Facial Herpes

This section provides information on facial herpes.

The information is not provided for the purpose of self diagnosis and should not be considered a substitute for medical advice from a doctor.

What is facial herpes?
Facial herpes is a very common condition that is caused by the herpes simplex virus and usually affects the area around the mouth and nose. It is frequently referred to as 'cold sores', but is also known as 'fever blisters', 'sun blisters', herpes labialis or orofacial herpes.

How common is facial herpes?
Facial herpes affects millions of people throughout the world. Research suggests that up to 90% of people over the age of 50 are infected with the HSV-1 virus, but only a relatively small proportion of these will experience regular symptoms: between 20 and 40% of adults experience recurrent facial herpes. (1,2). In the USA, it has been estimated that there are 500,000 new cases of facial herpes every year.(3)

What causes facial herpes?
Facial herpes is caused by the herpes simplex virus (HSV). There are two main types of HSV virus: HSV-1 is the most common strain and this is the type that usually causes facial herpes. HSV-2 is more commonly associated with genital herpes. Cross infection between the two types of virus does occur, but it is more likely to be from the face to the genitals (thus leading to genital herpes caused by infection from HSV-1) than from the genital areas to the face.

Recent research suggests that in some regions of the world, genital herpes infections are increasingly caused by HSV-1 - in some studies over half of new genital infections are caused by HSV-1.(4.5) This may be in part due to the fact that infection with HSV-1 during childhood is decreasing, which means that young individuals are more susceptible to HSV-1 infection when they become sexually active, and to changing sexual practices, with an increase in oral-genital contact.

What are the symptoms of facial herpes?
The initial infection
Most people are infected with HSV-1 during childhood. The virus invades the cells of the epidermis (the outer layer of the skin), often through an abrasion or tiny crack in the skin or through the lining of the mouth. Most people are unaware that they have been infected. At the time of the initial (primary) infection, facial herpes is more likely to present no symptoms than to be symptomatic.(6.) If symptoms do occur, they may include fever, flu-like feelings, a sore mouth and a sore throat (pharyngitis), which can make swallowing uncomfortable. Painful blisters can develop on the tongue and gums (gingivostomatitis) and on or around the lips. These blisters can last for more than 14 days if left untreated. Other possible symptoms include neck pain and enlarged lymph nodes.

If the primary infection occurs in later life rather than childhood, the symptoms may be more severe and may be confused with other conditions such as glandular fever.

Recurrences of facial herpes
Once the herpes simplex virus has entered the body, it travels along the nerve paths to the trigeminal ganglion, a bundle of nerves close to the inner ear, where it remains for the rest of a person's life. Some people experience no further episodes of facial herpes but in others, the virus is reactivated from time to time to cause a recurrence. When the virus is triggered into action, it makes its way back up the nerves towards the mouth area and leads to a new outbreak of symptoms, although these may not be in exactly the same location as during the primary infection. Recurrences are usually shorter and symptoms are less severe than during the primary infection.

Pathway of a herpes infection


Counseling Guide and Patient Information. GlaxoSmithKline. 2000

An outbreak usually has four distinct stages:

1. A tingling, burning or itchy feeling in the skin (known as the prodrome) which can last for 6-8 hours
2.Slight swelling of the skin, followed by the development of a number of fluid-filled blisters around the lips or nose. These can be sore and painful
3. Formation of the blisters into clusters, which then burst, leaving fluid-filled sores
4. Finally, drying out of the sores, which then scab over and heal without scarring, usually within a couple of weeks.

How is facial herpes transmitted?
Facial herpes is infectious and is spread by close physical contact with an infected person. It is most commonly acquired during childhood as a result of kissing or hugging members of the family or from close contact with other children who are infected. Similarly, the virus is frequently spread among adults by kissing and it can also be transmitted during an active phase via the sharing of cups or glasses, lipsticks, toothbrushes or face towels etc.

The most infectious phase of facial herpes is when the blisters rupture, but the virus can be shed before blisters appear or when a person has no obvious symptoms. This is known as 'asymptomatic shedding'.

What are the factors that can trigger recurrences of facial herpes?
Scientists have limited understanding of the factors that trigger recurrence but studies have shown that the following have some link with fresh outbreaks:

  • Exposure to strong sunlight or ultraviolet light (eg sun beds) or other extreme weather conditions (eg intense cold)
  • Trauma or damage to the lips or mouth area, such as dental treatment, injury, cuts from shaving or even drinking very hot liquids
  • Cosmetic procedures such as chemical peels and facial resurfacing.

