Help in the Management of Herpes Simplex Labialis

DECEMBER 01, 2006
Yvette C. Terrie, BSPharm, RPh

Brought to you by Merix Pharmaceutical Corp, the makers of Releev

It is estimated that 150 million individuals in the United States have herpes simplex labialis (HSL).1 Cold sores are generally caused by herpes simplex virus 1 (HSV-1), whereas the herpes simplex virus 2 is responsible for causing genital herpes. Both viruses, however, can cause cold sores and genital herpes if the skin comes in contact with either form of the virus. Once an individual is infected with either virus, he or she is infected for life and can experience both active and dormant phases. An outbreak of HSL can negatively impact various aspects of an individual's quality of life, including physical, social, and emotional well-being.

After the first exposure to HSL, the virus resides in the trigeminal ganglia. Reactivation may occur due to certain triggers such as1-3:

  • Stress/fatigue
  • Ultraviolet radiation/extreme exposure to the sun
  • Exposure to cold weather
  • Fever and upper respiratory infections
  • Trauma due to recent dental work
  • Infectious diseases
  • Menstruation or other hormonal changes
  • Factors that may compromise the immune system (chemotherapy, immunosuppressant agents)
  • Certain foods such as chocolate and others with a high content of the amino acid arginine

Some individuals may have as many as 3 to 4 outbreaks annually.4 It is crucial for pharmacists to be thoroughly informed about causes, transmission, treatment, and preventive measures in order to effectively care for individuals affected by this virus.

Pathophysiology of HSL

HSL is highly contagious and enters the host via a break in the skin or possibly through intact mucous membranes. The virus travels to the sensory neurons and then on to the sensory ganglia, where it may remain dormant.2,3 Because the virus may remain viable on surfaces for hours, an individual may also be infected from contact with contaminated objects.2

Signs and Symptoms

Although the lesions associated with an outbreak of HSV-1 typically occur on the lip, these lesions may also appear on the bordering areas around the lip and the nose. Cold sores are considered to be a self-limiting condition, and lesions typically heal without incidence of scarring in approximately 10 to 14 days.2,3 Scarring can occur in some individuals after repeated outbreaks, however. An outbreak of cold sores is often characterized by various stages, each with distinct characteristics. In the initial stage of an outbreak, cold sores are preceded by a prodrome. During this phase, the individual will notice a burning or tingling sensation and/or itching ~48 hours prior to the appearance of a cold sore. Other symptoms may include pain, fever, or swollen lymph glands. The cold sore usually appears first as a small erythematous vesicle, which typically ranges in size from 1 to 3 mm in diameter.2 Many lesions can combine to form a larger lesion. As time progresses and the lesions mature, a crust forms over the vesicles that have erupted. A secondary infection may be present if pus appears under the crusted area.2


No cure for HSL yet exists, but various products are available to alleviate the pain associated with cold sores and to reduce the duration of the outbreak (Tables 1 and 2). Other goals include preventing the occurrence of a secondary bacterial infection and preventing transmission of HSL to other individuals.

Current prescription agents approved for the treatment of recurrent HSL include topical acyclovir (Zovirax) cream and penciclovir (Denavir) cream. These topical agents are FDA-approved for use in both adults and children 12 years of age and older. Systemic agents include valacyclovir (Valtrex) capsules and famciclovir (Famvir), which recently received approval for an indication as a single-dose treatment for recurrent HSL in immunocompetent patients.5

RELEEV 1-Day Cold Sore Symptom Treatment is a new nonprescription product for the treatment for cold sores. It is designed to aid healing and reduce outbreak duration.6,7 RELEEV has been shown to relieve the symptoms of cold sores within 24 hours of initial use. RELEEV?s active ingredient is a topical microbicide that is a proprietary blend of benzalkonium chloride 0.13% and phytochemicals primarily derived from the Asteraceae family. RELEEV is a nontoxic botanical product and should be applied 3 to 4 times a day. It can be safely used in adults and children 2 years of age or older and is nonirritating. It is best used at the first sign of an outbreak but can be applied at any stage to relieve symptoms. It may be used as an antiseptic to help cleanse or dry cold sores and to help in preventing secondary infections. RELEEV may also be used on sores on the inside of the lips and on oral mucosa. RELEEV should not be used if an individual has an allergy to the Asteraceae (daisy) family of flowers.

There are other topical nonprescription products such as analgesics, antipruritics, anesthetics, and skin protectants that are available to provide symptomatic relief from the discomfort associated with a cold sore outbreak. These products, however, will not reduce the duration of the symptoms of HSL.2 Pharmacists may also recommend the use of a triple antibiotic ointment if lesions show evidence of a secondary infection.

Additional Help

Various measures can be recommended to patients in addition to pharmacologic therapy for managing the pain associated with cold sores and for reducing the frequency of future outbreaks:

?Use a cool, wet compress or ice on the affected area at least 3 times a day for 15 to 20 minutes to reduce swelling or erythema.

?If not contraindicated, consider the use of an OTC analgesic.

?To prevent possible infection, routinely cleanse the affected area with clear water without soap. The proteins in soap may exacerbate or prolong the outbreak.

?Use skin protectants to keep lesions moist, because drying and cracking may make the lesions more susceptible to secondary bacterial infection. Wait until any medication, especially RELEEV, has dried before applying any moisturizers.

?Carefully wash the hands regularly with warm water and soap to prevent transmission or spread of the virus.

The Role of the Pharmacist

Pharmacists can be a fundamental source of information for individuals affected by HSL. Pharmacists should inform patients about the treatments available for this condition and remind them about the preventive measures that may reduce or avoid the incidence of cold sore outbreaks. Patients should be reminded to avoid possible triggers of outbreaks. Pharmacists should stress the importance of therapy compliance and advise patients to always apply topical HSL medications at the prodromal stage of an outbreak to reduce the severity of symptoms. Pharmacists should remind patients about the highly contagious nature of HSL and inform them about measures for either reducing or preventing the transmission of the virus to other individuals.

Ms. Terrie is a clinical pharmacy writer based in Haymarket,Va.

For a list of references, send a stamped, self-addressed envelope to: References Department, Attn. A. Rybovic, Pharmacy Times, Ascend Media Healthcare, 103 College Road East, Princeton, NJ 08540; or send an e-mail request to: