Recurrent Herpes Labialis in Adults: New Tricks for an Old Dog

March 2017 | Volume 16 | Issue 3 | Supplement Individual Articles | 49 | Copyright © March 2017

Ted Rosen MD

Baylor College of Medicine, Houston, TX


Herpes labialis remains a common worldwide affliction. Recent advances in understanding the basic pathogenesis have led to new therapeutic intervention, both on-label and off-label. Aside from reducing the duration and symptomatology of acute outbreaks, another goal of treatment is to decrease the frequency of future episodes. Oral and topical acyclovir and its analogues are the mainstay of both chronic suppressive and episodic therapy. A new muco-adhesive formulation of acyclovir provides a decrease in outbreaks, probably due to a diminution of herpesvirus load in all reservoir sites. Acyclovir-resistant strains are rare in immunocompetent hosts; parenteral foscarnet and cidofovir are administered in this situation. Parenteral acyclovir is the drug of choice for eczema herpeticum, which may begin as herpes labialis in an atopic dermatitis patient. Thermotherapy may be beneficial, and a certified device to deliver heat is available outside the United States.

J Drugs Dermatol. 2017;16(3 Suppl):s49-53.


The prevalence of common herpes viruses varies greatly by continent, country, and even region within a country, as well as by population subgroup (such as age, gender, and immune status). However, based upon recent evidence, HSV-1 is rather ubiquitous worldwide, typically reaching about 40% seroprevalence by age 15 and then rising to a seroprevalence of 60-90% among older adults.1,2 While some HSV-1 infections cause genital herpes, this virus is predominantly responsible for oro-labial disease, commonly referred to as “cold sores” or “fever blisters.” This disorder is most common in Caucasian women, although it certainly can affect both genders and individuals from any ethnic group.Oro-labial herpes may occur as a singular event, or it may become a periodically recurrent disorder. Recurrent HSV-1 outbreaks are generally associated with mild morbidity, notably a low risk of scarring. However, outbreaks are also quite variable in both frequency and severity.3 For those who experience frequently recurrent oro-labial herpes, these often painful and usually unsightly lesions engender considerable stress and anxiety.4 It can be estimated that between 15-40% of those infected with HSV-1 involving the peri-oral region will develop bothersome recurrences.5-7 Factors that can lead to recurrences include, but are not limited to: emotional stress or physical fatigue, infection (most often upper respiratory), exposure to ultraviolet light, local trauma (including medical procedures in close proximity to the mouth), menses, and immunosuppression.8 On the other hand, some recurrences occur without any appreciable precipitating event. Interestingly, smoking tobacco products has been associated with both less frequent and less severe HSV-1, although it is doubtful that any healthcare provider would offer this as a therapeutic intervention.9Rationale for TreatmentIt is certainly worth a short discussion about whether such a common and relatively banal disease warrants any treatment at all. The opinion of this author is that therapy is justified for many disparate reasons. Treatment may shorten the duration of an attack, thereby reducing the duration of cosmetically distressing lesions and associated emotional upset. In fact, “cold sore” sufferers’ emotional upset is actually quite justified. A recent survey study disclosed that oro-labial herpes simplex infections are among the two most stigmatizing of all cutaneous disorders; so much so, that a majority of those surveyed would be ashamed if they themselves had herpes labialis, would find another person unattractive if they had herpes labialis, and wouldn’t want to touch or share food/drink with someone afflicted with HSV-1.10 Treatment may also decrease the duration of pain (or discomfort) attendant to an outbreak. Therapy may encourage or hasten healing, which normally takes 12-17 days from the onset of the associated prodrome. Despite an overall low inherent risk, treatment should reduce the potential for residual scarring. As discussed below, select treatments may even alter the natural disease history by reducing the frequency of future recurrences. A more theoretical rationale for treatment is to reduce the ongoing asymptomatic shedding of virus, which occurs on the oral mucosa about 20-25% of days of the year.11 Moreover, considering the high degree of safety of the current anti-viral therapeutic armamentarium directed toward HSV-1 infection, it appears that treatment is clearly warranted, especially if the patient desires therapy.