Anecdotal evidence suggests that other factors such as stress, fatigue and physical illness may also be linked to recurrences of herpes. Some people are able to identify clear factors that can trigger an episode of facial herpes and so can take steps to avoid certain situations or circumstances (eg protecting the face from strong sunlight).

  • Protect the face from strong sunlight by wearing a hat and applying sunblock to the lips and surrounding area
  • Start treatment immediately as soon as any signs of an impending episode are noticed, eg tingling or burning. (See the section 'How is facial herpes treated?'). If outbreaks are frequent, it is a good idea to keep a stock of the medication on hand to avoid any delay.
  • If episodes of facial herpes are severe or very frequent, it may be appropriate to consider suppressive therapy to reduce the number of outbreaks (see the section 'Oral antivirals').
  • Antiviral therapy can also be used as a preventive measure to reduce the risk of a recurrence if you are going to be exposed to a known trigger (such as a strong sunlight) or in the run up to an important event, such as a wedding. See the section 'Antiviral therapy'.
  • Avoid picking at the sores as this can result in a bacterial infection of the sores or, less commonly, spread the virus to other parts of the body
  • Always wash your hands after touching affected areas and before and after applying medication
  • Pay particular attention when applying or removing make-up around the eye area to avoid spreading the virus to the eyes
  • Always wash your hands before inserting and removing contact lenses and never use saliva to moisten the lens
  • A healthy lifestyle can strengthen the body's immune system. Ample sleep, regular exercise and a varied diet are the major contributors to healthy living.
What can be done to avoid transmitting the virus to other people?
During an outbreak of facial herpes, the advice outlined above about good hygiene will help to reduce the risk of transmitting the virus to others. You should also avoid:
  • kissing other people - even a friendly peck on the cheek could spread the virus
  • engaging in oral sex, if you are involved in a sexual relationship
  • sharing items that could spread the virus, such as face towels, glasses, mugs, toothbrushes etc.

How is facial herpes diagnosed?
Facial herpes can be diagnosed most easily and accurately at the time of an active herpes infection, ie when symptoms such as blisters are present. Diagnosis is based on a medical history and on the appearance of the characteristic blisters of facial herpes. In some cases, a swab of one of the blisters may be taken to detect the presence of the virus or a special blood test may be used to detect antibodies to HSV-1, showing that infection is present.



examples of facial herpes


How is facial herpes treated?
Facial herpes can usually be effectively managed and in some cases, even prevented from recurring. A range of treatments is available, including topical antivirals, oral antivirals and other treatments.

Antiviral therapy
Antiviral therapy works by attacking the herpes simplex virus, preventing it from replicating or multiplying. Antiviral therapy is now the standard treatment for facial herpes and is available in the form of topical treatments (to be applied to the skin) and oral therapy (to be taken in tablet form).

Topical antivirals
Aciclovir and penciclovir are available from the pharmacy in the form of creams and can be applied directly to the affected area. For maximum effect, these should be used at the first sign of an episode (often the tingling sensation that precedes the formation of blisters known as prodrome) in order to stop the virus from multiplying. This will reduce the length and intensity of an outbreak, speed the healing of any blisters and, in some cases, actually prevent a full episode from occurring.(7.)

Oral antivirals
The antivirals aciclovir, famciclovir and valaciclovir can be taken orally (in the form of tablets) to treat an episode of facial herpes. Antivirals taken in tablet form need to be prescribed by a doctor and are generally most useful for more severe episodes of facial herpes, or when lesions or blisters occur in areas that are difficult to reach, such as inside the nose. Once again, to obtain maximum relief, treatment should be started as soon as any symptoms are noticed.

If episodes of facial herpes are very frequent or problematic, it may be appropriate to take antiviral tablets on a daily basis to help prevent outbreaks. This type of treatment, called 'suppressive therapy', can reduce the number of outbreaks and, in some patients, prevent them completely.(8.)

Oral antiviral therapy is also advised to treat recurrent herpes around the eyes and for outbreaks in patients with active dermatitis on the head and neck, to avoid the risk of complications.

In some circumstances, it may be appropriate to consider using either oral or topical antiviral therapy prophylactically (as a preventive measure) to avoid the risk of a recurrence during exposure to known triggers. For example if sunlight is a known trigger, a course of treatment prior to a skiing trip or summer holiday may help to head off an episode of facial herpes. Similarly, if you have an important event, such as a wedding, coming up, you may wish to consider using antiviral therapy as a preventive measure.

