Cold Sores Flashcards
What is HSV
- 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
how is HSV-1 transmissed?
- 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)
describe pathophysiology of herpes
- 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
clinical presentation of primary oral HSV infection
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)
clinical presentation of reactivation/recurrence of oral HSV
- Asymptomatic (get asymptomatic shedding)
- Symptomatic (20-40%) get herpes labialis (minor ailment in ON)
what is gingivo stomatitis
- 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
What is Pharyngitis
- 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
what is herpes labialis
- 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)
precipitating factors for herpes labialis
Immunodeficiency, stress, sun exposure, fever or other infection, menstruation, trauma to area (e.g., dental work)
red flags for cold sore referral
- 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)
goals of therapy for herpes labialis
Prevent complications
Reduce spread to others (& self?)
Reduce intensity & duration of symptoms
Prevent recurrence
*HSV infection cannot be cured
non pharmacologic strategies to prevent complicaitons for herpes labialis
- 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
non pharmacologic strategies to prevent the spread of HSV
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!
symptomatic management of HSV
- 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
use of camphor/menthof/phenol to treat HSV
- 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
Benzocraine, lidocraine, pramoxine for HSV treatment
- anesthetic
- apply 1-5 hours then remove (3-4x a day)
- causes numbness and tingling
- may cause allerigc contact dermatitis but less likely
use of Docosanol 10% for HSV
- 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
topical acyclivor for HSV treatment
- 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
what oral antivirals are available to treat HSV
- 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
Use of antivirals in the setting of recurrent herpes labialis
- 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)
how to prevent recurrences
- 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
