Signs and Symptoms

This section provides information on the more common appearances of cold sores and genital herpes. It contains photographs of cold sores and genital herpes.

WARNING: some pictures are explicit. You can choose not to view the pictures and read the explanatory text only.

The information is not for diagnosis or medical treatment. It should not be considered a substitute for medical advice from a doctor

Cold sores

Cold sores (also called facial herpes, labial herpes or orofacial herpes) are caused by a virus, usually herpes simplex virus type 1 (HSV-1), which is passed from person to person by direct contact with infected skin or saliva.

Most people are infected with HSV-1 for the first time during childhood. The first infection, known as a primary infection, is not accompanied by symptoms in 70% of individuals. If symptoms do occur, they most often include a fever, flu-like symptoms, a sore mouth and a sore throat (pharyngitis). Painful blisters can occur on the tongue, in the mouth and near and on the lips. These blisters are most often mild [see photograph 1]. The blisters, which develop into ulcers, last for approximately 12 days. The number of blisters generally peaks at about 6 days and then decreases. There can be neck pain and enlarged lymph nodes. The lymph nodes can be seen or felt as bumps below the skin. There can be bad breath and drooling. In severe cases, children may refuse to eat or drink because of the pain caused by the infection. In such cases, their guardians should visit a physician. In older people (such as teenagers) who become infected with the virus for the first time, the symptoms may be more severe than in young children. The sore throat and flu-like symptoms may be difficult to distinguish from glandular fever.

This young man [see photographs 2 and 3] was admitted to the hospital because of fever, a flu-like illness and ulcerations of the mouth. Two weeks before being taken ill, he had several sexual contacts, both oral-genital and unprotected intercourse.

Recurrent cold sores (HSV-1 infection)

Infection with HSV-1 can cause recurrent symptoms, commonly known as cold sores. Most people are infected with HSV-1 but only one-fifth to two-fifths are thought to develop cold sores. Many people who experience cold sores, have two or three outbreaks (recurrences) each year. Recurrences are shorter and there is generally less discomfort than during a primary infection. Blisters tend to be more localized than during a primary infection and normally heal within 8–10 days. Pain subsides quickly, often in 4–5 days. The triggers for a cold sore outbreak are not certain but may include sunlight (UV light), fever, stress, or surgical procedures (e.g. dentistry).

Genital herpes

These classic symptoms [see photograph 4] of a first episode of genital herpes are familiar to most doctors with knowledge of sexually transmitted infections.

Following infection with herpes simplex virus (HSV), symptoms typically start within 10 days. The first sign on the skin may be an area of reddening. This is often followed by the development of blisters or ulcerations (often grouped together as ‘lesions’, which describes any irregularity of the skin). The blisters, which can look like small pimples, burst to form an ulcer and then crust over.

In women, the lesions in a first episode can occur on the lips of the vagina (the vulva), urethra, cervix, upper thigh and around the anus. In men, lesions can occur on the penis, urethra, scrotum, upper thigh and around the anus. The lesions are often painful for an average of 9 days and take 2–3 weeks to heal. Some patients may experience general symptoms such as fever, muscle pain/tiredness and swollen and tender glands (lymph nodes) in the groin.

In some people, the lesions that occur as part of primary genital herpes may be single and large, rather than the multiple, small ones seen in the photograph.

This woman was probably infected through sexual contact the week before she fell ill. The first symptom was pain on urination (dysuria) together with a general flu-like illness that included headache, muscle pain and fever. During the first week of symptoms, blisters and ulcerations occurred along with tender lymph nodes in the groin.

It is important to recognize these signs and symptoms as a herpes infection as soon as possible. An immediate appointment with a doctor should be made. A swab will probably be taken to confirm the diagnosis. Antiviral therapy will help to shorten the duration of the episode.

During the initial infection, the virus travels up the nerves to establish residency in nerve bodies (ganglia) near the spine. This is known as latency. Periodically, the virus emerges from latency to cause another episode of disease.

The first sign of an episode is often a tingling feeling in the skin (called the prodrome). A slight swelling may then develop and then the fluid-filled blisters appear [see photograph 5]. These are sometimes very painful.

The recurrences of genital herpes often develop in the same region of the body. This is because the virus is transported from the nerve ganglia along the nerve paths to the skin, which limits where a recurrence can take place (generally below the waist if the genital area is infected). However, the symptoms do not always occur in exactly the same place. For example, a lesion may appear on the genitals in one recurrence whereas in the next it may be on the upper thigh.

