Can hand foot mouth disease (HFMD) cause lesions on the palms and soles?

Hand, Foot, and Mouth Disease Typically Presents with Lesions on Palms and Soles

Yes, hand, foot, and mouth disease (HFMD) characteristically causes lesions on the palms of hands and soles of feet, along with oral lesions. 1, 2

Clinical 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 young children 1
• The characteristic rash typically appears 1-2 days after fever onset 2
• HFMD presents with a classic triad of:
  • Painful oral enanthem (mouth lesions) 2
  • Cutaneous eruptions (exanthem) on the palms 3
  • Cutaneous eruptions on the soles 3

Rash Characteristics

• The exanthem typically begins as small, pink macules that evolve to vesicular lesions 4
• Lesions are usually asymptomatic on the hands and feet but painful in the mouth 2
• The distribution on palms and soles is highly characteristic but not pathognomonic 4
• In some cases, especially with certain strains like Coxsackievirus A6, the rash may extend beyond the classic distribution to include limbs, buttocks, and trunk 5

Causative Agents

• Most commonly caused by enteroviruses, particularly:
  • Coxsackievirus A16 (traditional cause) 3
  • Enterovirus 71 (associated with more severe disease and neurological complications) 3
  • Coxsackievirus A6 (emerging cause with potentially more widespread distribution of lesions) 5

Differential Diagnosis

• A rash on the palms and soles is not unique to HFMD and can occur in other conditions including: 4
  • Drug hypersensitivity reactions
  • Infective endocarditis
  • Syphilis (Treponema pallidum)
  • Meningococcal infection (Neisseria meningitidis)
  • Streptobacillus moniliformis infection
  • Ehrlichiosis (E. chaffeensis)
  • Certain enteroviral infections
  • Rocky Mountain spotted fever (though this typically presents with petechial rash) 4

Disease Course and Management

• HFMD is typically self-limited, resolving within 7-10 days without sequelae 2
• Treatment is mainly symptomatic and supportive 2
• Unlike some other conditions with palm/sole involvement, HFMD does not typically require specific antiviral treatment in immunocompetent hosts 6
• Complications are rare in typical cases but can include nail changes that appear after a latency period 6

Special Considerations

• While HFMD primarily affects children under 5 years, adult cases are increasingly recognized, especially with Coxsackievirus A6 5
• Atypical presentations may occur in patients with underlying skin conditions like atopic dermatitis ("eczema coxsackium") 6
• More severe disease with systemic manifestations is associated with Enterovirus 71, particularly in epidemic outbreaks in Asia 3, 2

Understanding the characteristic distribution of HFMD lesions on the palms and soles helps distinguish it from other viral exanthems, though clinicians should be aware of atypical presentations and the expanding spectrum of disease manifestations.