Photo Rounds

Ulcers on upper lip

A 29-year-old woman sought care from her family physician (FP) for painful ulcers on her upper lip that had been there for 5 days. She had just returned from a vacation at the beach and noted that she typically got a painful outbreak like this twice a year following prolonged sun exposure or when she was under increased stress. She wanted to know how to best treat—and better prevent—the outbreaks.

What's your diagnosis?


The FP diagnosed recurrent orolabial herpes. Orolabial herpes typically takes the form of painful vesicles and ulcerative erosions on the tongue, palate, gingiva, buccal mucosa, and lips. Treatment for primary orolabial herpes includes oral acyclovir (200 mg 5 times daily for 5 days), which accelerates healing by one day and can reduce the mean duration of pain by 36%. Alternatively, valacyclovir can be given 2000 mg orally every 12 hours for one day and, like acyclovir, should be started as soon as possible after the onset of symptoms.

Docosanol cream is available without a prescription for oral herpes. One randomized controlled trial (RCT) of 743 patients with herpes labialis showed a faster healing time in patients treated with docosanol 10% cream when compared with placebo cream (4.1 vs 4.8 days), as well as reduced duration of pain symptoms (2.2 vs 2.7 days).1 More than 90% of patients in both groups healed completely within 10 days.1 Treatment with docosanol cream, when applied 5 times per day and within 12 hours of episode onset until symptoms are relieved, is safe and somewhat effective.

Suppression for patients with frequent recurrences may be provided with valacyclovir 500 mg daily or acyclovir 400 mg twice daily.

Suppression was not indicated for this patient since she had infrequent episodes. She was told that the best prevention would be to use a high-potency sunscreen on her lips and face when out in the sun and to use protective clothing such as a broad brim hat. To prevent skin cancers and recurrent oral labial herpes, she was told to avoid the midday sun whenever possible.

The FP also explained that it was too late now to start oral antiviral treatment, but that she might want to use topical petrolatum for symptom relief. He also offered her a prescription for an oral antiviral medicine that she could fill at the start of symptoms during a future outbreak. He explained that there is some benefit to the over-the-counter topical medicine, docosanol.

1. Sacks SL, Thisted RA, Jones TM, et al; Docosanol 10% Cream Study Group. Clinical efficacy of topical docosanol 10% cream for herpes simplex labialis: A multicenter, randomized, placebo-controlled trial. J Am Acad Dermatol. 2001;45:222-230.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux EJ, Carter K. Herpes simplex. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:735-742.

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