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All you need to know about oral herpes

Oral Herpes: Symptoms, causes, and treatment

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First published: 29.Aug.2023


Cold sores are blisters around the mouth provoked by a common virus, Herpes simplex virus 1 or HSV-1 for short.

It can't be cured, but its outbreaks can be mitigated and contained by treatment with antivirals such as acyclovir or, less aggressive but equaly effective alternative therapies involving vitamin C and E, zinc, botanicals such as aloe vera, tea tree oil, black and green tea antioxidants, licorice, rhubarb, honey, sage and stress management.

In this article we will explain what cold sores are, what causes them, how the illness progresses, its symptoms, prevention, and treatments.

In this Article (Index)

Cold sore caused by oral herpes on a man’s lip
Oral herpes cold sore

What is Herpes?


There are over one hundred types of herpesvirus that infect all types of animals.
Seven of them infect humans and are known as the human herpesviruses. These are the following: herpes simplex virus type 1, herpes simplex virus type 2, varicella-zoster virus, cytomegalovirus, Epstein-Barr virus, human herpesvirus 6, human herpesvirus 7 and, Kaposi's Sarcoma herpesvirus.

The herpes virus that causes cold sores in the mouth is the Herpes simplex virus.

There are two types of herpes simplex:

  • Type 1, (HSV-1). Causes infections in or around the mouth where it causes painful ulcers and blisters. It is spread by skin-to-skin contact.
    50 to 80% of the U.S. adults have oral herpes.
  • Type 2, (HSV-2). Causes genital herpes, and is spread by sexual contact. It can also cause cold sores in the mouth area.

This article focuses on HSV-1 which is one of the most widespread virus in humans and causes recurring oral infections.

Sypmtoms of Herpes

The cold sores are tiny, fluid filled blisters that appear around the lips forming groups. After they burst a scab forms and can take several days till it goes. An outbreak can last 2 to 3 weeks. The sores leave no scars (1).

How does Herpes HSV-1 infect you?

HSV-1 is transmitted orally, through contact with the virus in sores, saliva or surfaces in or around the mouth.

You can catch it by touching or kissing someone with cold sores, by sharing towels, lipstick, a glass, mug, cup or cuttlery used by an infected person.

Most people catch HSV-1 as kids, in kindergarden.

Can you prevent cold sores?

The herpes simplex virus is very contagious. If you have cold sores, you can prevent it from spreading by:

  • Washing your hands with soap and water, often, especially after touching a cold sore. Most infected people carry the virus on their hands!
  • Keep your towels, washcloths, eating and drinking utensils separate from those of the other people you live with, and washing them well after each use.
  • Don't kiss anyone even when the sores have healed: viral shedding -your body releasing virus- lasts several weeks, even after the sores get cured.
  • Don't touch your eyes, HSV-1 eye infections are very serious!

What is the course of an HSV-1 infection


The virus initially infects the contact zone, for instance the epithelial cells of the mouth, causing sores on the lips and mucosa.
Then it spreads to the nerves of the peripheral nervous system and travels to the Trigeminal ganglia (TG); a ganglion is like a hub, with a group of nerves that function in a similar manner and are enveloped by connective tissue. The TG is part of the trigeminal nerve that conducts the sensory stimuli form face and head and also controls chewing.

The Initial Infection

The first infection is usually the worst. It provokes flu-like symptoms and can cause swollen lymph nodes and sores appear in the mouth and around the lips.


HSV-1 settles in the TG and remains in a latent or dormant state there, waiting to be awakened. It can also settle in other parts of the nervous system such as the brainstem, temporal cortex or the olfactory bulb.

No Cure for HSV-1

Once infected, a person will have herpes simplex virus (1 or 2) for the rest of his or her life.
Some people never develop any symptoms, while others will have periodic outbreaks.

Treatment can help manage outbreaks and prescription antiviral medicine can help the cold sores heal quicker and delay the onset of future outbreaks.

HSV-1 awakens: the triggers

The virus reactivates by itself or responding to certain triggers such as Fever, corticosteroids, emotional distress, stress, fatigue, surgery, physical injury, infection with other viruses, menstrual periods, cold winds, exposure to UV light or low defenses.

The virus then travels down the nerves' axons and infects the area of the skin connected to that nerve.

A study by Cuddy et al., (2020) involving mice found that when the body responds to stress or inflammation it releases proteins known as cytokines. One of them known as Interleukin 1 β (IL-1β) is an early response against injury or infection; IL-1β is also released by the epithelial cells in the skin and eye when they are damaged by ultraviolet light. However, IL-1β excites the nerurons near it and this enhanced excitability causes HSV-1 to flare up (2).

