How do I treat a patient with hand, foot, and mouth disease (HFMD) presenting with a sore throat and white spots on the back of their throat?

Treatment of Hand, Foot, and Mouth Disease with Pharyngeal Involvement

This patient requires supportive care only—no antibiotics, no antivirals, and reassurance about the self-limiting nature of hand, foot, and mouth disease (HFMD). 1

Confirm the Diagnosis

Before treating, verify this is actually HFMD and not bacterial pharyngitis requiring different management:

• Look for the characteristic triad: fever, painful oral ulcerations, and maculopapular or papulovesicular rash on hands and soles of feet 1
• Check for vesiculopapular lesions on buttocks, which are also common 2
• The white spots on the throat are painful oral ulcerations, not exudates from streptococcal pharyngitis 1
• If uncertain about strep throat: Use rapid antigen detection test or throat culture for Group A Streptococcus, especially if the patient has fever, tonsillar exudates, tender anterior cervical adenopathy, and absence of cough (Centor criteria ≥3) 3

Symptomatic Treatment Protocol

Pain and fever management is the cornerstone of HFMD treatment:

• Acetaminophen or ibuprofen for pain relief and fever control 1
• Do NOT use oral lidocaine in HFMD patients—it is not recommended 1
• Ensure adequate hydration, as oral pain may reduce fluid intake 1

What NOT to Do

Several critical pitfalls must be avoided:

• Do not prescribe antibiotics—HFMD is viral and antibiotics provide no benefit 1
• Do not prescribe antivirals—no antiviral treatment is currently available for clinical use in HFMD 1
• Do not confuse HFMD oral lesions with streptococcal exudates—the white spots in HFMD are painful ulcerations, not the creamy exudates seen with strep throat 3, 1

Expected Clinical Course

Set appropriate expectations with the patient:

• Lesions typically resolve in 7-10 days without intervention 1
• The disease is self-limiting in the vast majority of cases 4, 2
• Symptoms usually last less than 1 week 2

When to Escalate Care

While rare, watch for complications that require urgent evaluation:

• Neurologic complications: severe headache, altered mental status, seizures, or focal neurologic deficits 1
• Cardiopulmonary complications: respiratory distress, chest pain, or signs of myocarditis 1
• Severe dehydration: inability to maintain oral intake due to pain 1

Infection Control Measures

Given the family exposure history, counsel on prevention:

• Handwashing is the most effective prevention method 1
• Disinfect potentially contaminated surfaces and fomites 1
• HFMD transmits via fecal-oral, oral-oral, and respiratory droplet contact 1
• Outbreaks commonly occur spring through fall in North America 1

Common Diagnostic Pitfalls

The white spots on the throat can mislead clinicians into treating for bacterial pharyngitis:

• HFMD oral lesions are ulcerations, not exudates—they appear as painful vesicles that rupture, leaving shallow ulcers with white-gray bases 1
• Streptococcal exudates are creamy, confluent patches on inflamed tonsils 3
• If the patient also has hand/foot rash, this is HFMD, not strep throat 1
• The differential diagnosis includes erythema multiforme, herpes, measles, and varicella, but the characteristic distribution of lesions helps distinguish HFMD 1