There are five stages of a cold sore outbreak, which include the early or beginning stage with tingling, the blister stage, the oozing or ulcer stage, the scabbing stage, and the healing stage.
Cold sores usually appear on lips, or the edge/ corner of the mouth, but they can also be seen on or around the nose, chin, cheeks, or near the eyes.
Overview
Cold sores, also known as oral herpes and fever blisters, are small, fluid-filled blisters that usually develop on or around the lips and are caused by the herpes simplex virus (HSV).
Cold sores are typically caused by the herpes simplex virus type 1 (HSV-1), while genital herpes usually occurs due to HSV-2.
Once a person is infected by this virus, it remains dormant in the nerve cells and can reactivate at any time, leading to recurrent cold sores.
In this article, we will talk in-depth about the various stages of cold sores, their timeline in days, and their progression. With each cold sore stage, you will find pictures depicting the healing process of cold sores.
The life cycle of a cold sore can be divided into the following five stages:
Stage 1: Early stage of a cold sore (Days 1-2)
The early or beginning stage of a cold sore typically starts 1-2 days before the blister becomes visible. This stage is also known as the prodromal stage. During this stage, you may experience discomfort such as tingling, itching, or a burning sensation in the area where the cold sore will eventually appear.
This area is often the lips, but cold sores can also be on the nose, under the nose, on the cheeks, chin, or near the eyes. Although there are no visible bumps at this stage, the affected area may be slightly swollen or reddish in color.
This is the ideal time to start treating a cold sore, as early treatment may help reduce the severity and duration of the outbreak.
The only over-the-counter available option that has an antiviral called docosanol is Abreva. Other over-the-counter treatment options can decrease discomfort but cannot speed up the healing process.
This is also the time you should consult your doctor for recommended treatment options such as antiviral topical creams (which may contain acyclovir or penciclovir) or oral pills (which may contain acyclovir, valacyclovir, or famciclovir).
Pictures
The pictures below show the early stage of a cold sore in which one may see slight redness or swelling of lips.
Stage 2: Blistering (Days 2-4)
The blister stage begins typically 1-2 days after the initial symptoms of tingling and itching. At this stage, one or more fluid-filled bumps, known as blisters, appear on the skin. The blisters are usually small, red, and filled with clear or cloudy fluid.
The cold sores on the lip may cause swelling of the lip and swollen lip is sometimes called a “fat lip”.
The blisters can increase in number and can become painful. Over-the-counter medication with analgesics like lidocaine or benzocaine (such as Carmex, and Orajel) can reduce the pain by numbing the area.
Do not try to pop these blisters yourself as it will delay healing and the virus can spread to other areas of the face.
Pictures
The pictures below show cold sores or fever blisters on the lips accompanied by lip swelling.
Stage 3: Weeping or Oozing (Days 4-5)
On days 4-5 of the outbreak, the fever blisters pop or burst to form open sores or ulcers that weep or ooze fluid. This is also called the ulcer stage.
The open sores are red and shallow with a depressed center. The ulcer stage is often considered as the most painful and contagious period as the oozing fluid can spread the virus to other parts of one’s own body or other individuals.
Pain, irritation, and itching may increase during this stage.
To avoid the spread of the herpes simplex virus at this stage, use a Q-tip applicator to apply the topical medication. If you use your fingers to apply topicals, make sure to wash your hands each time.
Avoid touching your sores to prevent the spread of the virus to other areas, like the eyes, which can lead to potentially serious complications. If your bedding, such as pillows, comes into direct contact with oozing fluid, make sure to wash them.
You can also take over-the-counter pain medications, such as Tylenol or Ibuprofen, to reduce discomfort.
Pictures
The picture below shows the ulcer stage of cold sores on the lower lip.
The picture below shows the ulcer stage of cold sores near the corner of the mouth.
Stage 4: Crusting or Scabbing (Days 5-8)
After the ulcers have drained, the cold sores begin to dry out and form a crust or scab, which can be yellow, reddish-brown, or dark brown in color.