Recurring Infections

They are milder and usually involve sores on the edges of the lips. Recurrence often happens at sites previously infected. The sores start with redness, itching, swelling of the spot where the infection will appear. Painful blisters may form on the lips and under the nose. These blisters and the fluid in them are highly contagious. The blisters break and become sores.

After a week, they form a crust and heal but the patient is still shedding virus and can infect others.

Other spots that can get infected

Although the most common infection site is the mouth and lips, it can also infect the eyes, a very dangerous infection known as herpetic keratitis.
Other places that can be infected are the hands and fingers (herpetic whitlow), the bearded area (herpetic sycosis) and the torso, found often in wrestlers, herpes gladiatorum.

Remember that the symptoms of oral herpes may look like other medical conditions so you should always consult your health care provider for an accurate diagnosis and treatment.

Treatment of Herpes sores

Cold sores are painful. They itch and can cause a burning sensation. Taking acetaminophen or ibuprofen may ease pain. The standard treatment uses acyclovir, an antiviral medicine that acts upon the virus' DNA building enzymes, eliminating it. It comes under many brand names (Zovirax, Cymex Ultra, Virasorb) and is effective in reducing the recurrence rate by 60 to 90%.

Acyclovir disadvantages

Acyclovir has side effects that range from light ones like dizinnes, nausea, and diarrhea to serious reactions including renal failure, and hepatitis (3).

The use of acyclovir has also led to some herpes virus strains to become acyclovir resistant, this is a major concern.
For these reasons other safer and effective alternatives have been explored, we describe them in the next section.

Natural and alternative treatments for herpes

Aloe Vera

A limited study in vitro (not on patients, but using test tubes) using Aloe Vera gel "revealed the possibility of presence of some bioactive components in Aloe vera gel with anti-HSV-1 activity without any significant toxic effect in concentrations of 0.2-5%. Suggest[ing] that Aloe vera gel can be a useful topical treatment for oral HSV-1 infections" (4).

Rhubarb & Sage

A double-blind, randomized clinical trial involving 145 participants were split into groups: one was the control group and received the standard treatment with acyclovir, another got a cream with dried rhubarb and sage extracts and the third group received a cream with dried sage extract. The healing time ranged from 7.6 days for the sage cream and 6.7 days for the rhubarb. to 6.5 days for the acyclovir. The authors concluded that "The combined topical sage-rhubarb preparation proved to be as effective as topical aciclovir cream and tended to be more active than the sage cream" (5).

Tea Antioxidants

Green Tea Antioxidants have antiviral activity and one of them, Epigallocatechin gallate (EGCG), has shown it can combat HSV-1 infection.
Crude black tea extract has anti-herpesviral effect probably due to its content of theaflavins; de Olivera et al (2015) reported that " application of these agents as natural topical remedy to prevent and treat HSV-1 infection and spreading is promising" (6).

Perhaps the home remedy of applying a cool damp teabag to the sore could be effective.>br> Kobayashi and Ikeda noted that one cup ov black tea contains 10 mg of theaflavins (7). Regarding ECGC, it accounts for 50 to 80% of green tea's antioxidant catechins and one brewed cup of green tea contains 200 to 300 mg of EGCG (8).

Lemon Balm

This plant (Melissa officinalis) produces an Essential Oil composed mainly of citral a, citral b and citronellal that can penetrate the skin easily.

In vitro tests showed that the oil inhibited the virus exerting an antiviral effect and concluded that "Melissa officinalis oil might be suitable for topical treatment of herpetic infections" (9).

Tea Tree Oil

Tea Tree Oil is another essential oil obtained from an Australian tree, Melaleuca alternifolia. Its anti-herpesviral effect was studied in a randomized, placebo controlled trial involving 20 participants where half received a placebo gel and the other half a 6% tea tree oil gel. They applied it 5 times a day.
The tea tree oil gel had a shorter healing time (9 days) vs. 12.5 days for the placebo, and the viral load of their sores was lower too. The study concluded that "Melaleuca alternifolia oil has potential to be a cost effective alternative topical treatment for herpes labialis infections" adding that it has the advantage of being cheaper, acceptable to the patients and " poses little threat of inducing resistance to systemic antiviral agents" (10).


Lysine is an essential amino acid meaning that the human body cannot make it, it must be eaten as part of a balanced diet. There are many sources of lysine such as meat, fish, dairy, eggs and soybean.

Like all aminoacids, it is a building block for making proteins in the body.

Its antiviral properties against HSV-1 have been shown in several studies: "One review found that oral lysine is more effective atpreventing an HSV outbreak than it is at reducing the severity and duration of an outbreak" (11).

The evidence suggests that oral supplementation of less than 1 g/day require a low-arginine diet to be effective and that doses above 3 g/day "appear to improve patients' subjective experience of the disease."

