What is the recommended antiviral treatment for hand, foot, and mouth disease?

Hand, Foot, and Mouth Disease: No Antiviral Treatment Recommended

There is no approved or recommended antiviral treatment for hand, foot, and mouth disease—management is entirely supportive with pain control and hydration. 1, 2

Why No Antiviral Therapy?

The evidence is clear and consistent across all guidelines:

• No antiviral agents are currently approved for treating HFMD, despite the disease being caused by enteroviruses (primarily coxsackievirus A16 and enterovirus A71) 2
• While experimental drugs like ribavirin, suramin, mulberroside C, aminothiazole analogs, and sertraline have emerged as potential candidates in research settings, none are approved for clinical use 3
• The disease is self-limited in the vast majority of cases, resolving in 7-10 days without sequelae, making antiviral development less of a priority 2, 3

Recommended Treatment Approach

For Mild Cases (>95% of patients)

Symptomatic management only:

• Oral analgesics: Acetaminophen or NSAIDs for limited duration to relieve pain and reduce fever 1
• Hydration support: Critical given painful oral lesions may reduce oral intake 1
• Oral care: Mild toothpaste and gentle oral hygiene 1
• Avoid oral lidocaine: Not recommended despite common use 2

For Severe Cases with Neurological Complications

Escalate to immunomodulatory therapy:

• Intravenous immunoglobulin (IVIG) should be considered for severe/complicated HFMD and is recommended by several national and international guideline committees 3
• Glucocorticoid therapy is commonly used alongside IVIG for neurological complications 4
• These interventions are reserved for patients with meningoencephalitis, brainstem encephalitis, or other severe neurological manifestations (primarily EV-A71 cases) 4, 5

Critical Warning Signs Requiring Escalation

Watch for these indicators of deterioration that warrant intensive treatment (not antivirals, but IVIG/steroids):

• Persistent hyperthermia despite antipyretics 5
• Nervous system involvement (myoclonic jerks, seizures, altered consciousness) 4, 5
• Worsening respiratory rate and rhythm 5
• Circulatory dysfunction 5
• Elevated peripheral WBC count, blood glucose, or lactic acid 5

Children under 3 years with EV-A71 infection and disease duration less than 3 days are highest risk 5

Common Pitfalls to Avoid

• Do not prescribe oral lidocaine for oral pain—it is specifically not recommended despite intuitive appeal 2
• Do not use topical antivirals (like acyclovir)—HFMD is not caused by herpes viruses 1
• Do not delay recognition of severe cases waiting for antiviral options that don't exist—early IVIG/steroid intervention for neurological complications is what saves lives 4, 3
• Do not confuse this with herpes simplex virus which does have antiviral treatment options 6

The mortality in severe HFMD comes from circulatory failure secondary to myocardial impairment and neurogenic pulmonary edema from brainstem damage—not from lack of antivirals, but from delayed recognition and supportive/immunomodulatory intervention 3