Stages of a Cold Sore Outbreak on Lips, Nose, and Face

Cold sores develop in stages, causing the outbreak of tiny blisters mainly on the mouth and lips but also around the nose and other parts of the face. The herpes blisters will quickly merge and rupture, causing a painful sore known as an ulcer. After drying and crusting over, the sore will gradually heal.

Cold sores—also known as fever blisters or herpes labialis—are mainly caused by the herpes simplex virus type 1 (HSV-1) and occasionally by HSV-2 (the virus that usually causes genital herpes). While HSV-1 and HSV-2 are incurable, antiviral drugs can reduce the severity and duration of outbreaks.

This article will describe the three stages of cold sores, including how herpes viruses are transmitted, treated, and prevented.

Cold Sore Stages and Symptoms

A first cold sore outbreak can occur anywhere from a few days to two weeks after exposure to HSV-1. The outbreak can last for 10 days to two weeks from the first appearance of blisters to when the sore is completely healed. A first outbreak may take longer to heal.

Many people who get HSV-1 will never have symptoms but still carry the virus and can infect others. Those who do get symptoms will develop cold sores in three characteristic stages:

Stage 1

The first stage of a cold sore lasts one to two days. During this time, symptoms like tingling, itching, or soreness may be felt around the site of the impending outbreak.

You may also experience prodromal symptoms. These are generalized and non-specific symptoms that develop before the main symptoms of an illness appear.

The prodromal symptoms of a cold sore are often described as flu-like and may include:

• Mild fever
• Headache
• Swollen lymph nodes
• Muscle aches
• Sore throat
• Difficulty swallowing
• Fatigue

People tend to experience prodromal symptoms with the first outbreak and never again. Others may experience prodromal symptoms without developing an actual cold sore.

Stage 2

After a few days, small, fluid-filled blisters will begin to form in a tight cluster on the lip. The blisters may itch and be painfully sensitive to the touch. An outbreak can also occur under the nose or on other parts of the face, such as the chin or cheeks. It is also possible for herpes blisters to develop inside the nose.

During the second stage of a cold sore outbreak, the blisters and fluid inside them are highly contagious, so it's important to avoid close contact with others.

The infection can also spread to other parts of your own body. This is known as auto-inoculation. If you touch a cold sore, wash your hands immediately to prevent spreading the virus to especially vulnerable parts of the body, like the eyes.

Stage 3

In the final stage of a cold sore outbreak, the blisters will converge into a larger blister and rupture (burst). This results in an open, concave sore called an ulcer. The ulcer is painful and the fluids inside them are highly contagious.

After a few days, the sore will start to dry out and form a crusty scab. The scab can be extremely itchy and may even crack. Try not to bite or pick at the scab as this can lead to bleeding and infection. It can also delay healing.

After about five to 15 days, the scab will begin to fall off as the sore heals, usually without leaving any scar.

What Causes Cold Sores?

Cold sores are caused by the HSV-1 virus, which is very contagious. Research suggests that 67% of people worldwide under the age of 50 have HSV-1. This includes children who often get sores in their mouth that are mistaken for cankers (aphthous ulcers).

Once infected, you'll have the virus for the rest of your life. The virus will embed itself in nerve cells near the spine where it will remain in an inactive (dormant) state. You won't have symptoms unless the virus is reactivated.

Not everyone with a cold sore experiences subsequent outbreaks. However, there are factors that can increase the risk of reactivation, including:

• Stress
• Fatigue
• Hormonal changes (such as with menstruation)
• Acute illness
• Dental work
• Exposure to extreme weather
• Excess sun exposure

If reactivated, the virus will usually cause an outbreak around or near the site of the initial outbreak. In most cases, the symptoms will be less severe than the first outbreak.

How Cold Sores Are Spread

Cold sores are potentially infectious until they are completely healed. You can be exposed to the virus through direct or indirect physical contact with an infected person, such as through:

• Kissing
• Touching a sore
  
• Sharing food, drinks, cups, utensils, toothbrushes, water flossers, e-cigarettes, or anything you put in your mouth
• Intimate contact (such as oral sex)

HSV-1 can also be spread when you touch surfaces that have been contaminated with fluids from a cold sore. If you have a cold sore, wash any surfaces you touch. Common household cleaners like Lysol can readily kill the virus.

Although it is harder to contaminate soft surfaces with HSV-1, you should wash pillowcases and beddings to reduce the risk of transmission, especially when the sore is oozing.

How Cold Sores Are Treated

Cold sores are painful, annoying, and possibly embarrassing. There are some things you can do to take care of a cold sore at home and help it heal faster.

Cold Sore Medications

Certain prescription oral antiviral medications can shorten the duration of a cold sore but they need to be taken within 72 hours of an outbreak to work. The earlier they are started, the more effective they are.

Antiviral medications for cold sores include:

• Famvir (famciclovir)
• Valtrex (valacyclovir)
• Acyclovir

Your provider might recommend antiviral creams to put directly on cold sores, such as:

• Abreva (docosanol 10% cream), available without a prescription
• Denavir (penciclovir 1% cream)
• Zovirax (acyclovir 5% cream)

Over-the-counter (OTC) pain relievers like Advil (ibuprofen) or Tylenol (acetaminophen) can help relieve pain, swelling, and irritation during an outbreak.

Home Remedies

There are other ways to care for cold sores at home that do not involve medications. These may ease some discomfort but won't lessen the severity or duration of the outbreak.

Among the self-care tips:

• Use a cold compress to reduce pain and irritation. Apply the compress to the sore several times a day for no more than 10 to 15 minutes to avoid frostbite.
• Keep the sore clean and dry. Do not put makeup on it.
• Avoid eating and drinking acidic foods like citrus, tomatoes, and coffee which can make pain worse.

How to Prevent Cold Sores

If you have frequent cold sore outbreaks, your provider may prescribe Zovirax or Valtrex daily to help prevent them from coming back.

Depending on what your cold sore triggers are, you may be able to prevent outbreaks without medications. For example, you can use sunscreen so you don't get too much sun exposure. Or you can practice meditation or breathing exercises to better manage stress.

It's also important to practice safe sex. HSV-1 can be passed through oral sex and cause genital herpes. Condoms help but don't entirely erase the risk. If you have a cold sore or feel one coming on, it is best to abstain from sex.

Remember, a person with HSV-1 can still spread the virus even if they don't have a cold sore.

Summary

Cold sores are mainly caused by the HSV-1 virus. During a cold sore outbreak, you may get blisters around your lips, nose, and cheeks, which eventually break to form an open, crusted sore.

Your first cold sore outbreak may be accompanied by flu-like symptoms. Subsequent outbreaks tend to be milder. Oral antivirals can shorten the duration and severity of outbreaks and may even be used on an ongoing basis to prevent outbreaks in those with recurrent infections.

HSV-1 is very contagious, so you need to avoid close contact and sharing personal items with others until the cold sore is completely healed.