystectomy can be both diagnostic and therapeutic with regard to nodal metastases.
Finally, RC may be considered overtreatment for many patients because a conservative bladder-sparing approach with BCG is effective in approximately 50% of cases. They hypothesised that the delay to definitive, radical surgery with increasing endoscopic interventions may have contributed to the increase in progression.
All pathology identified after the first cystoscopic assessment assumes adequate transurethral resection (ie, re-resection of T1 lesions). Long-term results, however, showed that the 10-yr risk of progression for T1G3 patients was 29%, with a 10-yr DSS of 71%. We present a risk-stratified approach for these lesions that should maximise the chances of safely identifying those patients in whom a bladder-preservation strategy can be pursued while also identifying those at high risk of progression for whom immediate or early cystectomy must be offered.
Hemangiomas can also be compound (or mixed), meaning they have both superficial and deep components.


Cavernous and mixed hemangiomas demonstrate the same patterns of proliferation as those of capillary lesions.
Plastic surgery is used for hemangiomas that are unresponsive to other treatments and present life-threatening complications or deformity. Immediate or early radical cystectomy (RC) should be offered to all patients with recurrent or multifocal T1G3 disease, those who are at high risk of progression, and those failing BCG treatment. In this review, we focus on contemporary treatment strategies for T1G3 TCC of the bladder, highlighting the initial workup and diagnosis of these lesions, and then concentrating on treatment and outcomes of conventional and alternative treatments. Adequate sampling of muscularis propria is essential, as numerous studies have documented the risk of understaging T1 lesions at 50–70% in the absence of muscularis propria (level 2b) [7] and [8]. The impact of this change in grading on outcomes is not yet fully understood [12] and [13], although both grading systems contribute independent information regarding disease progression [14]. Nevertheless, a decrease in the odds of recurrence rate by 39% was found with immediate prophylactic chemotherapy. If muscle is absent from the initial TUR, repeat resection is mandatory because of the high rate of understaging [8]. Patients in the repeat TUR group experienced a significantly improved 3-yr recurrence-free survival (RFS) of 69% compared to 37% in the group without secondary TUR.
Based on these data, residual T1 TCC on repeat TUR was deemed a negative prognostic indicator and a potential indication for immediate cystectomy in T1G3 patients. Cookson and investigators reported on 86 high-risk patients (44% pT1, 81% diffuse CIS) with median follow-up of 184 mo, half of which received induction (but not maintenance) BCG. A meta-analysis by Sylvester et al demonstrated the benefit of adjuvant BCG on progression [26].
These results were corroborated in a meta-analysis conducted by Shelley involving 1527 patients from six randomised, controlled trials of BCG versus MMC treatment. Thus, in T1G3 TCC, dose-reduced BCG regimens must be used with caution, with additional investigation of the role of reduced dose BCG warranted. Although the impact of additional maintenance (three cycles vs four or more cycles) was not statistically significant, none of the 12 patients who received five or more cycles of maintenance BCG experienced a recurrence. A low short-term disease free rate of 13% in high-risk patients (including T1G3 patients) was also noted by Bartoletti et al (level 3b) [47].
DSS for these patients ranges between approximately 80% and 90%, which is probably an underestimate of the true survival conferred to T1 patients treated with cystectomy, because the patients in these retrospective series were likely selected to undergo cystectomy because of adverse pathology (eg, multifocality, associated CIS).
Fourth, cystectomy obviates the need for repeated intravesical therapies and simplifies follow-up. Thus, an approach using reliable risk stratification in order to decide which patients to offer early cystectomy versus conservative treatment is required. Herr and Sogani studied 307 high-risk BCa patients, 90 of whom underwent cystectomy on relapse (level 2b) [56].
The presence of two or more of these risk factors at T1G3 diagnosis identifies candidates who must be advised to undergo immediate cystectomy [57] and [59].
Of note, the vast majority of patients were satisfied with their urinary function, suggesting that combined TUR with radiochemotherapy maintained QoL while achieving respectable disease outcomes. Rather, the type of tumour and its associated risk factors for progression along with patient factors such as age, comorbidity, and preferences must all be considered when making a final treatment recommendation. Some hemangiomas disappear completely, leaving little or no trace they were present; this can occur with mild superficial lesions.
However, involution is often incomplete, depending on the location and the presence of associated arteriovenous malformations. Where possible, we have provided levels of evidence as per the modified Oxford Centre for Evidence Based Medicine scheme [4]. Even with muscularis in the specimen, understaging rates based on cystectomy pathology are reported between approximately 20% and 30% after single TUR [7] and [9]. Even after accounting for the number of tumours, the year of resection, and the institution at which the resection occurred, recurrence rates displayed significant variability.
