What is the recommended treatment for hand, foot, and mouth disease (HFMD)?

Hand, Foot, and Mouth Disease: Clinical Presentation and Management

Clinical Presentation

Hand, foot, and mouth disease (HFMD) is a self-limited viral illness that presents with a characteristic triad: low-grade fever, painful oral ulcerations, and a maculopapular or papulovesicular rash on the palms and soles. 1

Key Clinical Features

• Constitutional symptoms: Fever is common and typically low-grade 2
• Oral manifestations: Painful ulcerative lesions develop in the oral mucosa, which are often the most distressing symptom 1, 3
• Skin findings: Vesicular or maculopapular rash appears on the palms of hands and soles of feet 1
• Atypical presentations: Widespread exanthema may extend beyond classic distribution to involve the legs and other areas 2
• Late sequelae: Nail dystrophies (Beau's lines or nail shedding) can occur weeks after initial symptom onset 4

Causative Agents and Epidemiology

• Primary pathogens: Coxsackievirus A16 is the most common cause in the United States, though coxsackievirus A6 has been associated with more severe presentations 1, 4
• High-risk pathogen: Enterovirus 71 (EV-A71), particularly genotype C4a, is associated with more severe outbreaks and neurological complications, especially in Asia 2, 3
• Age distribution: Most cases occur in children younger than 5-10 years, with 97% of neurological complications occurring in those under 15 years 1, 3
• Seasonality: Outbreaks typically occur in spring through fall in North America 1

Severe Complications (Rare but Critical to Recognize)

• Neurological complications: Meningoencephalitis and brainstem encephalitis account for 70% of neurological complications 3
• Other CNS manifestations: Acute flaccid myelitis (AFM), acute flaccid paralysis (AFP), myoclonic jerks, seizures, and convulsions 2, 3
• Cardiopulmonary complications: Circulatory failure from myocardial impairment and neurogenic pulmonary edema from brainstem damage are the main causes of death 5
• Warning signs requiring immediate evaluation: Vomiting, severe headache, myoclonic jerks, seizures, altered consciousness, or respiratory distress 3

Recommended Treatment Approach

Treatment for HFMD is entirely supportive, focusing on pain relief and hydration, as there are no approved antiviral agents for this condition. 1, 5

Primary Supportive Care

• Pain and fever management: Use oral acetaminophen or NSAIDs for a limited duration to relieve pain and reduce fever 2
• Hydration: Maintain adequate fluid intake, which can be challenging due to painful oral lesions 1
• Oral analgesics are preferred over topical agents: Oral lidocaine is NOT recommended 1

Management of Oral Lesions

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

Management of Hand and Foot Lesions

• Skin protection: Apply intensive skin care with moisturizing creams, particularly urea-containing products 2
• Avoid friction and heat exposure to affected areas 2
• For itchiness: Zinc oxide can be applied as a protective barrier after gentle cleansing, repeated as needed when itchiness returns 2
• Application technique: Apply zinc oxide in a thin layer; avoid applying to open or weeping lesions 2
• Enhanced nighttime relief: Consider applying zinc oxide followed by loose cotton gloves to create an occlusive barrier 2

Management of Open Sores on Feet

• Daily hygiene: Wash feet daily with careful drying, particularly between the toes 2
• Footwear protection: Avoid walking barefoot and wear appropriate cushioned footwear to protect open lesions 2
• Avoid foot soaking: Do not soak feet in footbaths, as this can induce skin maceration and worsen open sores 2
• Monitor for secondary infection: Watch for increased redness, warmth, purulent drainage, or worsening pain 2
• Avoid routine topical antimicrobials: Topical antiseptic or antimicrobial dressings are not recommended for routine HFMD foot lesions 2
• Treat secondary bacterial infections if they develop 2

Treatment of Severe/Complicated Cases

• Intravenous immunoglobulin (IVIG): Should be considered for severe/complicated HFMD and has been recommended by several national and international guideline committees 5
• Glucocorticoid therapy: Commonly used in conjunction with IVIG for severe neurological complications 3
• Close monitoring: Immunocompromised patients may experience more severe disease and require closer monitoring 2

Expected Clinical Course

• Resolution timeline: Lesions usually resolve in 7-10 days without sequelae 1, 5
• Reassessment: If lesions are not improving with standard care after 2 weeks, reassess the patient 2

Infection Control and Return to Activities

Prevention Measures

• Hand hygiene is the most important preventive measure: Thorough handwashing with soap and water is more effective than alcohol-based hand sanitizers 2
• Environmental cleaning: Disinfect toys and objects that may be placed in children's mouths 2, 1
• Avoid sharing: Do not share utensils, cups, or food 2

Return to Daycare/School Guidelines

• Children can return to daycare once fever has resolved and mouth sores have healed, even if skin rash is still present 2
• Exclusion based solely on healing skin lesions is not necessary 2
• Rationale: By the time HFMD is diagnosed, the child has likely had the infection for weeks, posing limited additional risk to others 2
• During illness: Children should avoid close contact with others until fever resolves and mouth sores heal 2

Transmission Considerations

• Routes of transmission: Fecal-oral, oral-oral, and respiratory droplet contact 1
• Healthcare settings: Follow standard precautions and good hand hygiene practices 2

Common Pitfalls to Avoid

• Do not use oral lidocaine for pain management 1
• Do not use chemical agents or plasters to remove corns or calluses on affected feet 2
• Do not routinely apply topical antimicrobials to HFMD lesions unless secondary bacterial infection is confirmed 2
• Do not exclude children from daycare based solely on persistent skin lesions after fever and oral lesions have resolved 2
• Do not overlook warning signs of neurological complications, particularly in EV-71 outbreaks 2, 3

Diagnostic Confirmation (When Needed)

• Preferred method: Reverse transcriptase PCR (RT-PCR) targeting the 5′ non-coding region of vesicle fluid samples, which have high viral loads 2
• Alternative samples: Respiratory samples and/or stool specimens can also be used for RT-PCR diagnosis 2
• Clinical diagnosis is usually sufficient for typical presentations in outbreak settings 1