Cold Sores Flashcards

1
Q

What is HSV

A
  • herpes simplex virus -> causes cold sores
  • member of the human herpesvirus family: includes varicella zoster virus (chickenpox and shingles) and Epstein Barr virus (mono)

Types

  • > HSV-1: usually causes mucocutaneous oral infections
  • > HSV-2 usually causes genital infections

* Either can cause ocular, CNS, or disseminated disease, not common if immunocompetent

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2
Q

how is HSV-1 transmissed?

A
  • esitmated that 65% of world is infected
  • reuqired direct contact w/ virus: present in herpes lesions, mucosal secretions and otherwise normal skin (asymptomatic shedding)

*viral load and transmission greater when lesions are present (majority of spread is asymptomatic tho)

  • Oral-oral, oral-genital, genetial-genital transmission is most common
  • less likely but possible: contamination of skin abrasiosn, maternal transmission, sharing saliva contaminated items

*autoinoculation not common (self spread from oral to genetal)

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3
Q

describe pathophysiology of herpes

A
  • DsDNA is in a capsid in a tegument
  • viral particle goes into cell and deposits its DNA into nucleus
  • can replicate and become lytic cuasing the cell to rupture
  • can also go into latent phase
  • first infection = primary, get a lot of litic infection

second, third etc = reactivation/recurrent infection

*virus lives in nerve root ganglion until reactivates -> infection will reoccur in same area it was caught

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4
Q

clinical presentation of primary oral HSV infection

A

Asymptomatic: Majority of seropositive patients do not recall previous symptoms

Symptomatic (20-25%): Gingivostomatitis (most common in young children) or Pharyngitis (most common in older children, teens, & adults)

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5
Q

clinical presentation of reactivation/recurrence of oral HSV

A
  • Asymptomatic (get asymptomatic shedding)
  • Symptomatic (20-40%) get herpes labialis (minor ailment in ON)
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6
Q

what is gingivo stomatitis

A
  • painful veiscles with fever and pharyngitis
  • lesions develop anywhere on pharyngeal or oral mucosa -> progress over several days to soft palat, buccal mucosa, tongue and floor of mouth
  • quickly ulcerates and crusts over
  • May also experience ymphadenopathy, malaise, myalgia, difficulty eating/ drinking/ swallowing
  • resolves spontaneously in 7-18 days

*refer

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7
Q

What is Pharyngitis

A
  • catch HSV when older
  • severe sore throast
  • can get pharyngeal edema, tonsillar exudate, oral exudative & ulcerative lesions
  • may experience local lymphadenopathy, malaise, myalgia, difficulty eating/ drinking/ swallowing
  • resolves spontaneously in 2-8 days, although lymphadenopahty can last 2 weeks
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8
Q

what is herpes labialis

A
  • generally no systemic features
  • many patietns get a prodrome (warning, imp to take antiviral ASAP)
  • > pain, burning, tingling, pruritis at site within 24 hr of lesions
  • vesicles develop unilaterally at vermillion boarder of lip
  • > rupture & ooze -> crust -> heal w/o scarring
  • freq, location and severity variable between patients but may be consistent within patients

(can rage from 1-12 episodes/year or none)

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9
Q

precipitating factors for herpes labialis

A

Immunodeficiency, stress, sun exposure, fever or other infection, menstruation, trauma to area (e.g., dental work)

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10
Q

red flags for cold sore referral

A
  • suggestion of an alternative diagnosis
  • > lesions present of >14 days, follow dermatomal distribution, present beyond lips and perioal area, excessively red/swollen legions or if contain pus
  • frequent recurrences (>6 episodes / year)
  • immunocompromise (due to disease or therapy_
  • primary infection (first ever, any systemic features, gingivostomatitis or pharyngitis)
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11
Q

goals of therapy for herpes labialis

A

Prevent complications

Reduce spread to others (& self?)

Reduce intensity & duration of symptoms

Prevent recurrence

*HSV infection cannot be cured

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12
Q

non pharmacologic strategies to prevent complicaitons for herpes labialis

A
  • prevent complciations of lip adhesions: use a barrier like petroleum jelly, cocoa butter, zinc oxide etc
  • prevent secondary bacterial infection: dont touch lesions, wash hands before touching, keep lesions clean w/ mild soap and water
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13
Q

non pharmacologic strategies to prevent the spread of HSV

A

Apply products with a disposable cotton swab

Avoid kissing & barrier-free oral-genital contact

Avoid touching lesions & wash hands frequently

Do not share cups, utensils, cosmetics, towels, etc.

Consider keeping young children who cannot yet control saliva out of daycare until lesions are crusted

*these apply from start of prodrone until lesion is fully crusted

*transmision can occur when patients are asymptomatic!

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14
Q

symptomatic management of HSV

A
  • Cool compress to dec pain and swelling

*ensure appropriate infection contorl

  • systemic analgesics (acetaminophen, NSAIDS)

*relief of moderate to severe pain (max 3 days)

  • Topical analgesics: temp relief of mild pain and itching
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15
Q

use of camphor/menthof/phenol to treat HSV

A
  • menthol and camphor = counter irritants, give body somehitng else to feel
  • phenol = anesthetic
  • ex: blistex or lypsyl
  • provide mild tingling, cool sensation

* if camphor >3% or menthol >1% cna get irritation or inflammation

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16
Q

Benzocraine, lidocraine, pramoxine for HSV treatment

A
  • anesthetic
  • apply 1-5 hours then remove (3-4x a day)
  • causes numbness and tingling
  • may cause allerigc contact dermatitis but less likely
17
Q

use of Docosanol 10% for HSV

A
  • abreva
  • blocks the lipid envelope from fusing
  • is a long chain alcohol that inhibits fusion between HSV envelope and cell membrane
  • excellent skin penetration and prolonged concentrations
  • initiate BEFORE lesions appear, 5x/day and continue until healed for max 10 days
  • onyl decreases time for less than a day
18
Q

topical acyclivor for HSV treatment

A
  • Rx only
  • inhibits DNA synthesis
  • 5% cream, point or combined with hydrocortisone
  • indicated for chidlren over 12
  • apple 5x/day f3d (start asap_
  • causes mild transient burning or stinign upon application
  • decrease by ~1/2 day, dec pain and increase number of aborted lesions but less effective than oral antivirals
19
Q

what oral antivirals are available to treat HSV

A
  • acyclovir 400mg 5x/day f5d: approved in children over 2 years
  • famciclovir 750 mg BID f1d (1500mg po once)
  • Valacyclovir 2g BID once (over 12 years)
  • decrease TTH be 1-2 days, when started during prodromal period
  • associated with mild headache, nausea
  • renal dose adjustment required
20
Q

Use of antivirals in the setting of recurrent herpes labialis

A
  • for patients with moderate-to-severe symptoms where symptomatic therapy is inadeuqte or significant psychosocial impact
  • ideally they have a well defines prodrome
  • patients must have therapy on hand and take ASAP
  • once vesicles have formed, antivirals unliekly to be of beenfit

(we cant prescribe this)

21
Q

how to prevent recurrences

A
  • avoid triggers: emotional stress, fatigue, sun exposure
  • Intermittent suppression with oral antivirals: surgical procedures like dermabrasion, laser resurfacing,
  • chronic suppression with oral antivirals
  • > Acyclovir 200 mg po QID or 400 mg po BID or Valacyclovir 500 mg po daily

*Famciclovir not indicated

Re-evaluate need periodically