What is the best approach for managing a reactivation of hand, foot, and mouth disease (HFMD)?

Reactivation of Hand, Foot, and Mouth Disease

Hand, foot, and mouth disease (HFMD) does not truly "reactivate" like herpes viruses do, as enteroviruses causing HFMD do not establish latent infections—what appears as recurrence is typically reinfection with a different enterovirus strain or, rarely, prolonged viral shedding from the initial infection. 1, 2

Understanding the Clinical Scenario

The concept of "reactivation" is a misnomer for HFMD because:

• Enteroviruses (coxsackieviruses and enterovirus 71) do not remain dormant in the body like herpes simplex virus or varicella zoster virus 1, 2
• Multiple different enterovirus strains circulate simultaneously, so a child can develop HFMD more than once from different causative agents 3, 4
• Viral shedding can persist for weeks after symptom resolution (particularly in stool), which may be confused with reactivation 1, 2

Management Approach for Recurrent or Persistent HFMD Symptoms

Initial Assessment

When a patient presents with what appears to be recurrent HFMD, immediately:

• Distinguish HFMD from herpes simplex virus, as HSV has available antiviral treatment options while HFMD does not 1
• Assess for severe disease indicators: fever, neurological symptoms (headache, altered mental status, weakness), cardiopulmonary symptoms, or signs of dehydration 5, 6
• Identify the causative strain if possible through RT-PCR of vesicle fluid (highest viral load), respiratory samples, or stool specimens targeting the 5' non-coding region 1, 4

Supportive Care Measures

For oral lesions:

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

For hand and foot lesions:

• Apply intensive moisturizing creams containing urea to hands and feet 1
• Use zinc oxide as a protective barrier on itchy lesions—apply in a thin layer after gentle cleansing, repeating as needed 1
• For nighttime relief, apply zinc oxide followed by loose cotton gloves to create an occlusive barrier 1
• Avoid friction and heat exposure to affected areas 1

For open sores on feet:

• Wash feet daily with careful drying between toes 1
• Avoid walking barefoot and wear appropriate cushioned footwear 1
• Do not soak feet in footbaths, as this induces skin maceration and worsens open sores 1
• Monitor for signs of secondary bacterial infection: increased redness, warmth, purulent drainage, or worsening pain 1

Pain and Fever Management

• Use oral acetaminophen or NSAIDs for limited duration to relieve pain and reduce fever 1, 2
• Oral lidocaine is not recommended 2

Special Considerations

For immunocompromised patients:

• Monitor closely for more severe disease and complications 1
• Consider earlier intervention and lower threshold for hospitalization 5

For coxsackievirus A6 infections:

• Be aware this strain causes more severe, widespread eruptions with targetoid vesicles, purpuric lesions, and involvement beyond classic distribution (scalp, ears, face, legs) 5, 4
• These patients may require hospitalization for supportive care, particularly if fevers, joint pains, or neurologic symptoms develop 5

For enterovirus 71 infections:

• Recognize higher risk of severe complications including encephalitis, meningitis, acute flaccid paralysis, and cardiopulmonary failure 1, 6, 4
• Intravenous immunoglobulin should be considered for severe/complicated cases 6

When to Reassess or Escalate Care

• Reassess after 2 weeks if lesions are not improving with standard care 1
• Immediately escalate for neurological complications (encephalitis, meningitis, acute flaccid myelitis/paralysis) or cardiopulmonary symptoms 1, 6, 4
• Activate emergency protocols ("Code DFI" concept can be adapted) for rapidly progressive severe disease 7

Prevention of Future Episodes

• Hand hygiene is the most important preventive measure—thorough handwashing with soap and water is more effective than alcohol-based sanitizers 1
• Environmental cleaning of toys and objects that may be placed in children's mouths 1
• Avoid sharing utensils, cups, or food 1
• Children can return to daycare once fever resolves and mouth sores heal, even if skin rash persists 1

Common Pitfalls to Avoid

• Do not use topical antiseptic or antimicrobial dressings routinely for HFMD foot lesions, as these are not recommended for wound healing 1
• Do not use chemical agents or plasters to remove corns or calluses on affected areas 1
• Do not exclude children from daycare based solely on healing skin lesions after fever and oral lesions have resolved 1
• Do not assume antiviral treatment is available—there are no approved specific antiviral agents for HFMD 2, 6