Management of Common Oral Sores

Mea A. Weinberg, DMD, MSD, RPh; Stuart L. Segelnick, DDS, MS


US Pharmacist. 2013;38(6):43-48. 

In This Article

Recurrent Herpetic Infections (Cold Sores)

Once the dormant herpes virus is reactivated, it becomes recurrent herpes. Usually outbreaks occur on the lips, a condition referred to as herpes labialis (also known as cold sores or fever blisters). There is typically a prodromal burning or itching at the site 12 to 36 hours preceding the eruption.[18] Clinically, a small, well-circumscribed cluster of small vesicles (blisters) appears on heavily keratinized oral mucosa, including the vermillion border of the lips, and the gingivae, hard palate, and tongue. These vesicles subsequently rupture, ulcerate, and crust within 24 to 48 hours. If left untreated, lesions may last past 14 days.[19]

Other nongenital manifestations of recurrent herpes include keratoconjunctivitis and herpetic whitlow of the finger. Typically, recurrent infections are not as severe as primary infections. Recurrence of herpetic lesions occurs due to stress, sunlight, immunosuppression, trauma (e.g., after a dental procedure), or other irritants.[18]


Oral and topical medications are used to treat the herpetic lesions, as well as to prevent recurrences (Table 4).[18,23] Antiviral drugs inhibit viral DNA synthesis, which may reduce healing time, viral shedding, and frequency of recurrences, but do not cure the condition.

Prescription drugs are effective when applied early and can reduce healing time by 1 to 2 days.[26] However, these prescription medications are also expensive and have adverse effects.[27] Penciclovir 1% cream (Denavir) is recommended in nonimmunocompromised individuals and should be applied during the prodromal stage.[28] Acyclovir (systemic, topical) is prescribed for immuno-compromised and immunocompetent patients. Adverse effects of oral acyclovir include malaise, nausea, vomiting, diarrhea, and headaches. Topical acyclovir can cause mild pain, burning, or stinging.[29]

OTC Abreva (docosanol 10% cream) is applied at the first sign of a cold sore until the infection is healed.[27] It works by inhibiting the fusion of the virus with the human cell membrane, thereby blocking entry and subsequent viral replication. Abreva has similar efficacy to prescription topical antiviral agents.[30] Caution should be used when recommending Abreva to pregnant and nursing women and should not be used in children under 12 years of age. Headache is the most common adverse effect.[30]

Viroxyn Professional Use (benzalkonium chloride 0.13% with 7.5% benzocaine) was FDA approved in 2012. It is a nonprescription product available through dental professionals only. In a retrospective study, it was shown to be significantly more effective than Abreva. Viroxyn reduces the discomfort of a cold sore and is applied in a single application.[27]

Other OTC products available for palliative or symptomatic relief include petrolatum and cocoa butter to keep lesions moist and prevent cracking, which would make them more susceptible to secondary infection. If it is too late after the first symptoms appear to apply an antiviral agent, then a topical anesthetic such as Orabase-B (20% benzocaine) may help reduce the pain, burning, and itching. Individuals allergic to para-aminobenzoic acid (PABA) or sulfonamides may also be allergic to benzocaine. Products containing camphor (not >3%) and menthol (not >1%) act as an analgesic to relieve pain and itching. Natural products such as bioflavonoids or acidophilus are not FDA approved and have not demonstrated efficacy in controlled clinical trials.[31]