Even with muscularis propria sampling at first resection, several reports have documented occult T2 disease in up to 10% of second resections (level 2b) [9], [19], and [20]. Of these patients, 31% had progression after 5 yr, four of which cases occurred after 10 yr and one beyond 15 yr (level 1b) [3]. The meta-analysis of Böhle and Bock [29] corroborated Sylvester et al's data, as discussed above. Although these data support the idea of early efficacy of maintenance therapy, patients nevertheless should be encouraged to continue maintenance beyond three cycles. Nevertheless, because the actuarial risk of progression with each additional 6-wk course of BCG is 7% [41], many urologists hesitate to provide a second course BCG except in select cases. In a recent report of 40 patients (90% pT1) followed for a median of 28 mo, 14 (35%) patients recurred, but no patients progressed [48].
Large cavernous hemangiomas may disappear on their own as well, but will likely leave the skin permanently distorted.Capillary hemangiomas are usually not present at birth but are antedated by a pale, well-demarcated, flat area, most visible with agitation. Finally, we provide a recommended treatment algorithm for patients with T1G3 bladder cancer (BCa) that incorporates bladder preservation and radical therapeutic techniques based on defined risk groups. The authors concluded that surgeon skill and resection technique were the major determinants of TUR outcome.
More recent reports have confirmed these findings but have suggested that the tumours prevented are primarily of the smaller variety (level 1a) [18]. These data suggest that the long-term risks associated with T1 bladder tumours are not trivial and mandate lifelong cystoscopic and cytologic follow-up. With respect to progression, Böhle and Bock in another meta-analysis analysed nine trials of BCG versus MMC adjuvant therapy comprising 2410 patients (level 1a) [29]. Soloway et al suggest a second course BCG if the recurrent lesion is Ta or CIS and cystectomy for recurrent T1G3 tumours [42].
On the basis of these preliminary data, intravesical gemcitabine cannot be recommended for pT1G3 TCC of the bladder. Likewise, Denzinger and colleagues examined 105 T1G3 patients with adverse pathologic features (at least two of multifocality, tumour size >3cm or CIS), all of whom underwent cystectomy (level 2b) [57].
Not listed are investigational molecular markers such as p53 or pRB, the prognostic ability of which in high-risk superficial BCa has not been established unequivocally (level 4) [60] and [61]. These prodromal lesions may appear as a pale halo surrounding an area of telangiectasis or as a very fine telangiectasia similar to the port-wine stain. Clearly, both the urologist and the pathologist play an important role in adequately defining T1G3 BCa. This approach has been verified in a study of 214 patients with high-risk BCa who experienced T1 recurrence [43]. Further studies confirming these results are needed before this approach can be recommended. Fifty-four patients opted for immediate cystectomy, and 51 underwent deferred cystectomy at a median of 11.2 mo after initial TUR. Clinical under staging of high risk nonmuscle invasive urothelial carcinoma treated with radical cystectomy. Unfortunately, a subset analysis with high-risk patients only was not possible in this study because of the small number of trials with high-risk patients.
A 71% cumulative incidence of progression to muscle invasion at 5 yr (48% death from disease) was noted for patients treated with second-course BCG compared to a 28% cumulative incidence of progression (31% death from disease) for patients treated with cystectomy (level 2b). These data clearly support the use of cystectomy in the treatment of patients with pT1G3 recurrence after BCG treatment.
Lambert et al also noted poorer disease-free survival and DSS in a cohort of patients undergoing cystectomy for T1G3 TCC after 1998 versus those treated with cystectomy before 1998 (level 3b) [58]. They postulated that the decrease in survival was the result of higher and perhaps inappropriately prolonged use of intravesical therapy in the modern era. However, if they get worse, don’t improve within seven days, or you have recurrent outbreaks, see your GP for advice. This is a condition that can develop if the sores become infected with bacteria, causing them to become crusty and yellow. HSV can spread into broken skin (for example, eczema or dermatitis) and cause a serious skin infection. The infection is passed on through skin-to-skin contact, for example by kissing someone who has the virus or by sharing objects that have been in contact with the virus, such as a razor or a lipstick. If you have any pain or discomfort, you can take over-the-counter painkillers, such as paracetamol or ibuprofen. Always read the patient information leaflet that comes with your medicine and if you have any questions, ask your pharmacist for advice. If you wear contact lenses, it’s particularly important to wash your hands before you touch them.
If possible, you should also try to discourage your child from sharing anything that may have come into contact with the cold sores, such as cutlery. If, and when HSV becomes active again, your son is unlikely to have severe blistering in his mouth and on his gums again. Young children can develop herpetic whitlow from sucking their thumbs or fingers when they have a cold sore.
If your child has a cold sore, it’s good to try and encourage him or her not to touch it, or if they do, to wash their hands with soap and water straightaway.



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