Facial herpes is most commonly associated with herpes simplex virus type 1 (HSV-1) and, very rarely, herpes simplex virus type 2 (HSV-2). The symptoms of facial herpes are clusters of small fluid-filled blisters, or sores that appear on the skin, in or around the nose and mouth.

If facial herpes is caused by HSV-2 it is important to note that this is rare. When it does occur, it tends to recur less often and shed virus less frequently than genital HSV-2, so the risk of transmission is lower.

Cold sores are very common. Many people carry the herpes virus without realising it, and not everyone who has the virus gets the symptoms of cold sores.

Cold sores are transmitted from someone carrying the herpes virus to a person who has not been exposed to it before. Infection is most commonly acquired as a baby or a child through every day family contact (for example kisses from relatives). The person transmitting the virus may not have typical cold sore symptoms at the time of transmission. The virus is often shed from the lips before blisters appear and it is also possible to shed infectious virus particles without noticeable symptoms. Many people will have come into contact with the virus between the ages of 3-5 years old, but only one in three of these will have a first episode with symptoms.

This explains why someone might get a cold sore without recalling a clear exposure, and why cold sores can sometimes appear in people in stable, long-term relationships.

If the herpes simplex virus (HSV) comes in contact with the skin of someone who hasn't been in contact with HSV before it enters the surface cells of the skin contact area. The virus then travels along the nerves to a "resting place" in a small nerve cluster called the trigeminal ganglion, where it stays quietly (inactive). Symptoms, if they occur, develop 1-3 weeks after initial transmission. Facial HSV stays in the trigeminal ganglion long-term, and it can occasionally reactivate and travel back to the skin, usually to the same place, causing repeat (or recurrent) cold sores.

Herpes doesn't "move around the body" from the face to the genitals on its own. Cold sores occur where they were acquired around the mouth/face, and any recurrences will be in that same region. Genital herpes happens when the virus is directly introduced to the genital area, most commonly through oral sex (HSV-1) or genital-to-genital contact (HSV-1 or HSV-2).

Cold sores don't always look the same, and they don't always follow a perfect pattern. But many outbreaks have four recognisable stages.

The four common stages:

1. Prodrome (early warning signs) stage
   Tingling, itching, burning, tightness, or odd feeling in one spot, this usually occurs 6-24 hours before blisters appear.
2. Blister stage
   Slight swelling and then a small cluster of tiny fluid-filled blisters, often painful or tender.
3. Ulcer stage
   Blisters break open and become shallow sores. If the lips are involved they can sting with talking or eating.
4. Crusting/healing stage
   The sore dries, forms a scab, and the skin usually heals within 8-10 days - without scarring, however you may notice some pink skin there for a short time.

Cold sores are more contagious from the prodrome stage (stage 1) until the skin has fully healed. There is also a lower risk of transmission at times when no sore is visible, because HSV can sometimes shed without symptoms.

When a person comes into contact with herpes and experiences symptoms, this episode is called a primary infection. The primary infection can progress in different ways. Some people will have mild symptoms and others will experience discomfort - but remember that most people will have no symptoms. Sores can develop on the face, inside the nose or inside the mouth. The primary infection may be accompanied by a fever and general aches and pains.

This first outbreak (if it occurs) usually starts 1-3 weeks after the virus has been in contact with the skin and may last 10-14 days (without antiviral treatment), subsequent episodes known as recurrences may last 7-10 days (without antiviral treatment).

In children, the first infection may present as herpetic gingivostomatitis, which can include:

• Painful mouth/gum ulcers
• Drooling
• Reluctance to eat or drink
• Fever and irritability

This can look dramatic and can be very distressing, but it is treatable. The biggest practical risk for children is dehydration, because it hurts to drink, so early pain relief, antiviral medication, and supportive care are important.

Most commonly, facial herpes affects the lips or nose. Recurrences can also appear on nearby facial skin such as the chin or cheek. If HSV involves the eye or the area around the eye, this can be serious and requires urgent specialist assessment, as herpes infection of the eye (often called herpes keratitis) can threaten vision.

The virus remains hidden in the nerves for the rest of the person's life and can become active again from time to time. What is "normal" varies: some people get a cold sore once every few years while others get several per year, especially if they have strong triggers. Normal cold sore recurrences become less frequent with age.

What triggers recurrences of cold sores?

Recurrence triggers are individual. Common triggers:

• Skin trauma like chapping from wind or sun exposure or accidental lip biting.
• Exposure to sunlight (if sunlight is a trigger for you, a high-SPF lip balm and regular sunscreen and hats can make a difference).
• Emotional stress and tiredness.
• Anything that lowers the immune system, such as feeling unwell with a cold, flu or other illness.
• Hormonal changes (e.g. menstruation, menopause, puberty).

Some people have no obvious triggers.

Preventing frequent recurrences

If you get frequent, disruptive cold sores, there are preventative strategies:

• Identify triggers and address them.
• Consider advance supply of oral medication, discuss with your clinician or pharmacist (so you can start treatment quickly).
• Discuss with a clinician whether suppressive antiviral therapy is appropriate.
• If your lesions are around the lips - use a high-SPF lip balm if sun exposure triggers your cold sores. Keep lips moisturised in cold/windy weather.
• The body's defences can be strengthened by a healthy lifestyle. Try to eat a varied diet, exercise regularly and get enough sleep.

