What is the course of treatment for hand, foot, and mouth disease?

Hand, Foot, and Mouth Disease: Course of Illness

Hand, foot, and mouth disease is a self-limited viral illness that typically resolves completely within 7-10 days without sequelae, requiring only supportive care focused on hydration and pain management. 1, 2

Natural History and Timeline

Initial Presentation (Days 1-2)

• Low-grade fever develops as the first symptom 1
• Constitutional symptoms including malaise may occur 3
• Fever is a common early feature before the characteristic rash appears 3

Peak Symptoms (Days 2-5)

• Painful oral ulcerations develop, typically appearing before skin lesions 1
• Maculopapular or papulovesicular rash emerges on hands (including palms) and soles of feet 1
• Lesions may extend beyond classic distribution to involve legs and buttocks 3, 1
• Oral lesions are usually the first clinical signs and cause the most discomfort 4

Resolution Phase (Days 7-10)

• Lesions typically resolve completely within 7-10 days 1, 2
• Oral ulcerations heal before skin lesions in most cases 3
• Complete recovery without complications occurs in the vast majority of cases 2

Transmission Period and Contagiousness

Critical timing consideration: By the time HFMD is diagnosed, the child has likely been shedding virus for weeks, posing limited additional risk to others 3

Return to activities: Children can return to daycare once fever has resolved and mouth sores have healed, even if skin rash is still present, as exclusion based solely on healing skin lesions is unnecessary 3

Complications to Monitor (Rare but Important)

Neurological complications (particularly with Enterovirus 71):

• Encephalitis/meningitis 3
• Acute flaccid myelitis (AFM) 3
• Acute flaccid paralysis (AFP) 3
• Brainstem damage leading to neurogenic pulmonary edema 2

Cardiopulmonary complications:

• Circulatory failure secondary to myocardial impairment 2
• These represent the main causes of death in severe cases 2

Immunocompromised patients may experience more severe disease and require closer monitoring 3

Management Throughout the Course

Supportive care measures:

• Oral analgesics (acetaminophen or NSAIDs) for limited duration to relieve pain and reduce fever 3
• Maintain hydration, particularly important given painful oral lesions 1
• Oral lidocaine is not recommended 1

Oral lesion management:

• Apply white soft paraffin ointment to lips every 2 hours to prevent drying and cracking 3
• Benzydamine hydrochloride oral rinse or spray every 3 hours, particularly before eating 3
• Chlorhexidine oral rinse twice daily as antiseptic measure 3
• Mild toothpaste and gentle oral hygiene 3

Skin manifestation care:

• Intensive moisturizing with urea-containing creams for hands and feet 3
• Avoid friction and heat exposure to affected areas 3
• Zinc oxide can be applied as protective barrier for itchy lesions 3
• Monitor for secondary bacterial infections requiring treatment 3

For open sores on feet:

• Wash feet daily with careful drying between toes 3
• Avoid walking barefoot; wear cushioned footwear 3
• Do not soak feet in footbaths as this induces maceration 3

When to Reassess

Re-evaluation is warranted if:

• Evidence of infection has not resolved after 4 weeks 3
• Signs of secondary infection develop: increased redness, warmth, purulent drainage, or worsening pain 3
• Lesions are not improving with standard care after 2 weeks 3

Common Pitfalls to Avoid

Do not confuse with herpes simplex virus, which has available antiviral treatment whereas HFMD does not 3

Do not use:

• Antiviral medications (none are approved or available for HFMD) 1, 2
• Topical antiseptic or antimicrobial dressings routinely for foot lesions 3
• Chemical agents or plasters to remove corns or calluses 3

Prevention measures during illness:

• Handwashing with soap and water is more effective than alcohol-based sanitizers 3
• Avoid sharing utensils, cups, or food 3
• Disinfect toys and objects that may be placed in children's mouths 3