All patients undergoing cosmetic procedures such as facial resurfacing are routinely treated with oral antiviral therapy effective against HSV-1 to avoid reactivation of facial herpes.

Non antiviral topical treatments
Painkillers and local anaesthetics can be used to relieve any pain and discomfort associated with facial herpes and to make it easier to eat and drink. However, these compounds do not have any effect on the action of the virus and they have not been extensively studied.

What are the possible complications of facial herpes?
When facial herpes recurs after the primary infection, it can sometimes affect the area around the eye, or even the eye itself. This is known as herpes keratitis, herpes conjunctivitis or herpes stromal keratitis. In rare cases, this can lead to a deep infection (acute retinal necrosis), which can cause permanent damage to the eye. If eye infection is suspected, it is wise to consult a doctor as soon as possible.

In people with eczema or dermatitis, facial herpes can spread to other parts of the body (eczema herpeticum) and in rare cases, can affect a large area of skin. This is a potentially serious condition and should be reported to a doctor immediately.

The development of a number of large cold sores may be a sign that the immune system has been weakened by another problem, such as pneumonia or HIV, and should be investigated by a doctor.

The emotional impact of facial herpes
Understandably, those affected by facial herpes can feel self-conscious and embarrassed. Facial herpes is often at its peak during childhood and teenage years, when it is natural to feel sensitive about external appearances and the way in which others perceive us. Although usually short-lived, the symptoms are often very visible and the blisters can be painful.

People with facial herpes may worry about infecting other people and feel anxious about broaching the subject with sexual partners. It is important to remember that facial herpes is extremely common. By acting promptly when recurrences occur, it is entirely possible to take control of the situation by avoiding known triggers and using antiviral medication to help reduce the number and severity of episodes.

COMMON QUESTIONS

How did I catch facial herpes?
There is usually no way of knowing precisely how or when you were exposed to the virus that causes facial herpes. It is likely that you were infected during childhood through contact with a family member or another child with the HSV-1 virus. Many people experience no symptoms when they are first infected with facial herpes and remain unaware that they have the virus throughout life.

Can I pass my herpes onto other people?
Yes, facial herpes is infectious but it is possible to minimise the risk of transmitting the virus to other people. You are more likely to pass the virus on when you are experiencing a recurrence, especially if sores or blisters are present, but it is possible to transmit the virus even when you have no symptoms. The sections above on preventing recurrences and reducing the risk of transmission include useful advice on this subject.

I am getting regular attacks of facial herpes - can I do anything to prevent them?
If you are experiencing regular or severe outbreaks, it may be appropriate to talk to your doctor about trying suppressive therapy with antiviral treatments. This involves taking antiviral tablets on a daily basis for an agreed period of time, normally around 6 months. This type of treatment can be highly effective at reducing the number of outbreaks or can even prevent them completely.

How long does it take for an outbreak of facial herpes to heal?
In most cases, blisters or 'cold sores' will heal completely within a couple of weeks. This can usually be reduced if antiviral medication is used.

Information about facial herpes is also available in the leaflet; Facial Herpes which can be downloaded as a PDF

References

1. Embil JA, Stephens RG and Manual FR. 1975. Prevalence of recurrent herpes labialis and aphthous ulcers among young adults on six continents. Can Med Assoc J. 113:627-630
2. Notkins AL et al. 1973. Workshop on the treatment and prevention of herpes simplex virus infections. J Infect Dis. 127:117-119
3. Wheeler CE. Jr 1988. The herpes simplex problem. The Journal of the American Academy of Dermatology. 18: 163-8
4. Scoular A et al. Longitudinal study of genital infection by herpes simplex virus type 1 in Western Scotland over 15 years. BMJ 2002; 324:1366-1367
5. Coyle PV, O'Neill HJ, Wyatt DE, McCaughey C, Quah S, McBride MO. Emergence of herpes simplex type 1 as the main cause of recurrent genital ulcerative disease in women in Northern Ireland. J Clin Virol. 2003 May;27(1):22-9.
6. Whitley RJ & Gnann JW (1993). The epidemiology and clinical manifestations of herpes simplex virus infections. In The Human Herpesviruses (Roizman B, Whitley RJ and Lopez C Eds), pp69-105. Raven Press, New York, NY
7. Fiddian AP, Yeo JM, Stubbings R, Dean D. Successful treatment of herpes labialis with topical acyclovir. BMJ 1983;286:1699-1701
8. Baker D, Eisen D. Valacyclovir for Prevention of Recurrent Herpes Labialis: Two Double-Blind, Placebo-Controlled Studies. Cutis 71:239-242, 2003