What is the management approach for hand, foot, and mouth disease (HFMD) in a child?

Management of Hand, Foot, and Mouth Disease in Children

Hand, foot, and mouth disease (HFMD) in children is primarily managed with supportive care including oral analgesics for pain and fever control, intensive hand hygiene with soap and water, and symptomatic treatment of oral lesions. 1

Supportive Care and Pain Management

• Use acetaminophen or NSAIDs for pain relief and fever reduction for a limited duration to manage discomfort from oral and skin lesions 1
• Most mild cases can be treated as outpatients with isolation to avoid cross-infection 2
• The disease typically resolves spontaneously in 7-10 days without sequelae 3

Oral Lesion Management

For painful mouth sores that interfere with eating and drinking:

• Apply white soft paraffin ointment to the lips every 2 hours to prevent drying and cracking 1, 4
• Use benzydamine hydrochloride oral rinse or spray every 3 hours, particularly before eating, to reduce inflammation and pain 1, 4
• Clean the mouth daily with warm saline mouthwashes or use an oral sponge for comfort 1, 4
• Consider chlorhexidine oral rinse twice daily as an antiseptic measure 1, 4
• For more severe oral involvement, use betamethasone sodium phosphate mouthwash four times daily 1, 4
• Maintain gentle oral hygiene with mild toothpaste 1

Skin Lesion Management

For hand and foot lesions:

• Apply intensive moisturizing creams containing urea to hands and feet 1
• Zinc oxide can be applied as a protective barrier to soothe inflamed areas and reduce itchiness, repeated as needed when itchiness returns 1
• Apply zinc oxide in a thin layer after gentle cleansing of affected areas 1
• For nighttime relief, apply zinc oxide followed by loose cotton gloves to create an occlusive barrier 1
• Avoid applying zinc oxide to open or weeping lesions 1
• Avoid friction and heat exposure to affected areas 1

For open sores on feet:

• Wash feet daily with careful drying, particularly between the toes 1
• Avoid walking barefoot and wear appropriate cushioned footwear to protect open lesions 1
• Do not soak feet in footbaths, as this can induce skin maceration and worsen open sores 1
• Monitor for signs of secondary bacterial infection including increased redness, warmth, purulent drainage, or worsening pain 1

Infection Control and Prevention

Hand hygiene is the single most important preventive measure:

• Thorough handwashing with soap and water is more effective than alcohol-based hand sanitizers for HFMD prevention 1
• Hands should be washed before and after each patient encounter 5
• Environmental cleaning, particularly of toys and objects that may be placed in children's mouths, is crucial 1
• Avoid sharing utensils, cups, or food 1

Return to Daycare/School Criteria

Children can return to daycare once:

• Fever has resolved AND mouth sores have healed, even if skin rash is still present 1
• Exclusion based solely on healing skin lesions is not necessary 1
• By the time HFMD is diagnosed, the child has likely had the infection for weeks, posing limited additional risk to others 1

Warning Signs Requiring Urgent Evaluation

Monitor closely for severe disease indicators, particularly in children under 3 years with EV-A71 infection and disease duration less than 3 days: 2

• Persistent hyperthermia 2
• Involvement of nervous system (altered mental status, seizures, weakness) 2
• Worsening respiratory rate and rhythm 2
• Circulatory dysfunction 2
• Elevated peripheral WBC count 2
• Elevated blood glucose 2
• Elevated blood lactic acid 2

Severe complications can include:

• Encephalitis/meningitis 1, 6
• Acute flaccid myelitis or paralysis 1
• Neurogenic pulmonary edema 3, 2
• Myocardial impairment with circulatory failure 3

Special Considerations

• Immunocompromised patients may experience more severe disease and should be monitored closely 1
• Intravenous immunoglobulin should be considered for severe/complicated HFMD 3
• Nail dystrophies (Beau's lines or nail shedding) may occur weeks after initial symptom onset 7
• Currently, there are no specific antiviral agents approved for routine treatment 3

Common Pitfalls to Avoid

• Do not use topical antiseptic or antimicrobial dressings routinely for HFMD foot lesions 1
• Do not use chemical agents or plasters to remove corns or calluses 1
• Do not rely solely on alcohol-based hand sanitizers; soap and water is superior for HFMD prevention 1
• Reassess after 2 weeks if lesions are not improving with standard care 1