Can you have Hand, Foot, and Mouth Disease (HFMD) without a rash on the hands and mouth?

Hand, Foot, and Mouth Disease Without Typical Rash Distribution

Yes, Hand, Foot, and Mouth Disease (HFMD) can occur without the characteristic rash on hands, feet, or in the mouth, as atypical presentations are increasingly recognized and can affect disease diagnosis and management.

Clinical Presentation of HFMD

Typical Presentation

• Classic HFMD presents with tender lesions on the hands, feet, and oral mucosa 1
• Usually accompanied by fever, which typically appears 3-5 days before the rash 2
• Most common causative agents include coxsackievirus A16 and enterovirus 71 2, 3

Atypical Presentations

• Atypical HFMD has been increasingly reported, particularly with coxsackievirus A6 infections 4, 5
• Variations in rash distribution and morphology include:
  • Vesiculobullous exanthema on the trunk or extremities 5
  • Perioral zone involvement instead of intraoral lesions 5
  • Eczema coxsackium - preferential involvement of pre-existing eczematous skin 1
  • Variable distribution that may spare the classic hand-foot-mouth locations 4

Diagnostic Considerations

When to Suspect HFMD Despite Atypical Presentation

• Fever with any vesicular or maculopapular rash, especially during summer/autumn months 2
• Recent exposure to confirmed HFMD cases, particularly in childcare settings
• Presence of oral lesions alone or skin lesions in atypical locations
• Consider HFMD in the differential diagnosis of any febrile exanthematous illness in children

Differentiating from Other Conditions

• A rash on the palms and soles is not pathognomonic and can occur in other conditions including:
  • Drug hypersensitivity reactions
  • Infective endocarditis
  • Infections with Treponema pallidum, Neisseria meningitidis, and certain enteroviruses 6

Management Approach

Treatment

• HFMD typically follows a benign and self-limiting course 5
• Management is primarily supportive:
  • Adequate hydration, especially if oral lesions limit intake
  • Antipyretics for fever control
  • Topical pain relief for oral lesions if needed

Complications to Monitor

• While rare, severe complications can occur, including:
  • Neurological complications (encephalitis, meningitis)
  • Cardiopulmonary complications
  • Nail changes (dystrophies, shedding) weeks after initial symptoms 2, 3

Prevention

• Hand hygiene and avoiding close contact with infected individuals
• Proper disinfection of contaminated surfaces
• Exclusion of symptomatic children from school/daycare until fever resolves and lesions crust over

Key Clinical Pearls

• The absence of the classic triad (rash on hands, feet, and mouth) should not exclude HFMD diagnosis
• Familial transmission can occur, affecting both children and immunocompetent adults 5
• Consider HFMD in the differential diagnosis of nail changes that appear weeks after a febrile illness 1
• Coxsackievirus A6 is increasingly associated with atypical presentations of HFMD 4, 5

Understanding that HFMD can present without the classic distribution of lesions is crucial for accurate diagnosis and appropriate management, particularly in outbreak settings where early recognition can help limit disease spread.