What are the signs and symptoms of Hand, Foot, and Mouth Disease (HFMD)?

Signs and Symptoms of Hand, Foot, and Mouth Disease (HFMD)

Hand, Foot, and Mouth Disease (HFMD) typically presents with fever, characteristic oral lesions, and vesicular rashes on the hands, feet, and sometimes other body areas. 1

Initial Presentation

• Fever is usually the first symptom, typically low-grade but can exceed 102.2°F (39°C), often accompanied by malaise, general discomfort, sore throat, and irritability in toddlers 2
• Respiratory symptoms such as cough and rhinitis may accompany the classic presentation, especially in younger children 2
• Gastrointestinal symptoms including nausea, vomiting, and diarrhea are occasionally reported 2, 3
• Incubation period ranges from 3 to 10 days before symptoms appear 3

Characteristic Skin Manifestations

• Maculopapular or vesicular eruptions develop on the palms and soles a few days after fever onset 3
• Lesions typically appear as small vesicles on an erythematous base 1
• Distribution classically involves hands, feet, and oral cavity, but can spread to legs and other body areas 1
• Skin lesions may be pruritic and painful 4
• Atypical presentations can include more widespread exanthema beyond the classic distribution 1, 5

Oral Manifestations

• Oral lesions appear as vesicles that rapidly ulcerate, causing significant pain 1
• Lesions typically affect the tongue, gums, and buccal mucosa 3
• Oral pain may lead to decreased oral intake and risk of dehydration 1

Disease Course and Duration

• Symptoms typically last 7-10 days in uncomplicated cases 4
• Fever usually resolves within 3-4 days 2
• Skin lesions heal without scarring in most cases 1

Atypical Presentations

• Coxsackievirus A6 (CVA6) can cause atypical HFMD with more severe presentations including:
  • Gianotti-Crosti-like eruptions
  • Eczema coxsackium (vesicular lesions at sites of existing eczema)
  • Petechial/purpuric eruptions
  • Vesiculobullous exanthema 5
• Adult cases are increasingly recognized, particularly with CVA6 infections, with more severe and widespread skin manifestations 4
• Onychomadesis (nail shedding) may occur 1-2 months after initial infection 3

Distinguishing Features from Similar Conditions

• Unlike Kawasaki disease, HFMD presents with vesicular lesions rather than diffuse erythema 2
• Unlike chickenpox, HFMD vesicles are typically concentrated on hands, feet, and mouth rather than being widely distributed 2
• HFMD does not typically present with the high, persistent fever seen in more serious conditions like Kawasaki disease 2

Potential Complications

• Most cases are self-limiting without complications 3
• Severe cases, particularly those caused by Enterovirus 71 (EV-A71), may develop neurological complications:
  • Encephalitis/meningitis
  • Acute flaccid myelitis
  • Acute flaccid paralysis 1
• Cardiopulmonary complications can occur in rare severe cases 6

Clinical Pearls

• The disease is highly contagious, with transmission occurring through direct contact with nasal discharge, saliva, fluid from vesicles, or feces of infected individuals 7
• Children under 5 years are most commonly affected, but adults can also contract the disease 4
• Multiple family members may be affected due to high household transmission rates 7
• Laboratory confirmation can be achieved through RT-PCR testing of vesicle fluid, respiratory samples, or stool specimens 1