What is the diagnosis, management, and treatment of hand-foot-mouth disease?

Hand-Foot-and-Mouth Disease: Diagnosis, Management, and Treatment

Hand-foot-and-mouth disease (HFMD) is a self-limited viral illness requiring supportive care only—do not prescribe corticosteroids as they suppress the necessary immune response for viral clearance and may increase risk of severe complications and death. 1

Clinical Presentation

Classic Features

• Fever is a common constitutional symptom that typically precedes the rash 2
• Oral lesions (herpangina) with painful vesicles and ulcers on the tongue, gums, and buccal mucosa 3
• Papulovesicular rash on the palms of hands and soles of feet 4
• Duration: Symptoms typically resolve within 7-10 days 5

Atypical Presentations (Particularly with Coxsackievirus A6)

• Widespread exanthema extending beyond classic distribution to involve the legs, arms, trunk, and buttocks 2, 5
• Higher fever and longer disease duration compared to typical HFMD 5
• "Eczema coxsackium" in children with atopic dermatitis, where eczematous skin becomes superinfected with coxsackievirus, resembling herpes infection 3
• Nail changes (Beau's lines or nail shedding) occurring weeks after initial symptom onset 4
• Adult involvement is more common with CVA6 strains 5

Causative Agents

• Coxsackievirus A16 and Enterovirus 71 (EV-A71) are traditional causes 5, 6
• Coxsackievirus A6 (CVA6) has become a major cause of outbreaks in the United States and worldwide since 2011, associated with more severe and atypical presentations 5, 4
• EV-A71 is associated with more severe outbreaks, especially in Asia, with potential neurological complications 2

Diagnosis

Clinical Diagnosis

HFMD is diagnosed clinically based on the characteristic distribution of oral and cutaneous lesions 3

Laboratory Confirmation (When Needed)

• Reverse transcriptase PCR (RT-PCR) targeting the 5' non-coding region is the preferred diagnostic method due to its sensitivity and specificity 2
• Vesicle fluid samples have the highest viral loads and are ideal for testing 2
• Respiratory samples and/or stool specimens can also be used for diagnosis 2

Critical Differential Diagnosis

It is crucial to distinguish HFMD from herpes simplex virus infection, as HSV has available antiviral treatment options whereas HFMD does not 2

Severe Complications to Monitor For

• Neurological complications: encephalitis/meningitis, acute flaccid myelitis (AFM), acute flaccid paralysis (AFP)—particularly with EV-A71 2, 6
• Cardiopulmonary complications in severe cases 6
• Immunocompromised patients may experience more severe disease and require close monitoring 2

Treatment

Supportive Care (Mainstay of Treatment)

Pain and Fever Management

• Oral analgesics such as acetaminophen or NSAIDs for a limited duration to relieve pain and reduce fever 2

Oral Lesion Management

• White soft paraffin ointment applied to the lips every 2 hours to prevent drying and cracking 2
• Warm saline mouthwashes or oral sponge for daily mouth cleaning 2
• Benzydamine hydrochloride oral rinse or spray every 3 hours, particularly before eating, to reduce inflammation and pain 2, 1
• Chlorhexidine oral rinse twice daily as an antiseptic measure 2
• Betamethasone sodium phosphate mouthwash four times daily for more severe oral involvement 2
• Mild toothpaste and gentle oral hygiene practices 2

Skin Lesion Management

• Intensive moisturizing care of hands and feet with urea-containing creams/ointments 2, 1
• Avoid friction and heat exposure to affected areas 2
• Zinc oxide can be applied as a protective barrier for itchy skin lesions in a thin layer after gentle cleansing 2, 1
  • Apply to intact skin, avoiding open or weeping lesions 2
  • Can be repeated as needed when itchiness returns 2
  • For nighttime relief, consider applying zinc oxide followed by loose cotton gloves 2

Management of Open Sores on Feet

• Wash feet daily with careful drying, particularly between the toes 2
• Avoid walking barefoot and wear appropriate cushioned footwear to protect open lesions 2
• Do not soak feet in footbaths, as this can induce skin maceration and worsen open sores 2
• Monitor for signs of secondary bacterial infection: increased redness, warmth, purulent drainage, or worsening pain 2
• Treat any secondary bacterial infections that develop 2
• Reassess after 2 weeks if lesions are not improving with standard care 2

What NOT to Do

Critical Pitfall: Do not prescribe corticosteroids for HFMD based on the presence of inflammation or fever, as they suppress the necessary immune response for viral clearance and may increase the risk of severe complications and death 1

• Do not use topical antiseptic or antimicrobial dressings routinely for HFMD foot lesions 2
• Do not use chemical agents or plasters to remove associated corns or calluses 2

Prevention and Control

Hand Hygiene (Most Important Preventive Measure)

• Thorough handwashing with soap and water is more effective than alcohol-based hand sanitizers 2

Environmental Measures

• Clean toys and objects that may be placed in children's mouths 2
• Avoid sharing utensils, cups, or food 2

Isolation 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
• By the time HFMD is diagnosed, the child has likely had the infection for weeks, posing limited additional risk to others 2
• In healthcare settings, follow standard precautions and good hand hygiene practices 2

Common Pitfalls to Avoid

• Misdiagnosing atypical HFMD as chickenpox, impetigo, or vasculitis due to variable morphological characteristics of lesions 7
• Prescribing corticosteroids thinking they will reduce inflammation—this is contraindicated 1
• Failing to distinguish from herpes simplex virus, which has specific antiviral treatment options 2
• Not monitoring for neurological complications in severe cases, particularly with EV-A71 2