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Patient information: See related handout on cold sores, written by the authors of this article.
A cross-sectional study of herpes simplex virus types 1 and 2 in college students: occurrence and determinants of infection. Longitudinal evaluation of herpes simplex virus DNA load during episodes of herpes labialis.
The natural history of recurrent herpes simplex labialis: implications for antiviral therapy. Comparison of Chemicon SimulFluor direct fluorescent antibody staining with cell culture and shell vial direct immunoperoxidase staining for detection of herpes simplex virus and with cytospin direct immunofluorescence staining for detection of varicellazoster virus. Acute herpetic gingivostomatitis in adults: a review of 13 cases, including diagnosis and management.
Treatment of herpes simplex gingivostomatitis with aciclovir in children: a randomised double blind placebo controlled study. Interventions for the prevention and treatment of herpes simplex virus in patients being treated for cancer. Single-dose, patient-initiated famciclovir: a randomized, double-blind, placebo-controlled trial for episodic treatment of herpes labialis.
Valacyclovir and topical clobetasol gel for the episodic treatment of herpes labialis: a patient-initiated, double-blind, placebo-controlled pilot trial.
Clinical efficacy of topical docosanol 10% cream for herpes simplex labialis: a multi-center, randomized, placebo-controlled trial.
Acyclovir cream for treatment of herpes simplex labialis: results of two randomized, double-blind, vehicle-controlled, multicenter clinical trials.
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Pyogenic granuloma: a mass of granulation tissue sticking out of the gum between the teeth. The virus is mysteriously reactivated by injury, fever, stress, hormonal chaos, UV light, and so forth.
The tumor is usually located superficially and the facial nerve may be spared by the surgeon. This HIV-positive patient was exhibiting a chronic mucocutaneous herpes lesion for one month in duration.
The virus travels from the skin during contact to the sensory dorsal root ganglion, where latency is established.


The mouth lesions (herpetic gingivostomatitis) consist of painful vesicles on a red, swollen base that occur on the lips, gingiva, oral palate, or tongue. However, if the pattern of the lesions is not specific to HSV, its diagnosis can be made by viral culture, PCR, serology, direct fluorescent antibody testing, or Tzanck test. In one randomized controlled trial (RCT), children receiving acyclovir had oral lesions for a shorter time than children receiving placebo (median of four versus 10 days). Herpes simplex virus type1 usually is the cause for oral lesions sometimes referred to as “cold sores”, “fever blisters” or more technically known as “recurrent herpes labialis”. The diagnosis of an infection with herpes simplex virus type 1 is usually made by the appearance of the lesions (grouped vesicles or ulcers on an erythematous base) and patient history.
Oral HSV-1 infections reactivate from the trigeminal sensory ganglia, affecting the facial, oral, labial, oropharyngeal, and ocular mucosa.Primary infection appears two to 20 days after contact with an infected person. However, if uncertain, the diagnosis of herpes labialis can be made by viral culture, polymerase chain reaction, serology, direct fluorescent antibody testing, or Tzanck test.
The vesicle should be unroofed with a scalpel or sterile needle, and a swab should be used to soak up the fluid and to scrape the base. Other nonoral herpes simplex virus type 1 infections include herpetic keratitis, herpetic whitlow, herpes gladiatorum, and herpetic sycosis of the beard area. The swab should be sent in special viral transport media directly to the laboratory (or placed on ice if transport will be delayed). The differential diagnosis of nongenital herpes simplex virus infection includes aphthous ulcers, acute paronychia, varicellazoster virus infection, herpangina, herpes gestationis (pemphigoid gestationis), pemphigus vulgaris, and BehA§et syndrome. There were more aborted lesions in the valacyclovirclobetasol group compared with the placebo-placebo group (50 versus 15.8 percent). Oral acyclovir suspension is an effective treatment for children with primary herpetic gingivostomatitis.
Usatine, MDFigure 2.Primary herpetic gingivostomatitis caused by herpes simplex virus type 1 shown in (A) a four-year-old girl with lower lip ulcers and crusting on the upper lip, and (B) a two-year-old girl with ulcers on the lower lip and tongue. Direct fluorescent antibody testing may be performed from air-dried specimens, and can detect 80 percent of true HSV-positive cases compared with culture results.10 Immunoglobulin G antibodies that are type-specific to HSV develop the first several weeks after infection and persist indefinitely. Oral acyclovir, valacyclovir, and famciclovir are effective in treating acute recurrence of herpes labialis (cold sores).
A Tzanck test is difficult to perform correctly without specific training in its use, but it may be done in the office setting by scraping the floor of the herpetic vesicle, staining the specimen, and looking for multinucleated giant cells.
Recurrences of herpes labialis may be diminished with daily oral acyclovir or valacyclovir. Usatine, MDIn recurrent herpes labialis, symptoms of tingling, pain, paresthesias, itching, and burning precede the lesions in 60 percent of persons.5 The lesions then appear as clusters of vesicles on the lip or vermilion border (Figure 1).


They applied penciclovir cream or placebo within one hour of the first sign or symptom of a recurrence, and then every two hours while awake for four days.
Topical acyclovir, penciclovir, and docosanol are optional treatments for recurrent herpes labialis, but they are less effective than oral treatment. Resolution of symptoms occurred more rapidly in the penciclovir group regardless of whether the medication was applied in the early or late stage.
Nongenital herpes simplex virus type 1 (HSV-1) is a common infection that most often involves the oral mucosa or lips (herpes labialis). The primary oral infection may range from asymptomatic to very painful, leading to poor oral intake and dehydration. Usatine, MDFigure 3.(A) Ulcers that form after the vesicles break, as shown in an adult women with herpes labialis.
Common symptoms are eye pain, light sensitivity, and discharge with gritty sensation in the eye. Fluorescein stain with a ultraviolet light may show a classic dendritic ulcer on the cornea (Figure 47).
Usatine, MDHerpetic whitlow is a vesicular lesion found on the hands or digits (Figures 68 and 7). It occurs in children who suck their thumbs or medical and dental workers exposed to HSV-1 while not wearing gloves.
Herpes gladiatorum is often seen in athletes who wrestle, which may put them in close physical contact with an infected person. Vesicular eruptions are often seen on the torso, but can occur in any location where skin-to-skin contact has occurred. Herpetic sycosis is a follicular infection with HSV that causes vesiculopapular lesions in the beard area.
Usatine, MDHSV infection is one of the most common causes of erythema multiforme (Figure 8), which some patients have with a recurrent HSV infection.
Usatine, MDFigure 9.Vesicles on a red base of the wrist in a woman with herpes gestationis after the loss of a pregnancy.



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