Cold Sores Question

[Lite41]

Hello Doctors, I have written you before on this topic and I have some more questions.

Usually I get one to two cold sores a year. I take Lysine tablets daily for suppresion. However, beginning in November I have gotten at least one a month. As such I contacted my doctor and was prescribed valacyclovir hcl which I took (2 1 gram tablets twice daily). The cold sore remained small and eventually went away. After this I went 1-2 days without taking any Lysine or valacyclovir and on the second day I noticed the cold sore coming back again and now appears to have come back and crusted over. I did not think the new cold sore was actually one but then it crusted over. Is this possible if it appeared to have went away and/or is it possible that a new one could come on so quickly?

Thank you so much for your time

[Edward W Hook, MD]

Daily valacyclovir can be used to suppress recurrent HSV.  Typically HSV-1 infections may be a bit more difficult to suppress than HSV-2 infections for reason that are unclear but most people do find some benefit from suppressive valacyclovir.

You discussed the issue of the infectivity of HSV lesions at various stages of the course of infection.  Typically infectivitiy decreases over time and as the ulcer disappears there is less infectivity.  EWH

[Lite41]

One follow-up. Dr. Anna Wald told me that valacyclovir hcl is not suppressive therapy but episodic therapy. Can Valacyclovir hcl also work to suppress or no?

If not, what would you recommend by way of suppressive therapy?

Further, when a cold sore lesion is no longer visible and all that remains is raised red skin, how infectious does one remain?

[Edward W Hook, MD]

Welcome to our Forum. In preparing to answer your question I reviewed your earlier interactions with Dr. Handsfield.  From this is appears to me that you are quite knowledgeable about HSV in general and you know yourself and your own infection well.  Congratulations.  In answering your question I need to first point out the huge amount of person to person variability that is seen with herpes infections. Different people have different disease courses, different responses to therapy and different manifestations of infection over time.  I will try to provide information that will help.

For your cold sore to have come back so quickly after an initial response to valacyclovir is, more consistent with a continuation of your initial recurrence than a second recurrence coming on the heels of the first one.  The distinction however is a difficult one and, equaly important, I'm not sure it changes anything in terms of management of your infection.  Typically there are at least several weeks between recurrences even in persons with frequent recurrences.  

I hope this comment is helpful to you. EWH