What is the recommended treatment for hand, foot, and mouth disease (HFMD) in children?

Hand, Foot, and Mouth Disease in Children

Hand, foot, and mouth disease (HFMD) in children is a self-limited viral illness requiring only supportive care with oral analgesics for pain and fever management, along with meticulous hand hygiene to prevent transmission. 1

Clinical Recognition and Diagnosis

HFMD typically presents after a 3-10 day incubation period with fever and sore throat, followed by characteristic vesicular eruptions on the palms, soles, and oral cavity. 2 The disease predominantly affects children under 5 years of age and usually resolves within 7-10 days without complications. 3

Diagnostic confirmation can be obtained through reverse transcriptase PCR (RT-PCR) of vesicle fluid, respiratory samples, or stool specimens, with vesicle fluid having the highest viral loads. 1

Warning Signs Requiring Urgent Evaluation

Clinicians must recognize indicators of potential severe disease progression, particularly in children under 3 years with EV-A71 infection and disease duration less than 3 days: 4

• Persistent high fever 4
• Neurological involvement (altered mental status, seizures, acute flaccid paralysis) 1, 4
• Worsening respiratory rate and rhythm 4
• Circulatory dysfunction 4
• Elevated peripheral white blood cell count 4
• Elevated blood glucose or lactic acid 4

Treatment Approach

Symptomatic Management

Use acetaminophen or NSAIDs for pain relief and fever reduction for a limited duration. 1 Most mild cases can be managed as outpatients with supportive care alone. 4

Oral Lesion Care

For painful oral lesions that interfere with eating or drinking: 1

• Apply white soft paraffin ointment to lips every 2 hours 1
• Clean mouth daily with warm saline mouthwashes or oral sponge 1
• Apply benzydamine hydrochloride oral rinse or spray every 3 hours, particularly before eating 1
• Use mild toothpaste and gentle oral hygiene 1

Skin Lesion Management

Apply intensive moisturizing care to hands and feet using urea-containing creams, while avoiding friction and heat exposure to affected areas. 1 Zinc oxide can be applied as a protective barrier to reduce itchiness, though it should not be used on open or weeping lesions. 1

For open sores on feet: 1

• Wash feet daily with careful drying, particularly between toes 1
• Avoid walking barefoot and use cushioned footwear 1
• Do not soak feet in footbaths, as this causes maceration 1
• Monitor for secondary bacterial infection (increased redness, warmth, purulent drainage) 1

Infection Control and Prevention

Hand hygiene with soap and water is the single most important preventive measure and is more effective than alcohol-based hand sanitizers for HFMD. 1, 5 Thorough handwashing should occur before and after each patient contact. 5

Additional preventive measures include: 1

• Environmental cleaning of toys and objects that may be placed in children's mouths 1
• Avoiding sharing utensils, cups, or food 1
• Standard precautions in healthcare settings 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 unnecessary, as by the time HFMD is diagnosed, the child has likely been shedding virus for weeks. 1

Critical Differential Diagnoses

Distinguish HFMD from: 1

• Herpes simplex virus infection (which has available antiviral treatment, unlike HFMD) 1
• Drug hypersensitivity reactions 1
• Kawasaki disease (diffuse erythema vs. vesicular lesions) 1

Special Considerations

Enterovirus 71 (EV-A71) causes more severe outbreaks with higher complication rates, particularly in Asia, and can lead to neurological complications including encephalitis, meningitis, and acute flaccid paralysis. 1, 2 Immunocompromised patients may experience more severe disease and require closer monitoring. 1

There are no specific antiviral agents approved for HFMD treatment. 3 Intravenous immunoglobulin should be considered for severe or complicated cases. 3

Follow-Up

If symptoms have not resolved after 4 weeks, re-evaluate and consider alternative diagnoses. 1 Reassess after 2 weeks if foot lesions are not improving with standard care. 1