How do I differentiate and treat hand, foot, and mouth disease (HFMD) versus a wart?

Differentiating and Treating Hand, Foot, and Mouth Disease vs. Warts

Hand, foot, and mouth disease (HFMD) is a viral illness characterized by fever, painful oral lesions, and vesicular rash on hands, feet, and sometimes buttocks, while warts (verruca vulgaris) are benign epithelial proliferations caused by human papillomavirus that typically appear as painless, multiple growths on hands, feet, and around nails. 1, 2

Clinical Features for Differentiation

Hand, Foot, and Mouth Disease

• Acute onset with fever as a common constitutional symptom 2
• Painful oral enanthem (ulcers/vesicles in the mouth) 3
• Vesicular rash on palms, soles, and sometimes buttocks that develops within days to weeks 2, 4
• May present with widespread exanthema beyond classic distribution (hands, feet, mouth), involving legs and other areas 2, 4
• Typically affects children under 5 years of age 5, 3
• Self-limited disease that usually resolves in 7-10 days 3, 6

Warts (Verruca Vulgaris)

• Typically painless, multiple growths on epithelial surfaces, most commonly on hands, feet, and around/under nails 1
• No associated fever or systemic symptoms 1
• Slow-growing with gradual onset 1
• May persist for months to years if untreated 1
• 30% regress spontaneously within 6 months and approximately 60% within 2 years 1

Diagnostic Approaches

For Hand, Foot, and Mouth Disease

• Primarily a clinical diagnosis based on characteristic distribution of lesions 2, 3
• Laboratory confirmation can be achieved through:
  • Vesicle fluid samples (ideal) for reverse transcriptase PCR (RT-PCR) 2
  • Respiratory samples or stool specimens for RT-PCR 2

For Warts

• Clinical diagnosis based on appearance of lesions 1
• No specific laboratory tests typically needed 1

Treatment Approaches

For Hand, Foot, and Mouth Disease

• Supportive care is the mainstay of treatment as the condition is typically self-limited 2, 3
• Manage symptoms with:
  • Oral analgesics such as acetaminophen or NSAIDs for pain relief and fever reduction 2
  • Mild toothpaste and gentle oral hygiene for oral lesions 2
  • Moisturizing creams for skin manifestations 2
  • Zinc oxide may help reduce itchiness by forming a protective barrier on skin lesions 2
• Avoid sharing utensils, cups, or food to prevent spread 2

For Warts

• Many cases will spontaneously regress without treatment 1
• Treatment options include:
  • Chemical destruction: Salicylic acid-based products or tretinoin cream 1
  • Physical destruction: Freezing with liquid nitrogen (cryotherapy) 1
  • Surgical or laser removal for resistant cases 1
  • Topical immunomodulating agents 1
  • More recently, cantharidin combined with podophyllotoxin-salicylic acid (though may cause pain and blistering) 1

Prevention Strategies

For Hand, Foot, and Mouth Disease

• Hand hygiene is the most important preventive measure (thorough handwashing with soap and water) 2
• Environmental cleaning, particularly of toys and objects that may be placed in children's mouths 2
• Children should avoid close contact with others until fever resolves and mouth sores heal 2

For Warts

• Precise prevention mechanisms are unknown 1
• Avoid sharing equipment that may come in contact with warts 1
• Cover active lesions to reduce transmission risk 1

Return to School/Daycare Guidelines

For Hand, Foot, and Mouth Disease

• Children can return once fever has resolved and mouth sores have healed, even if skin rash is still present 2
• By the time HFMD is diagnosed, the child has likely had the infection for weeks, posing limited additional risk to others 2

For Warts

• No specific exclusion criteria; children with warts can generally attend school/daycare 1

Special Considerations and Complications

For Hand, Foot, and Mouth Disease

• Neurological complications (encephalitis/meningitis, acute flaccid myelitis) can occur in severe cases, particularly with Enterovirus 71 2, 3
• Immunocompromised patients may experience more severe disease 2

For Warts

• More destructive treatment methods may lead to pain that could inhibit athletic activity 1
• Warts may occur in outbreaks among athletes 1

Clinical Pearls

• HFMD is typically acute with systemic symptoms, while warts are chronic and localized 1, 2
• HFMD lesions are painful and resolve within days to weeks; warts are usually painless and may persist for months to years 1, 3
• HFMD requires mainly supportive care, while warts often need destructive therapies for resolution 1, 2