What is the management approach for Hand, Foot, and Mouth Disease (HFMD)?

Management of Hand, Foot, and Mouth Disease (HFMD)

Hand, foot, and mouth disease is a self-limited viral illness that typically resolves within 7-10 days without specific treatment, and management should focus on supportive care including adequate hydration, pain relief with acetaminophen or ibuprofen, and good hygiene practices to prevent transmission.

Clinical Presentation and Diagnosis

• HFMD is characterized by:
  • Low-grade fever
  • Painful oral ulcerations/enanthem
  • Maculopapular or papulovesicular rash on hands and feet (particularly palms and soles)
  • Occasionally buttock involvement
• Most commonly affects children under 5 years of age
• Predominantly caused by enteroviruses, particularly:
  • Coxsackievirus A16 (milder cases)
  • Enterovirus A71 (associated with more severe complications) 1

Supportive Management

Pain and Fever Control

• Acetaminophen or ibuprofen for pain relief and fever reduction 2
• Avoid oral lidocaine (not recommended) 2

Hydration

• Ensure adequate fluid intake
• Cold fluids, popsicles, or ice cream may soothe oral pain and help maintain hydration
• In severe cases with significant oral pain limiting oral intake, IV hydration may be necessary

Oral Care

• Gentle oral hygiene with soft toothbrush
• Mild saltwater rinses for older children who can rinse and spit

Monitoring for Complications

Neurological Complications

• Monitor for signs of neurological involvement:
  • Persistent high fever
  • Headache
  • Vomiting
  • Myoclonic jerks or seizures
  • Altered mental status
  • Meningeal signs 3

Severe Complications

• Meningoencephalitis and brainstem encephalitis account for approximately 70% of neurological complications 3
• EV-A71 is associated with more severe disease and higher rates of complications 4
• Circulatory failure and neurogenic pulmonary edema are the main causes of death in severe cases 4

Management of Severe/Complicated HFMD

• Intravenous immunoglobulin should be considered for severe or complicated HFMD cases 4
• Glucocorticoid therapy may be beneficial in severe cases 3
• Hospital admission for:
  • Neurological complications
  • Inability to maintain hydration
  • Respiratory distress
  • Circulatory compromise

Prevention of Transmission

• Handwashing is the most effective method to prevent spread 2
• Disinfection of potentially contaminated surfaces and fomites
• Children should stay home from school/daycare until:
  • Fever resolves
  • Oral lesions heal
  • No new lesions appear for 24 hours
• Transmission occurs via:
  • Fecal-oral route
  • Oral-oral contact
  • Respiratory droplets 2

Special Considerations

• Most cases resolve within 7-10 days without sequelae 4
• No specific antiviral treatment is currently approved for HFMD 2, 4
• EV-A71 vaccine is available in China but not globally 1
• Boys appear to have higher rates of neurological complications than girls 3

When to Refer

• Persistent high fever beyond 3 days
• Signs of neurological involvement
• Inability to maintain adequate hydration
• Respiratory distress
• Unusual or severe rash distribution
• Immunocompromised patients

By following these management principles, most cases of HFMD can be effectively managed with good outcomes, while promptly identifying those rare cases requiring more intensive intervention.