After the blisters have burst, small ulcerations (sores) develop. Sometimes this process is very fast and the only thing that may be noticed are sores. The sores can be painful, especially if exposed to water or urine.

The sores eventually dry and sometimes form scabs as a part of the healing process. If the area under the foreskin (prepuce) is affected, scabs do not usually develop. Instead, the sore will heal slowly without scarring and the skin may change colour slightly over time [see photographs 6 and 7].

The signs and symptoms of genital herpes can differ from the ‘classic’ pattern of blisters. Recurrences of genital herpes may be so mild that the diagnosis is not suspected by either the patient or by their doctor. The mild symptoms often do not bother the patient physically but can be very annoying in other ways (e.g. by interfering with sex).

Having recurrent symptoms, often on the same area in the genital region, suggests that the cause is herpes. For example, in this case [see photograph 8] a small split (fissure) developed every month after the menstrual period.

Sometimes, recurrences may occur where there are no obvious symptoms but the virus is still produced on the skin. In such cases, the virus can still be spread from one person to another – this is known as asymptomatic shedding.

Genital herpes does not always occur on the groin. A common manifestation is blisters or pustules on the buttock [see photographs 9 and 10] that develop into ulcerations after a day or two. Less commonly, lesions can occur on other sites of the body (e.g. behind a knee).

As with most recurrences of genital herpes, there can be warning (prodromal) symptoms. A typical warning symptom is a tingling sensation at the spot where the blister will appear, or a sciatica-like pain down the leg on which the recurrence occurs.

A recurrence in the genital area will usually resolve in a week or less but one on the buttock may last longer. This is because the skin on the buttock is thicker than in the genital tract and possibly because the skin is more exposed to friction from clothing.

Genital herpes need not be restricted to the genitals and may affect the skin anywhere in the groin.In this case [see photographs 11 and 12], the blisters are on the inner thigh close to the groin. The woman had recurrences on three different locations in the genital area. The blisters occurred most frequently on a buttock, then on the perineum and on the inner thigh. While the inner thigh is not the most common location for genital herpes, it shows that it is important to be suspicious of recurring blisters and that they may not occur in the same area every time.

Occurrences on the thigh and buttock are often associated with a severe sciatica-like pain. The pain usually resolves as soon as the blisters become visible.

Condoms are an effective way to prevent the spread of many sexually transmitted infections. The chances of transmitting chlamydia and HIV are much reduced if a condom is used correctly, that is, used during the entire sexual act.

In the case of genital herpes, the evidence suggests that women are protected from HSV-2 infection through the use of condoms. More studies are needed before we have data confirming that men are also protected from HSV-2 infection by condom use.

Condoms may not offer complete protection from transmitting the virus as the blisters or ulcers can occur in an area that is not protected by a condom [see photograph 13].

In some cases, lesions can occur over a large area of the groin. When this occurs, it may resemble a first episode of genital herpes.

In people with an underlying skin disorder, such as atopic eczema, the virus may infect a wider area. This condition is known as eczema herpeticum.

Shaving the genital area may spread the infection over the entire genital tract [see photographs 14 and 15].

Damaged skin, regardless of whether or not it is due to eczema, some other skin condition or the use of a razor, allows the virus to more easily infect a person or spread over the skin.

A razor blade can spread the virus over the entire shaved area. In these two cases [see photographs 16 and 17], both the woman and the man had used the same razor. This resulted in the spread of virus from one person to the other. Therefore, hygiene is important for people with a herpes infection regardless if it is in the genital or facial area.

HSV can be spread during oral sex from the mouth to the genital tract. This has occurred more frequently during the last decade and more in Europe than in the US. Of people who have a first episode of genital herpes, as many as half of the cases are the result of HSV-1 infection. In most cases, the virus has been transmitted because of oral-to-genital contact (oral sex).

Not all genital sores are due to herpes. For example, they can be caused by bacterial infection.

Herpetic Whitlow

HSV can infect regions of the body other than the genitals and face. For example it can infect a finger and is known as herpes whitlow [see photograph 18]. This infection can occur when someone touches a herpes lesion on their mouth or genitals. HSV can also cause lesions at the base of the fingers [see photograph 19].