This crust stage generally begins 5-8 days after the onset of the outbreak. The scabbing can cause an uncomfortable tightness and may crack and lead to bleeding.
Keeping the area moisturized with an ointment or lip balm at this stage can prevent cracking and splitting.
It’s also important not to pick the scabs prematurely, as this can delay the healing process and increase the risk of scarring.
Pictures
The pictures below show cold sores with crust or scab formation on the lips.
The picture below shows cold sores on the nose with scab formation.
The picture below shows cold sores on the chin with scabbing.
Stage 5: Healing (Days 8-10)
In the healing stage of a cold sore, which starts 8-10 days after the outbreak, new skin forms under the scab, and the scab falls off naturally. The underlying skin may be slightly pink, red, or swollen and there may be some flakiness.
However, this returns to normal skin over the course of a few days, and complete healing is usually done within 2 weeks. At this stage, keep your lips moisturized to heal the flaky areas.
Cold sores usually don’t leave behind any scars.
If the sores were large or it was the first or primary infection, the healing process may take 3-4 weeks.
Pictures
The picture below shows the healing stage of a cold sore with the scab fallen off.
The picture below shows the complete healing of a cold sore.
Which stages are contagious?
All the stages of cold sores are contagious. A person is contagious from the very first symptom of itching and tingling and stays contagious until they heal and completely disappear.
Of all the stages, the oozing stage is considered the most contagious as the fluid oozing from the cold sores can easily spread the virus.
When to see a doctor
You should consult a doctor if:
- The cold sores are large and very painful.
- The sores do not heal in 2 weeks.
- The sores are near or involve the eyes, or you experience any eye irritation.
- The sores are also present in the mouth or gums.
- You have systemic symptoms like a high fever.
- You have a suppressed immune system.
- You have a history of eczema.
Precautions
Cold sores are highly contagious and one can follow certain measures to avoid the spread of the virus.
- Do not make close or intimate contact with anyone, like kissing.
- Do not share your personal items like brushes, utensils, or lip balms with anyone else.
- Always wash your hands after taking care of the cold sores.
- Avoid direct exposure to the sun and use sunscreen.
- Do not pick on the scabs or pop the blisters.
- Avoid salty, acidic, or spicy foods as these can irritate the sores.
- Drink plenty of water to avoid dehydration.
- After your cold sores heal, discard the toothbrush and lip balms you used on cold sores to avoid re-infection in the future.
Key points
Cold sores, or oral herpes, typically go through five stages as they heal: the early stage of tingling followed by blistering, weeping, crusting or scabbing, and healing.
Understanding the stages of cold sores can help manage symptoms and speed up the healing process. Although the herpes simplex virus that causes cold sores is not curable, there are many treatments available to relieve symptoms, speed up the healing process, and reduce the frequency of outbreaks.
These include antiviral creams or oral pills, topical ointments, and lifestyle modifications. If you experience recurrent cold sores, it’s advisable to see your doctor to discuss the best way to manage and treat them.
Further reading
- Causes of blisters on the lip
- Canker sores vs. cold sores
- Cold sore vs. pimple
- Cold sores: Causes, Treatment, Fever blisters vs cold sores
- Cold sores pictures and symptoms
- How long do cold sores last?
References
- Ramchandani M, Kong M, Tronstein E, Selke S, Mikhaylova A, Magaret A, Huang ML, Johnston C, Corey L, Wald A. Herpes Simplex Virus Type 1 Shedding in Tears and Nasal and Oral Mucosa of Healthy Adults. Sex Transm Dis. 2016 Dec;43(12):756-760. PMID: 27835628; PMCID: PMC5117635.
- Saleh D, Yarrarapu SNS, Sharma S. Herpes Simplex Type 1. [Updated 2022 Aug 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan.
Disclaimer: This article is for information purposes only and does not replace medical advice.