What are the evaluation and management strategies for hand foot and mouth disease?

Evaluation and Management of Hand, Foot, and Mouth Disease

Clinical Presentation and Diagnosis

Hand, foot, and mouth disease (HFMD) is typically a self-limited viral syndrome that resolves within 7-10 days without specific treatment, requiring primarily supportive care focused on hydration and pain management. 1

HFMD is characterized by:

• Low-grade fever
• Painful oral ulcerations/enanthem (often the first clinical sign)
• Maculopapular or papulovesicular rash primarily affecting:
  • Hands (palms)
  • Feet (soles)
  • Sometimes buttocks
• Constitutional symptoms (malaise, decreased appetite)

Diagnostic Approach

• Diagnosis is primarily clinical based on characteristic presentation
• Laboratory testing is generally unnecessary but may include:
  • Viral panel testing for human rhinovirus/enterovirus when diagnosis is uncertain 2
  • Samples from vesicle fluid, throat, or stool may be collected in atypical or severe cases

Causative Agents

• Human enteroviruses and coxsackieviruses
• Coxsackievirus A16 is most common in typical cases
• Enterovirus A71 is associated with more severe disease and higher complication rates 3

Management Strategy

Supportive Care (Primary Treatment)

1. Hydration management:

   • Encourage fluid intake
   • Consider cold liquids, popsicles, or ice cream to soothe oral pain
   • Avoid acidic, spicy, or hot foods/beverages that may exacerbate oral pain

2. Pain management:

   • Acetaminophen or ibuprofen as needed for pain and fever 1
   • Oral lidocaine is NOT recommended 1

3. Oral hygiene:

   • Gentle mouth rinses with warm salt water
   • Soft toothbrushes during acute phase

When to Refer to Emergency Department

While most cases are mild, emergency evaluation is indicated for:

• Signs of dehydration due to inability to swallow liquids
• Neurologic symptoms (altered mental status, confusion)
• High or persistent fever unresponsive to antipyretics
• Respiratory distress
• Rapidly progressive or extensive rash beyond typical distribution

Special Considerations

• Adults: Though less common in adults, management principles remain the same 2
• Immunocompromised patients: May require closer monitoring for complications
• Pregnant women: Should be monitored for potential complications

Complications and Prognosis

Potential Complications (Rare)

• Neurologic complications (meningitis, encephalitis)
• Cardiopulmonary complications
• Dehydration from reduced oral intake

Prognosis

• Complete resolution typically occurs within 7-10 days 2, 1
• Lesions usually heal without scarring
• Immunity to the specific viral strain develops, but reinfection with different strains is possible

Prevention and Infection Control

Prevention Strategies

• Handwashing is the most effective prevention method 1
• Disinfection of potentially contaminated surfaces and fomites
• Avoiding close contact with infected individuals
• Proper disposal of tissues and diapers from infected individuals

Transmission Control

• HFMD is transmitted via:
  • Fecal-oral contact
  • Oral-oral contact
  • Respiratory droplets
• Patients are most contagious during the first week of illness
• Children should avoid school/daycare until fever resolves and mouth sores have healed

Common Pitfalls to Avoid

1. Misdiagnosis: HFMD can be confused with other conditions including:

   • Erythema multiforme
   • Herpes simplex virus infection
   • Measles
   • Varicella (chickenpox)
   • Herpangina

2. Overtreatment: No specific antiviral treatment is currently approved for HFMD 3

3. Underestimating dehydration risk: Painful oral lesions may significantly reduce fluid intake, especially in young children

4. Delayed recognition in adults: HFMD can affect adults but may be overlooked due to its reputation as a childhood illness 2

By focusing on supportive care and appropriate infection control measures, most patients with HFMD will recover completely without complications.