Apparently the mechanism by which lysine affects HSV is the following: the virus requires arginine-rich proteins to reproduce and lysine inhibits the synthesis of arginine. Arginine unlike lysine, is made by the body and plays a role in growth, wound healing and other metabolic processes that is why lysine should be used with caution in patients with gallstones, asthma, heart disesease or immune issues.

Low Arginine and High Lysine Foods

Note that arginine and lysine are found in the same high-protein foods! so it is complicated to lower one without lowering the other or vice versa, for example: meat (beef, turkey, chicken), fish, nuts (almonds, cashews, pumpkin seeds), legumes (soybeans, chickpeas), whole grains (oats, brown rice) and dairy products (milk, yogurt, cheese) have a high content of arginine.

Foods with a high lysine content include fish like sardines and cod, red meat, pork and poultry, eggs, soybeans, tofu, and berwer's yeast.

The optimal solution is to verify the ratio of Lysine to Arginine and eat those foods with a higher value, some examples (there are many tables on the internet, a valuable resource is the Component Search option of the U.S. Department of Agriculture (USDA), for Arginine and Lysine; it also has a wealth of information on food: nutrients, calories, and nutritional value.

view of the USDA website showing arginine content in different foods
The USDA tool, showing arginine content. Click on image to enlarge it

This table shows some lysine (L) rich foods, and their content of lysine in mg/g and the ratio of lysine vs. arginine (L-A ratio) that if it is above 1, means the food has more lysine than arginine. On the internet there is a table attributed to James M. Scutero with L-A ratios, we haven't validated it.


L mg/g

L-A ratio

Plain Yogurt



Parmesan Cheese



Tuna in water



Beef T-bone steak



Peanut butter



Parmesan cheese has a high ratio (lysine vs. arginine) and also a high content of lysine (33.46 mg⁄g) on the opposite end, peanut butter has a ratio lower than 1 meaning it has more arginine than lysine, despite having a good content of the latter (11.7 mg⁄g) it has 3.5 times more arginine (40.9 mg⁄g).


Zinc taken orally has proven to be effective and topical Zinc Sulfate solution also improves the symptoms and delays recurrence (12).
So perhaps a supplement of Zinc could help inhibit HSV.

Vitamin C

It has been known since the late 1970s that vitamin C taken orally or applied topically improves the healing of cold sores. One trial involved using Ascoxal, an ascorbic acid-containing pharmaceutical formulation used for mucolytic purposes. A cotton wool pad was soaked in the product and pressed onto the sore 3 times, for 2 minutes each time, every 30 minutesm on the first day of outbreak. Its effect "reduces number of days with scabs, number of cases of worsening of symptoms" (13).

Another trial involved using Vitamin C with water-soluble bioflavonoids (these can be purchased OTC) and found that "1000 mg water-soluble bioflavonoids and 1000 mg vitamin C in equal increments five times daily at first onset and continued 3 days reduces outbreak of vesiculation and prevents disruption of vesicular membranes" (14).

Vitamin E

Topical application of vitamin E reduced healing time and pain. The dose was the contents of one capsule every 4 hours (12).

Licorice Root

Licorice root (Glycyrrhiza glabra) inhibits the grouth and effects of HSV. Applied topically it shortens healing time and pain.


Found in grapes, it has shown anti-HSV activity in vitro. Topical creams block HSV replication and block the eruption of lesions if applied early and frequently (12).


A statistical analysis of publications on the effectiveness of honey and propolis in comparison to acyclovir "confirm[ed] the use of honey and propolis as potent antiherpetic agents." Propolis and honey had a better healing effect against the HSV wounds than acyclovir, honey also acted quicker with an 8 day sore healing time vs. 9 days for the acyclovir, and its pain reduction was similar to the standard drug's effect (15).

Stress Management

Handling stress can reduce the HSV outbreaks, and here are some tips to do so:

  • Exercise on a regular basis
  • Get plenty of sleep
  • Follow a healthy and well-balanced diet
  • Avoid unhealthy habits (alcohol, substances and tobacco.)
  • Unwind with yoga, meditation, stretching.
  • Take control of your problems, work smarter not harder
  • Connect with friends and family
  • Have some "me time"

Closing comments

Cold sores are uncurable but you can treat them to improve your life quality. Acyclovir, the standard medical treatment has its shortcomings: adverse side effects and a growing herpes virus resistance.

There are alternative treatments involving botanicals such as black and green tea, aloe vera, tea tree oil, licorice, sage, and supplements like vitamins C, E and zinc. Furthermore diets with a higher content of lysine and a lower content of arginine can also help treat it.
Stress management and a healthy lifestyle can also contribute to a better outcome.

