Timing is everything — antivirals work best at the first tingle, not once the blister forms.
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Cold sores are caused by herpes simplex virus, usually type 1. Most adults carry it — typically acquired in childhood from an ordinary kiss from a relative — and around one in five gets recurrent cold sores. It is about as common as a virus gets.
After the first infection the virus stays dormant in a nerve near the ear and reactivates from time to time, travelling down the nerve to the same spot on the lip. That is why cold sores recur in the same place.
The single most useful thing here is about timing. Most people get a warning — tingling, itching or burning at the site — for around 24 hours before anything appears. Treatment started during that window can stop the cold sore developing at all. Started once the blister is visible, it barely shortens things. Almost everyone applies the cream on day two, which is why so many people conclude it does not work.
One thing carries genuine risk and deserves stating plainly: never kiss a newborn baby if you have a cold sore. Herpes in a newborn is a serious and occasionally fatal illness, and this is not widely enough known.
The first time can be much more severe, particularly in children — widespread painful mouth ulcers, swollen gums, fever, sore throat and difficulty eating and drinking. That illness lasts one to two weeks. Recurrences afterwards are far milder and confined to the lip.
By direct contact with the blisters or their fluid — kissing, sharing lip products, cups, cutlery or towels, and oral sex.
You are most contagious while blisters are present and weeping, until they have fully crusted. Some viral shedding occurs even without a visible sore, though at much lower levels.
Never kiss a newborn baby with an active cold sore. Neonatal herpes is uncommon but serious and can be life-threatening, and babies under three months are most vulnerable because their immune systems are immature. This applies to anyone — parents, grandparents, visitors — and it is worth saying out loud to visiting relatives, however awkward that feels.
Oral herpes can cause genital herpes through oral sex, and this now accounts for a substantial share of first genital herpes episodes. Avoid oral sex while you have an active cold sore.
Cold sores are diagnosed by appearance, and a good photograph is usually all that is needed — which makes this well suited to a remote consultation, particularly given how much the timing matters.
Rarely needed. A viral swab can confirm herpes where the picture is unclear — particularly a first episode, an unusual site, or anything not settling. Blood tests for herpes antibodies are not useful here: they show past exposure, which most of the population has, and cannot tell you whether the sore in front of you is herpes.
Start treatment at the first tingle, before anything is visible. Antivirals work by stopping the virus replicating, so once the blister has formed the replication is largely done and the benefit is small.
If you get recurrent cold sores, keep treatment at home so you can start within minutes rather than waiting to buy it. That single change is worth more than any difference between products.
For anyone with very frequent outbreaks — six or more a year — or where cold sores reliably ruin something important, a daily antiviral taken continuously for several months substantially reduces frequency. It is safe, well tolerated, and rarely offered unless someone asks.
It can also be used short-term around a known trigger — a holiday, a wedding, dental surgery.
Antibiotic creams do nothing for a viral infection. Neither do most of the products marketed for cold sores beyond antivirals and patches. Lysine supplements have weak and inconsistent evidence — harmless, but not treatment.
Anything involving the eye, anyone with widespread eczema and a spreading rash, or anyone significantly immunosuppressed needs urgent in-person care rather than a remote prescription.
Go to A&E or seek same-day care for:
Seek prompt assessment for:
Book a routine consultation if: you get six or more outbreaks a year, or outbreaks that are severe, disfiguring or affecting your work — suppressive treatment is available and works well.
Cold sores carry more embarrassment than they warrant. Most of the population carries the virus, having caught it as a small child from an entirely ordinary kiss. It says nothing about hygiene or behaviour.
Aciclovir cream is available over the counter for a few pounds, and cold sore patches and lip barriers are on the same shelf. Your NHS GP treats cold sores free. For an ordinary cold sore, a pharmacy is the right answer and we would say so.
The honest point about the cream is that its benefit is modest. Antiviral cream shortens an episode by around a day, and only if started at the very first tingle — once a blister has formed it does very little. Keeping a tube at home so you can start within hours is worth more than any prescription obtained after two days.
Where a consultation is genuinely worth it is frequent recurrence — six or more episodes a year, or outbreaks that reliably wreck something that matters. Oral aciclovir taken as suppressive treatment is far more effective than cream, is cheap, and is under-offered.
What needs urgent attention rather than treatment: a cold sore near or in the eye, which threatens sight and needs same-day ophthalmology; cold sores in someone whose immune system is suppressed; and anyone with eczema who develops painful clustered sores — eczema herpeticum is an emergency.
NICE Clinical Knowledge Summary, Herpes simplex — oral, is the principal reference. It notes that most episodes are self-limiting over 7 to 10 days, that topical antivirals offer limited benefit and only when started in the prodrome, and that oral antivirals are reserved for severe, frequent or complicated disease.
CKS covers suppressive oral antiviral therapy for frequently recurrent herpes labialis, which is the basis for the point above about recurrence.
CKS and the Royal College of Ophthalmologists guidance identify herpes simplex keratitis as requiring urgent ophthalmology assessment — the reason a lesion near the eye is treated differently.
NICE CKS, Eczema — atopic, sets out eczema herpeticum as a dermatological emergency requiring same-day assessment and systemic aciclovir, and warns that topical corticosteroids worsen it.
Triggers including sunlight, illness and stress are documented in CKS, supporting the preventive use of lip sunblock.
Because it is almost always started too late. Antivirals stop the virus replicating, and by the time a blister is visible most of that has already happened. Start at the first tingle, before anything appears — which means keeping treatment at home rather than going to buy it once you can see something.
Not with an active cold sore, and this genuinely matters. Neonatal herpes is uncommon but can be life-threatening, and babies under three months are most at risk. Avoid kissing them until the sore has fully crusted, wash your hands, and do not be shy about asking visiting relatives to do the same.
No. Oral herpes is usually caught in early childhood from ordinary family contact and is carried by most of the population. It is a different situation from genital herpes — though the same virus can cause genital infection if transmitted through oral sex, which is why avoiding that during an outbreak matters.
The virus stays in your system permanently, but outbreaks typically become less frequent over the years. Identifying your triggers — sunlight is the commonest — and using suppressive treatment where they are frequent makes a considerable difference.
Yes. Cold sores spread by direct contact, not through the air. Avoid sharing cups and cutlery, wash your hands, and do not touch the sore — unless you work with newborns or immunosuppressed patients, in which case ask about covering it or being redeployed.
The evidence is weak and inconsistent. They are harmless, and if you find they help there is no reason to stop — but they are not a substitute for starting an antiviral early, which does have evidence behind it.
Ultraviolet light is one of the strongest triggers, and holidays combine sun exposure with travel fatigue and disrupted sleep. A daily SPF lip balm, and in some cases a short antiviral course started before you travel, prevents a great many of them.
No — no treatment clears herpes simplex from the body. What treatment does is prevent and shorten outbreaks, which for most people is enough to make it a minor issue rather than a recurring one.
August 23, 2026
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