What is the management approach for Hand, Foot, and Mouth Disease (HFMD)?

Management of Hand, Foot, and Mouth Disease (HFMD)

HFMD management is primarily supportive, focusing on pain relief with oral analgesics (acetaminophen or NSAIDs), maintaining hydration, and implementing strict hand hygiene to prevent transmission. 1, 2

Symptomatic Treatment

Pain and Fever Management

• Administer acetaminophen or NSAIDs for a limited duration to relieve pain and reduce fever. 1
• Oral lidocaine is not recommended for pain management. 2
• No antiviral treatment is available for HFMD. 2, 3

Oral Lesion 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 Manifestations Management

• Apply intensive skin care to hands and feet with moisturizing creams, particularly urea-containing products. 1
• Avoid friction and heat exposure to affected areas. 1
• Do not use chemical agents or plasters to remove corns or calluses. 1
• For itchiness, apply zinc oxide 20% as a protective barrier after gentle cleansing of affected areas; reapply as needed. 1
• Apply zinc oxide in a thin layer; for nighttime relief, consider application followed by loose cotton gloves. 1
• Avoid applying zinc oxide to open or weeping lesions. 1

Foot Lesion Care (When Open Sores Present)

• 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
• Do not use topical antiseptic or antimicrobial dressings routinely, as these are not recommended for wound healing. 1

Hydration Support

• Focus treatment on maintaining adequate hydration, as oral ulcerations can make eating and drinking painful. 2
• Monitor for signs of dehydration, particularly in young children with severe oral lesions. 3

Infection Control and Prevention

Hand Hygiene (Most Critical Preventive Measure)

• Thorough handwashing with soap and water is more effective than alcohol-based hand sanitizers and represents the single most important preventive measure. 1
• Disinfect potentially contaminated surfaces and fomites, particularly toys and objects that may be placed in children's mouths. 1, 2

Isolation Precautions

• Children should avoid close contact with others until fever resolves and mouth sores heal. 1
• Follow standard precautions and good hand hygiene practices in healthcare settings. 1
• Avoid sharing utensils, cups, or food. 1

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, as by the time HFMD is diagnosed, the child has likely had the infection for weeks. 1

Monitoring and Follow-Up

Routine Monitoring

• Monitor for signs of secondary bacterial infection, including increased redness, warmth, purulent drainage, or worsening pain. 1
• Treat any secondary bacterial infections that develop. 1
• Reassess after 2 weeks if lesions are not improving with standard care. 1
• If evidence of infection has not resolved after 4 weeks, re-evaluate and consider alternative diagnoses. 1

Special Populations

• Immunocompromised patients may experience more severe disease and should be monitored closely. 1
• Watch for neurological complications (encephalitis/meningitis, acute flaccid myelitis, acute flaccid paralysis), particularly with Enterovirus 71 infections. 1, 4, 5
• Monitor for cardiopulmonary complications in severe cases. 6, 4

Diagnostic Considerations

Laboratory Confirmation (When Needed)

• Reverse transcriptase PCR (RT-PCR) targeting the 5′ non-coding region is the preferred diagnostic method. 1
• Vesicle fluid samples have high viral loads and are ideal for testing. 1
• Respiratory samples and/or stool specimens can also be used for diagnosis. 1

Critical Differential Diagnoses

• Distinguish from herpes simplex virus infection, as HSV has available antiviral treatment whereas HFMD does not. 1
• Rule out drug hypersensitivity reactions, which can also present with palmar-plantar rash. 1
• Differentiate from Kawasaki disease (HFMD has vesicular lesions vs. diffuse erythema). 1
• Consider syphilis, meningococcemia, and Rocky Mountain spotted fever in atypical presentations with palmar-plantar involvement. 1
• In children with atopic dermatitis, distinguish from "eczema coxsackium," which can resemble herpes infection. 5

Common Pitfalls to Avoid

• Do not prescribe oral lidocaine for pain management. 2
• Do not use topical antiseptic or antimicrobial dressings routinely for HFMD lesions. 1
• Do not exclude children from daycare based solely on persistent skin rash after fever and oral lesions have resolved. 1
• Do not overlook the possibility of nail shedding (onychomadesis) occurring up to two months after initial symptoms. 4, 5
• Do not assume all cases are benign; remain vigilant for severe complications, particularly with Enterovirus 71 strains. 6, 4