Herpes is a very common infection, however there is still stigma associated with it. It makes natural that when you think of herpes symptoms, your mind could immediately picture lumps on your vagina because those ulcers frequently alert people to the fact that they have herpes symptoms in the first place.

Yet, another obvious sign of herpes is cold sores, which are painful lesions on the lips, mouth, and surrounding area. According to a 2018 data brief from the Centers for Disease Control and Prevention, over half of Americans have been infected with the herpes virus, which typically causes cold sores. Whether you get cold sores frequently or even infrequently, you’re absolutely not alone.

It might be challenging to distinguish between cold sores and herpes, so you might wonder: Are all cold sores caused by herpes? The vast majority of them are, but sometimes the reasons why aren’t so obvious.

First, what is a cold sore, exactly?

According to the American Academy of Dermatology, a cold sore is a fluid-filled blister or cluster of blisters that is typically brought on by the herpes simplex virus (HSV) and typically appears on your lips or around your mouth (AAD). Fever blisters, oral herpes, mouth herpes, and herpes labialis are further names for these blisters.

According to board-certified dermatologist Ife J. Rodney, M.D., founding director of Eternal Dermatology + Aesthetics and professor of dermatology at Howard University and George Washington University, a cold sore may initially present as a small amount of skin crusting.

They are therefore not always clear. The board-certified ob-gyn and New York practice director for the Colorado Center for Reproductive Medicine, Brian A. Levine, M.D., tells us that sometimes people contract herpes and develop a cold sore without realizing what it is. He describes the typical herpetic lesion as looking like a thin layer of dew or rain on top of the skin. “When it ruptures, you get a crater and crustiness,” the speaker said.

What causes cold sores? And are all cold sores herpes-related?

It’s crucial to understand that not all mouth sores are brought on by herpes. According to the U.S. National Library of Medicine, Behcet’s illness, a rare disorder that can resemble herpes in appearance and cause mouth sores, is one example.

Having said that, herpes is related to what we typically refer to as cold sores. But, Jamil Abdur-Rahman, M.D., a board-certified obstetrician and chairman of obstetrics and gynecology at Vista East Medical Center in Waukegan, Illinois, tells SELF that it’s not necessarily true that herpes simplex 1 (HSV-1) causes cold sores and herpes simplex 2 (HSV-2) causes genital outbreaks. Even when his patients are aware of the etiology of their cold sores, he explains, they still believe that the sort of herpes that results in cold sores is distinct from genital herpes. They are unaware that both types might result in genital or oral herpes.

The HSV-1 and HSV-2 viruses can affect your mouth or genitalia, so yes. You can observe HSV-2 in the mouth area and HSV-1 in the genital area because of sexual behaviors including oral sex, according to Dr. Rodney. It’s not fixed in stone.

The herpes virus manifests itself on the skin as cold sores, he continues. Many associate herpes with stigma and fear when they hear the word, but the HSV-1 virus is typically to blame. It’s incredibly typical. Nothing to be embarrassed about.

According to Dr. Abdur-Rahman, some people even want a swab test that identifies the type of herpes they have when they are unsure of how they contracted it. He clarifies, however, that “testing positive for type 2 only indicates that the herpes is brought on by the virus that often causes genital herpes. It doesn’t imply that you didn’t acquire it through romantic kissing. Herpes is not always sexually transmitted, but intimate contact, such as kissing and oral sex, is frequently how people get cold sores. According to the Mayo Clinic, sharing towels, razors, and dining utensils can also spread the illness.

Practically speaking, it doesn’t really matter where your herpes manifests itself; regardless of whatever strain caused it or how you contracted it, wherever it manifests itself is where it manifests itself. No matter which strain you have, it’s important to understand that if you have herpes, you can transmit it to someone else through kissing or oral sex. According to the Mayo Clinic, cold sores are contagious, especially if you’re going through a flare-up and have an oozing blister.

What are common cold sore symptoms to be aware of?

At least in the beginning before the blister opens up, people may mistake a cold sore for a canker sore, an angry noncontagious lesion unrelated to herpes, or an excruciatingly painful pimple. According to the Mayo Clinic, the following cold sore symptoms are typical:

Lip tingling, burning, and itching
a tiny, hard area that hurts.
You have a few tiny, fluid-filled blisters on the edge of your lips.
crusting and oozing

Before the cold sore really emerges, you could occasionally experience discomfort and tingling in the area, according to Dr. Rodney. Moreover, cold sores frequently appear in the same area or site each time. According to Dr. Rodney, if you typically develop cold sores on your right upper lip, they will likely return in the same location in the future.

The initial occurrence of cold sores can cause slightly different symptoms, though. According to the AAD, this initial infection often occurs during childhood and can cause the symptoms listed below in addition to those already mentioned:

Fever
Headache
muscle pain
enlarged lymph nodes
Nausea
unwell throat
difficulty swallowing

Why do some cold sores come out of nowhere?

The strange thing about cold sores is that you might have HSV-1 or HSV-2 infection and not show any symptoms for years. In fact, depending on your physiology, some people may only experience one or two cold sores in their lifetime while others may experience dozens.

Many of my patients have expressed concern that their partner may have cheated on them after suddenly developing a cold sore, according to Dr. Rodney. Yet that’s not the case—they just experienced their first apparent outbreak in adulthood.

This is due to the virus’s dormant state in the nerve cells of your skin, which causes it to only become active when provoked. According to the Mayo Clinic, a number of various factors, including a viral infection or fever, hormonal changes, stress, weariness, exposure to sunshine and wind, immune system changes, or a skin injury, can cause these recurrences. Hence, if you have a cold sore, it won’t likely be noticeable permanently.

Can you have herpes with no symptoms at all?

Most herpes sufferers are unaware that they have the disease. According to the World Health Organization, approximately two thirds of the world’s population under 50 has HSV-1, and the CDC estimates that one in every six Americans between the ages of 14 and 49 has genital herpes. In fact, because to its prevalence, herpes is frequently not even tested for during the standard STI workup.

This is due to the fact that neither the diagnosis of genital herpes in a person without symptoms nor the prevention of the virus’ transmission have resulted in any modification of that person’s sexual behavior (such as the use of a condom or the avoidance of sex). Moreover, false-positive test results—test results that indicate you have herpes when you do not—are conceivable.

How to prevent the spread of herpes

For safe sex, barrier techniques like a condom are essential. But, condoms do not completely prevent against herpes, therefore you need also take some other precautions. Dr. Abdur-Rahman advises patients to exercise extreme caution: “Don’t kiss anyone and don’t have any oral intercourse if you have oral herpes and you have an outbreak,” he says. “You shouldn’t have sex or oral sex either if you have a genital herpes outbreak.”

When you have an active cold sore, you should also refrain from sharing personal objects like towels, lip balm, or eating utensils. You can also make an effort to prevent your triggers from happening, the Mayo Clinic advises. For example, if spending a day in the sun usually results in a new blister, be sure to use lots of sunscreen in that area.

Nevertheless, the reality is that you can spread the virus even if there isn’t a current outbreak. You can take antiviral medications like Valtrex, which, according to Dr. Levine, decreases your viral load if you frequently suffer with herpes symptoms and promptly controls outbreaks, decreasing your risk of spreading the disease to others. But, that does not imply that while taking the medication, you cannot spread it to someone else.

That contributes to both the prevalence of herpes and the needless stigma associated with it. Depending on your situation, there’s a strong chance that you either already have herpes in some form without knowing it or might have it in the future. Either way, it’s okay. There are a lot of people right there with you, as you can see.