Globally, about 67% of people below the age of 50 years have herpes simplex virus type 1 (HSV-1). This is the virus that most often causes oral herpes.1 The virus is very contagious and is caught through close contact. Once a person has the virus, they will have it for life as it stays latent in the body in nerve endings. The most common areas that people suffer with cold sores are on the lips and around their mouth, but they can also develop on the nose and cheeks.2
Severe infective complications can occur in patients who suffer immune complications. It has been confirmed during a recent study that those with immune complications will be affected by flare-ups five to six times throughout the year, however those with stronger immune systems will notice on average two flare-ups in a year.3
HSV can be triggered when people are rundown, have been exposed to the sun or are particularly stressed, however, dermal filler injections can also exacerbate or trigger HSV due to the skin damage to an active area.4 Therefore, it is important for practitioners to be aware of how to prevent HSV from occurring, or how to treat it should it occur.
The link between dermal fillers and cold sores
During facial dermal filler injections, virus reactivations can be caused by direct damage to the axon by the needle which is being injected into the irritated area.5 In addition to this, tissue manipulation and inflammatory reactions after filler injection could play a role in a viral reactivation within our bodies. The damage is believed to cause infection reactivation, but hyaluronic acid itself has been demonstrated to act as a protective agent, preventing viral replication.5 During injections of dermal fillers, HSV will mostly be triggered around the mouth perimeter of the face, known as oral herpes, but can also cause concerns of other areas of the body. No matter where herpes arises, the virus will remain contagious and so will require medical treatment. Oral herpes causes sores on the lips and around the mouth which we know as cold sores or fever blisters.6
Despite this, you still should not let that hold you back from performing dermal filler injections on sufferers completely. HSV is quite a common virus, and many practitioners have treated HSV positive patients with no problem. In fact, the risk of HSV reactivation after dermal filler is estimated to occur in less than 1.45% cases.7
Diagnosis of HSV can be done through recognition of visible signs and symptoms, such as the development of a cold sore. There are several stages to the development of a cold sore. The first stage is a tingling or itchy feeling that precedes the blister, then 12 to 24 hours after the initial tingle, tiny blisters start to form. At this stage, the cold sore is often red and painful. The blisters will ooze fluid which will last a few days. Eventually, a scab will form and crust over. The whole cycle can take up to 15 days and the person is contagious for the entire cycle of a cold sore, which explains why they are so easily transmissible.8
However, there are not always obvious signs of HSV. Patients may not have any symptoms that they can feel, or the signs of herpes can be extremely mild that they will not notice them at all. It is also quite common for people to confuse herpes symptoms with other skin concerns such as ingrown hairs, the flu, or pimples. Symptoms of herpes can come and go, but that does not always mean that the infection does too, and even though the symptoms are not there, it does not also mean that it cannot spread to other people.
It is worth noting here though that if the cold sore presents following treatment, the initial symptoms of cold sores could also look like a necrosis. It is important that you see your patient in person, to make the differential diagnosis and be able to treat the patient accordingly. According to guidelines published by the Aesthetic Complications Expert Group World, when a blistering reaction occurs outside of the areas typical of herpes eruptions or in a high-risk area for necrosis, vascular compromise should be seriously considered.
To begin with, I always ask about cold sores in the medical history section during the initial consultation.5 If one of my patients frequently suffers with cold sores or had any recently, then I would suggest prescribing an antiviral drug such as acyclovir two before the treatment, as a prophylaxis. It is recommended that patients take 400mg of the drug two times a day (or three times if immunocompromised).5
If my patient does not suffer from cold sores regularly and the cold sores are not showing as active at the time of the appointment, I would still prescribe antiviral medication to ensure that the bacteria is kept under control. Aciclovir is widely used to treat infections caused by certain types of viruses, including outbreaks of herpes on the mouth or on other areas of the body. In those with frequent outbreaks, aciclovir is used to help reduce the number of future flare-ups. It is an antiviral drug, but it is not classed as a cure. The viruses that contribute to these infections will continue to live within our bodies even between outbreaks with the use of Aciclovir. However, the drug does decrease the severity and longevity of these outbreaks, and it enables the sores to heal faster whilst keeping new sores from forming and eventually reducing the pain and itchiness patients get from them.9 Aciclovir can be taken orally without the consumption of food. The most frequent side effects with aciclovir are abdominal pain, diarrhea, and vomiting; and so if these side effects occur, practitioners may want to look into prescribing an alternative such as Valaciclovir.5
When you do treat the patient, I would advise that when injecting you should avoid the area which flares-up, if possible. You should also be ensuring that the area is sterilised as usual and ensure you are using a separate needle when injecting into a different area. If your patient is having lip fillers, the flare-up area is hard to avoid as is where cold sores typically present, so you should only treat them once the HSV has subsided and isn’t flared-up already.