Remember, most of us acquire facial herpes in the first five years of our lives. People who experience an episode of herpes, either facial or genital, should consider themselves infectious from the start of the episode (i.e. the tingling sensations) to the healing of the last ulcer. During this time the virus can be transmitted to other people by touching someone else with the part of your body which has the cold sore.

While you have symptoms of facial herpes you should avoid:

• Kissing and close face-to-face contact.
• Sharing anything you put in or on your mouth if you have sores around your mouth e.g. lip balm, cigarettes, drink bottles, cups, cutlery, toothbrushes, towels/face cloths. Transmission via shared objects is highly unlikely as the virus dies if it dries out on objects.
• Giving oral sex, because facial herpes can cause genital herpes through oral-to-genital contact.
• Using saliva to wet contact lenses if you have oral herpes (whether you have sores around your mouth or not).
• Avoid picking the scab as this can delay healing and can spread virus to other skin.

Try not to touch the cold sore. If you do (for example, when applying cream), wash your hands well with soap and water and dry thoroughly afterwards. Do not use soaps or scrub the cold sore, using water when washing the lesions is enough.

HSV doesn't survive on dry surfaces. The main risk of transmission is direct contact with the sore or fluid from the sore.

Most cold sores can be diagnosed by appearance and history. A swab of the lesion can be used to confirm it, but is not required. Sometimes a swab might be helpful when:

• The infection doesn't look like "typical herpes".
• The sores are severe or slow to heal.
• If you have a compromised immune system.
• If you have sores near the eye, or eye symptoms.

If testing is needed, a swab taken from an active sore is the best test. Blood tests do not tell you with any accuracy if you have HSV or where on the body the HSV is.

Most cold sores are uncomplicated, but some situations need urgent medical review:

• Eye symptoms: red eye, eye pain, blurred vision, light sensitivity, or sores near the eye.
• Widespread painful rash, fever, or rapidly worsening symptoms, especially in people with eczema/atopic dermatitis.
• Severe headache, confusion, drowsiness, seizures (very rare).
• Newborn babies with fever, lack of energy, irritability, poor feeding, with or without small, fluid-filled skin blisters (often on the eyes, mouth, or scalp).
• Sores are extensive, very painful, or not improving.

Visit your doctor if:

• Sores are repeatedly getting infected (yellow crust, increasing redness, pus, not healing).
• Outbreaks are frequent and affecting wellbeing.
• You're unsure whether it's facial herpes or something else.

Starting treatment early can sometimes prevent sores from fully appearing, or reduce how severe symptoms become. If cold sores happen often or are particularly troublesome, taking antiviral tablets every day, called suppressive therapy, can help stop cold sores from occurring.

Supportive care

Supportive care can be started at any time and helps with comfort while the sore heals.

• Paracetamol and/or ibuprofen for pain relief (if appropriate for you).
• Cool compresses for comfort.
• Keep the area clean and dry; avoid soaps or scrubbing, use water or a saline (sale water) rinse to clean.
• Lip balm can protect cracked skin and reduce painful splitting.

Over the counter medications

A pharmacist can advise on antiviral (with aciclovir) creams or patches. Some people find these useful. The antiviral creams and patches work best when started at the tingling stage or very early blister stage and can only be used on external skin. Trained pharmacists can also supply oral antiviral tablets for a one-off treatment for someone with known cold sores. Oral antiviral tablets are generally more effective, especially for more severe, frequent, or troublesome episodes.

Prescription medication: oral antivirals

Oral antivirals (valaciclovir/aciclovir) can shorten episodes and reduce severity, for example: skin blistering can be prevented, especially if started early. They are particularly useful for:

• Severe or painful episodes.
• Frequent recurrences.
• People who are immunocompromised.
• Significant primary oral infection (especially in children/young people with gingivostomatitis - clinician assessment is needed).

Oral antiviral dosing depends on the person and the scenario; a clinician will choose the appropriate regimen. You can get a prescription for suppressive and/or episodic oral antivirals from your primary care provider (GP/Nurse Practitioner)*.

*As mentioned above, some credentialled pharmacists can supply an episodic course of antiviral medication for people with known recurrent facial or genital herpes. Not all pharmacists can provide this service.

If you're a parent who gets cold sores, it's completely understandable to worry about passing the virus on, especially if you have a newborn. The reassuring news is that day-to-day parenting is safe, and cold sores can be managed in a way that keeps the risk to your pēpi very low. Facial herpes is mainly spread through direct contact with a sore, most commonly by kissing, and occasionally by touch if someone touches an active sore and then immediately touches the baby. It is not spread through normal family life, such as: cuddles, shared bedding, bathing, toilet seats, towels washed in the same machine, or surfaces.

The most important practical advice is simple: if you have an active cold sore (or the tingling stage), avoid kissing your baby and consider keeping the sore covered with a patch where possible, wash your hands after touching your face or applying cream, and ask others with cold sores to do the same.

These precautions are most important for babies in the first weeks of life, because neonatal HSV is rare but can be serious. If your baby develops a fever, unusual sleepiness, poor feeding, or blisters, seek urgent medical review.

Babies, especially newborns, can get very unwell from infections that are mild in adults. It can feel awkward asking friends and whānau not to kiss your baby, but you are absolutely allowed to set this boundary to help keep your pēpi safe. You could say: "Please don't take offence - we're asking everyone not to kiss the baby yet, just to help protect them from infections." Or: "Our midwife or doctor has advised us not to let people kiss the baby yet, so we're sticking with that for everyone."

Please feel welcome to contact the Herpes Helpline for reassurance and guidance.