References and Further Reading

(1) Mayo Clinic (2023). Cold Sore May 2023.

(2) Sean R Cuddy, et al. (2020). Neuronal hyperexcitability is a DLK-dependent trigger of herpes simplex virus reactivation that can be induced by IL-1. eLife 9:e58037

(3) NHS (2022). Side effects of acyclovir.

(4) Rezazadeh F, Moshaverinia M, Motamedifar M, Alyaseri M. (2016). Assessment of Anti HSV-1 Activity of Aloe Vera Gel Extract: an In Vitro Study J Dent (Shiraz). 2016 Mar;17(1):49-54. PMID: 26966709; PMCID: PMC4771053

(5) Saller R, Büechi S, Meyrat R, Schmidhauser C. (2001). Combined herbal preparation for topical treatment of Herpes labialis. Forsch Komplementarmed Klass Naturheilkd. 2001 Dec;8(6):373-82. doi: 10.1159/000057255. PMID: 11799306

(6) Aline de Oliveira, Derek Prince, Chih-Yu Lo, Lee H. Lee, Tin-Chun Chu. (2015). Antiviral activity of theaflavin digallate against herpes simplex virus type 1. Antiviral Research, Vol 118 2015, p56-67, ISSN 0166-3542,

(7) Makoto Kobayashi, Ikuo Ikeda, (2014). Chapter 48 - Modulation of Intestinal Cholesterol Absorption by Dietary Tea Polyphenols. Editor(s): Ronald Ross Watson, Victor R. Preedy, Sherma Zibadi, Polyphenols in Human Health and Disease, Academic Press, p 625-638, ISBN 9780123984562,

(8) Brahma N. Singh, Sharmila Shankar, and Rakesh K. Srivastava, (2011). Green tea catechin, epigallocatechin-3-gallate (EGCG): mechanisms, perspectives and clinical applications. Biochem Pharmacol. 2011 Dec 15; 82(12): 1807–1821. doi: 10.1016/j.bcp.2011.07.093

(9) Schnitzler P, Schuhmacher A, Astani A, Reichling J. (2008). Melissa officinalis oil affects infectivity of enveloped herpesviruses. Phytomedicine. 2008 Sep;15(9):734-40. doi: 10.1016/j.phymed.2008.04.018. PMID: 18693101

(10) Carson CF, Ashton L, Dry L, Smith DW, Riley TV. (2001). Melaleuca alternifolia (tea tree) oil gel (6%) for the treatment of recurrent herpes labialis. J Antimicrob Chemother. 2001 Sep;48(3):450-1. doi: 10.1093/jac/48.3.450. PMID: 11533019

(11) Mailoo VJ, Rampes S. (2017). Lysine for Herpes Simplex Prophylaxis: A Review of the Evidence. Integr Med (Encinitas). 2017 Jun;16(3):42-46. PMID: 30881246; PMCID: PMC6419779

(12) Joseph E. Pizzorno, Michael T. Murray, Herb Joiner-Bey, (2016). 34 - Herpes simplex. Editor(s): Joseph E. Pizzorno, Michael T. Murray, Herb Joiner-Bey, The Clinician's Handbook of Natural Medicine (Third Edition), Churchill Livingstone, p375-380, ISBN 9780702055140,

(13) Hovi T, Hirvimies A, Stenvik M, Vuola E, Pippuri R. (1995). Topical treatment of recurrent mucocutaneous herpes with ascorbic acid-containing solution. Antiviral Res. 1995 Jun;27(3):263-70. doi: 10.1016/0166-3542(95)00010-j. PMID: 8540748

(14) G.T. Terezhalmy, W.K. Bottomley, G.B. Pelleu, (1978). The use of water-soluble bioflavonoid-ascorbic acid complex in the treatment of recurrent herpes labialis. Oral Surgery, Oral Medicine, Oral Pathology, Vol 45:1, p56-62, ISSN 0030-4220,

(15) Rocha MP, Amorim JM, Lima WG, Brito JCM, da Cruz Nizer WS. (2021). Effect of honey and propolis, compared to acyclovir, against Herpes Simplex Virus (HSV)-induced lesions: A systematic review and meta-analysis. J Ethnopharmacol. 2022 Apr 6;287:114939. doi: 10.1016/j.jep.2021.114939. Epub 2021 Dec 26. PMID: 34965458

About this Article

All about Oral Herpes: causes, symptoms and treatment of Herpes simplex virus 1, A. Whittall

©2023, 29 Aug. 2023. Update scheduled for 29 Aug. 2025.

Tags: herpes, HSV-1, cold sores, oral herpes, herpes treatment, alternative treatments for herpes.

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