What are the management strategies for hand foot mouth disease?

Management of Hand, Foot, and Mouth Disease

Hand, foot, and mouth disease requires supportive care focused on pain relief and hydration, with acetaminophen or NSAIDs for analgesia, intensive skin moisturization, and specific oral hygiene measures, while monitoring for rare but serious neurological and cardiopulmonary complications. 1

Symptomatic Pain and Fever Management

• Use oral acetaminophen or NSAIDs for a limited duration to relieve pain and reduce fever 1
• Avoid oral lidocaine, as it is not recommended for HFMD 2
• No antiviral treatment is available for HFMD, unlike herpes simplex virus which has antiviral options 1, 2

Oral Lesion Management

The mouth sores are often the most painful aspect of HFMD and require aggressive local care:

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

Skin and Foot Lesion Care

For Intact Skin Lesions:

• Apply intensive skin care with moisturizing creams, particularly urea-containing products, to hands and feet 1
• Avoid friction and heat exposure to affected areas 1
• Apply zinc oxide in a thin layer to soothe inflamed areas and reduce itchiness, which can be repeated as needed 1
• For nighttime relief, apply zinc oxide followed by loose cotton gloves to create an occlusive barrier 1
• Avoid chemical agents or plasters to remove corns or calluses 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 induces skin maceration and worsens open sores 1
• Avoid applying zinc oxide to open or weeping lesions 1
• Do not use topical antiseptic or antimicrobial dressings routinely, as these are not recommended for wound healing 1

Hydration Support

• Focus on maintaining adequate hydration, as painful oral lesions may limit oral intake 2
• This is particularly critical in young children who may refuse to eat or drink 3

Monitoring for Complications

While most cases are benign and self-limited, certain red flags require immediate attention:

• Monitor immunocompromised patients closely, as they may experience more severe disease 1
• Watch for neurological complications including encephalitis/meningitis, acute flaccid myelitis, and acute flaccid paralysis, particularly with Enterovirus 71 1
• Monitor for signs of secondary bacterial infection: increased redness, warmth, purulent drainage, or worsening pain 1
• Be alert for cardiopulmonary complications in severe cases 1, 4
• Reassess after 2 weeks if lesions are not improving with standard care 1

Severe/Complicated Disease

• Consider intravenous immunoglobulin for severe or complicated HFMD, as recommended by several national and international guideline committees 3
• Mechanical ventilation may be necessary in severe cases with respiratory complications 4

Infection Control and Return to Activities

Prevention Measures:

• Handwashing with soap and water is the most important preventive measure and is more effective than alcohol-based hand sanitizers 1
• Clean toys and objects that may be placed in children's mouths 1
• Avoid sharing utensils, cups, or food 1
• Disinfect potentially contaminated surfaces and fomites 2

Return to Daycare/School:

• 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

Important Diagnostic Consideration

• Distinguish HFMD from herpes simplex virus, as HSV has available antiviral treatment options 1
• If diagnostic confirmation is needed, RT-PCR of vesicle fluid (preferred), respiratory samples, or stool specimens can be performed 1

Common Pitfalls to Avoid

• Do not prescribe oral lidocaine for pain management 2
• Do not exclude children from daycare based solely on persistent skin lesions after fever and oral lesions have resolved 1
• Do not use chemical corn/callus removers on HFMD lesions 1
• Do not routinely apply topical antimicrobials to foot lesions 1