Following filler treatment
Upon completion of the treatment, I always recommend that my patients follow the general protocols of dermal filler aftercare, such as ice on the area if required, no lying down for four hours post-procedure and avoidance of hot water, steam rooms and saunas.
In addition to these protocols, I would recommend continuing taking the antiviral medication two times a day for five days to ensure that there are no severe reactions after the treatment. Alongside the two days prior, the medication should also be taken five to seven days after the initial treatment.5 Ensuring the area is constantly kept clean for the next 24 hours is recommended to avoid any further infection in the open wounds, and I would advise to avoid using lip products or facial products that have already been opened, such as lip balms or foundation. This is so any bacteria build-up within the products is not transferred on the open wounded area.
HSV and other aesthetic treatments
It is worth noting that it is not just injectables that can trigger cold sores, and other treatments that puncture or wound the skin such as botulinum toxin, threads, laser or radiofrequency can also cause reactions when used on the face. As such, I do not do any facial aesthetic work on any patient with an active cold sore as there is always a risk of spreading the virus to other areas, which can be a lot more complicated and painful for the patient.
As we know that most cold sores have a cycle of 15 days, as with dermal fillers, I will invite my patients back to the clinic after two to three weeks following the initial symptoms and perform the treatment when I know that the flare-up has gone down. I also prescribe antivirals to prevent an outbreak, as you can never be too cautious and always want to ensure the safety of your patient.
Practitioners should take a thorough medical history prior to treatment and prescribe patients with antiviral medication for two to five days should they have an active infection or regularly experience flare-ups. The medication should also be prescribed for five to seven days after treatment. As always, practitioners should be ensuring they are performing treatment in a safe, sterilised environment to avoid any infection. If your patient suffers a reaction after injection, you should ensure that you prescribe the correct medication for them to use at-home to subside the effects.
1. World Health Organisation, Two Third of the Population under 50 are Infected with Herpes Simplex Virus, 2015, <https://www.who.int/news-room/detail/28-10-2015-globally-an-estimated-two-thirds-of-the-population-under-50-are-infected-with-herpes-simplex-virus-type-1>
2. Jill Sheladi Schuman, How Many People Have Herpes, 2020, <https://www.medicalnewstoday.com/articles/how-many-people-have-herpes>
3. Denise J. Wedel M.D., Terese T. Horlocker, Infectious Complications, Complications in Regional Anesthesia & Pain Medicine, 2007
4. Kenneth M. Kaye, Herpes Labialis; Herpetic Gingivostomatitis, <https://www.msdmanuals.com/en-gb/professional/infectious-diseases/herpesviruses/herpes-simplex-virus-hsv-infections>
5. Martyn King, Prophylaxis and Treatment of Herpetic Infections, <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5300736/>
6. Riccardo Gazzola et al., 2012, Herpes Virus Outbreaks After Dermal Filler Injections, Aesthetic Surgery Journal, <Herpes Virus Outbreaks After Dermal Hyaluronic Acid Filler Injections | Aesthetic Surgery Journal | Oxford Academic (oup.com)>
7. Kim B, Somia N. Herpes reactivation after injection of dermal fillers. ANZ J Surg. 2013;83(12):998
8. NHS, Cold Sores, <https://www.nhs.uk/conditions/cold-sores/>
9. NHS, How and When to take Aciclovir, <https://www.nhs.uk/medicines/aciclovir/how-and-when-to-take-or-use-aciclovir/>