Cold sores are among the most common issues I get asked about in the pharmacy. They’re unsightly and can cause physical and mental distress for a lot of people.
Cold sores are primarily related to 2 viruses: Herpes Simplex Virus’ 1 and 2 (HSV-1, HSV-2). HSV-1 causes those fluid-filled sacs that appear most commonly on your lip border. They are transmitted by saliva, sharing cosmetics, razors, towels, eating utensils, and kissing. Since this virus persists for life, this will frame our expectations as we discuss the possible therapies.
Most individuals who are about to experience another cold sore will have what we call a “prodrome.” This is basically a warning that your body gives you which feels like tingling, itching, or burning around your lips where the cold sore is likely to appear within the next couple of days, and will last around 10 days.
Our goal for treatment is to reduce discomfort, duration of the cold sore, and prevent recurrences of the infection.
As with any of my recommendations, you should always speak with your primary care provider to have a formal assessment done, and ensure the treatment is right for you, especially if you’re immunocompromised.
So now that we have some background knowledge, let’s dive into the therapies. The most common, and most effective treatments will require you to see a doctor or nurse practitioner. However, there are telemedicine options to get these shipped right to you after consulting with a medical professional.
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The usual medications we see are valacyclovir (Valtrex), famciclovir (Famvir), and acyclovir. These are antivirals that can help prevent viral replication. Data shows that valacyclovir and famciclovir shorten the time frame of infection by about 2 days and reduce pain more effectively than acyclovir.
Valacyclovir is the prodrug of acyclovir (prodrug means “before your body breaks it down into acyclovir”). The benefit of this is that it’s only converted to acyclovir once in the infected cells, improving the bioavailability and reducing side effects.
It also has shorter treatment durations, less frequent dosing, and lower overall cost. making it the option I would recommend to most patients, barring any contraindications. However, this is not prescriptive. Talk to your doctor and discuss what’s best for you.
Editor’s Note: Luckily with a service called Strut Health, you can link up with a doctor online and try Valacyclovir for free. Try Valacyclovir for free on Struth Health.
Famciclovir is the prodrug of penciclovir, and similarly to valacyclovir, this formulation improves its bioavailability and reduces negative side effects. It’s a more targeted formulation. Otherwise, this and valacyclovir are incredibly similar in terms of price, effectiveness, and even the dosing regimen.
Acyclovir is also a specifically targeted medication for infected cells. However, it has much lower oral bioavailability and shorter half-life than valacyclovir and famciclovir, meaning you have to take doses more frequently. It’s also slightly less effective, taking longer to heal the infection, and with less pain reduction.
Docosanol, known by the brand name Abreva, provides some reduction in healing time (almost a day), and reduces discomfort about 12 hours earlier than placebo. It’s best applied 5 times a day, and should be started at the same time you feel the prodromal symptoms.
This pump-style bottle reduces the risk of reinfection from a contaminated tube. Think of those lip balms you dip your fingers in, rub on your lips, and then double-dip back into – you’re introducing the virus to those balms.
There is some evidence suggesting that a lemon balm cream (containing 1% of a 70:1 leaf extract containing Melissa officinalis) can reduce the number of lesions, as well as the size.
This, along with the other therapies we discussed, should be applied at the first sign of that pesky prodrome. This cream should be applied 2-4 times daily, and up to a few days after the lesions have healed.
Lysine is an essential amino acid (protein building block), and is thought to compete with another amino acid, Arginine, which the virus uses to replicate. By providing a high amount of Lysine locally, it may compete with the Arginine and prevent the virus from replicating.
The Quantum Health Super Lysine+ formulation includes lysine, as well as beeswax which can help seal the lip area and reduce cracking and dryness.
For more on lysine, you can check out our article on the best lysine supplements.
You can also take lysine orally. Studies have shown that taking 2 capsules at the start of the prodrome, and then 1 capsule every 12 hours for 5 days. This regimen reduced the number of outbreaks, and may reduce the duration and severity of outbreaks as well.
Here are a few tips and tricks to reduce your chances of having another cold sore.
Here are the factors that went into our decision-making process.
The first options are by far the most effective. Antivirals taken orally are more effective than the topical treatments we mentioned. However, I want to make sure you have access to the full scope of therapies available
The oral antivirals are more convenient to take (often twice daily, compared to applying a cream up to 5 times a day). They are also relatively cheap, and the drugs listed all have generic options available, which can bring down the price even more.
The antiviral medications listed are all FDA-approved and undergo stringent testing for safety.
However, the supplement industry isn’t regulated by the FDA, so we choose products that contain high-quality ingredients and in proper doses.
All else equal, we chose high-quality products that are also affordable. We did our best to find you the best value for your money with the above-listed products.
In terms of side effects, all these therapies are well tolerated. The oral antivirals might cause some stomach upset and taking them with food may help reduce this.
So, there you have it, some recommendations and therapies that can arm you against those troublesome pustules. If you have any questions, pop into your local pharmacy, and speak to your pharmacist. If you live in downtown Toronto, maybe you’ll see me.
Caustic substances, like silver nitrate, may worsen the lesions, and should not be applied to cold sores.
Another therapy that has been tried in the past is tannic acid. I don’t recommend this either, because it can cause excessive drying of the area, and cause the skin to crack. This is much more uncomfortable and may lead to bacterial superinfection. Needless to say, we want to avoid that.
Lastly, we often do not use corticosteroids (eg. Hydrocortisone) alone to treat cold sores. This is because it may actually suppress the natural immune response. However, you may find it in combination therapies with antivirals, but should not use it as a sole therapy.
Common Treatment Modalities for Medications
If you opt for the medication route, which are our top three options, then here are the most common treatment methods.
Intermittent Episodic Therapy (IET)
This is by far the most common. This is when we treat at the first sign of a recurrent episode. Think back to the prodromal symptoms I mentioned at the beginning. If you notice these, it’s time to start therapy.
Intermittent Suppressive Therapy (IST)
This is for those of you who have known triggers for cold sores (like UV exposure, dental extractions, menstruation). The guidelines are less clear on this treatment style, but we do see it from time to time.
Chronic Suppressive Therapy (CST)
One final treatment style is less common, but I’ll mention it here anyway. However, just know that this is uncommon and reserved for a select group of patients. This is called Chronic Suppressive Therapy (CST).
It includes the same treatment medications we talked about for IET, but instead a lower dose is taken daily. This is for those patients who have frequent (6 or more per year) recurrences. In these patients, we don’t usually recommend topical treatment – the oral therapy should be enough.