One such conviction is that English food is awful; it is not, as London alone has numerous Michelin-listed and starred restaurants. Recently, at a new and very hip joint, I joined a dear aviation friend for a superb, relaxed lunch, and while the menu and wine list merited my full attention, it was diverted by the large and painful-looking cold sore on the sommelier’s upper lip.
Cold sores are common, ancient adversaries that are painful, socially inconvenient, and occasionally, harbingers of doom. For pilots, they carry special implications, and given our friends at the FAA also cannot take their eyes off them, don’t be a sore loser and read on!
Cold sores are a sign of infection with the Herpes simplex virus type 1 (HSV-1), a relative of the viruses that cause chickenpox, shingles, and genital herpes. Everyone recalls those media images of the Covid-19 virus; well, HSV-1 looks similar—some genetic information wrapped in a spiky protein and fatty ball. Some question whether viruses qualify as living entities, but whether animal, mineral or vegetable they are a darn nuisance.
Hippocrates—he of oath fame—described lip and mouth sores more than two millennia ago. Roman emperor Tiberius was concerned that kissing might transmit sores and reportedly banned smooching in public to prevent these eruptions from sweeping through his court. In Romeo & Juliet, Shakespeare makes references to blisters plaguing ladies’ lips, probably implying the afflicted women were up to no good, because in those days there was little distinction between venereal disease and cold sores.
Once one is infected with HSV-1, it never leaves, lurking quietly in nerve cells and when stressed, fatigued, run down by fever or suffering from immune suppression, the virus gets frisky and pops out. This causes an inflammatory “fever blister” which then bursts, leaving a sore, red ulcer on the lip. The ancients had it right, as this virus is highly infectious and easily transmitted when a sore is present, and as prevention is better than cure, avoid kissing, close contact, and sharing drinks, utensils, toothbrushes, and razors with anyone who has an active sore. However, the virus can also shed when there is no sore present.
Episodes usually begin with a prodrome, the early signs of a tingling, burning, or itching lip. A few hours, or a day or two later, redness and small fluid-filled vesicles (blisters) appear. Rather like one of those mass parachute groups, they coalesce into a cluster, but there the similarity to free fall ends as they break open into weeping sores and form a crust. Often painful, unsightly, and embarrassing, they eventually settle down in 7–10 days, but the sufferer knows they will return.
Sores may also induce swollen neck lymph nodes, low-grade fever, and feeling generally unwell, particularly with a first episode. Recurrent outbreaks are usually milder, but any stressor can trigger an outbreak such as a check ride, ramp check or opening an email from your A&P mechanic or your wife’s lawyer. Additionally, UV exposure and the dry atmosphere at altitude can provoke an outbreak, so using high SPF cream makes sense.
After touching a cold sore, wash hands with hot soapy water, as the virus can spread to one’s eyes or fingers. Herpetic whitlow (finger infection) or herpetic keratitis (eye infection) can be very serious, even threatening sight. For healthy adults, HSV-1 is more nuisance than menace, but if the immune system is compromised from cancer, chemotherapy, other serious infections, or transplant, widespread viral infections can develop including a rare, but very nasty condition called herpetic encephalitis, a life-threatening brain infection. For the average aviator, cold sores heal without trace—until the next trigger stirs the viral beast.
However, not every lip lesion is HSV-1, and when a sore occurs for the first time, or if it looks or feels different from a prior occurrence, your doctor will also consider:
Making a correct diagnosis is critically important, so if a “cold sore” persists more than two weeks, looks unusual, or recurs in the exact same spot with growing intensity, medical evaluation is essential.
Anyone who has suffered from cold sores knows that they usually heal spontaneously, but several options help shorten misery or reduce recurrence:
It is important to stress that antibiotics have no role—this is a viral, not bacterial, infection so antibiotics do not work.
During the prodromal phase, if fever or malaise is an issue, self-ground. A small sore should not impair one’s ability to fly, but if painful, that may be a sufficient distraction to merit staying out the cockpit. If the eye is involved with pain, impaired vision or sensitivity to light, see an ophthalmologist and do not fly. If taking antivirals, initially self-ground as side effects might impair flight safety, but recurrent use is acceptable if well-tolerated and there are no systemic symptoms.
In 1932 Herman Hupfeld wrote “As Time Goes By,” immortalized in Casablanca. The lyrics suggest that a kiss is just a kiss, but if a cold sore is present it can lead to something that persists as time goes by. Telling someone their smile is contagious should be a compliment, and not something that goes viral.
Fly well!
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