What is the treatment for hand foot and mouth disease (HFMD)?

Treatment of Hand, Foot, and Mouth Disease

Hand, foot, and mouth disease requires only supportive care with oral analgesics for pain and fever control, as there is no approved antiviral therapy for this self-limited viral illness. 1

Primary Treatment Approach

Symptomatic Pain and Fever Management

• Use acetaminophen or NSAIDs for a limited duration to relieve pain and reduce fever. 1 This represents the cornerstone of HFMD management, as the disease typically resolves spontaneously within 7-10 days without complications. 2, 3

Oral Lesion Management

The oral ulcers are often the most painful aspect of HFMD and require specific attention:

• Apply white soft paraffin ointment to the lips every 2 hours to prevent drying and cracking. 1
• Use benzydamine hydrochloride oral rinse or spray every 3 hours, particularly before eating, to reduce inflammation and pain. 1
• Clean the mouth daily with warm saline mouthwashes or use an oral sponge for comfort. 1
• Use chlorhexidine oral rinse twice daily as an antiseptic measure. 1
• For more severe oral involvement, consider betamethasone sodium phosphate mouthwash four times daily. 1
• Practice mild toothpaste and gentle oral hygiene. 1

Skin Manifestation Management

For hand and foot lesions:

• Apply intensive skin care 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 any associated corns or calluses. 1

For itchy skin lesions:

• Apply zinc oxide in a thin layer after gentle cleansing of affected areas. 1 In a randomized controlled trial, zinc oxide 20% achieved 50% clearance of skin lesions. 1
• Avoid applying zinc oxide to open or weeping lesions. 1
• For nighttime relief, apply zinc oxide followed by loose cotton gloves to create an occlusive barrier. 1

For open sores on feet:

• Wash feet daily with careful drying, particularly between the toes. 1
• Avoid walking barefoot and wear appropriate cushioned footwear. 1
• Do not soak feet in footbaths, as this can induce skin maceration and worsen open sores. 1

Infection Control and Prevention

When to Exclude from Daycare

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 had the infection for weeks. 1

Preventive Measures

• Hand hygiene with thorough handwashing using soap and water is the most important preventive measure and is more effective than alcohol-based hand sanitizers. 1
• Clean toys and objects that may be placed in children's mouths. 1
• Avoid sharing utensils, cups, or food. 1
• Children with HFMD should avoid close contact with others until fever resolves and mouth sores heal. 1

Monitoring for Complications

Red Flags Requiring Closer Monitoring

While most cases are benign, certain populations and presentations require vigilance:

• Immunocompromised patients may experience more severe disease and should be monitored closely. 1
• Monitor for signs of secondary bacterial infection: increased redness, warmth, purulent drainage, or worsening pain. 1
• Be aware that enterovirus 71 (EV-A71) is associated with more severe outbreaks, particularly in Asia, with potential neurological complications including encephalitis/meningitis, acute flaccid myelitis, and acute flaccid paralysis. 1, 2

Follow-Up Timing

• 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

Important Clinical Pitfalls

Differential Diagnosis Considerations

Distinguish HFMD from herpes simplex virus infection, as HSV has available antiviral treatment whereas HFMD does not. 1 Also rule out drug hypersensitivity reactions, Kawasaki disease (which has diffuse erythema vs. vesicular lesions), syphilis, meningococcemia, and Rocky Mountain spotted fever in atypical presentations. 1

What NOT to Do

• Do not use topical antiseptic or antimicrobial dressings routinely for HFMD foot lesions, as these are not recommended for wound healing. 1
• Do not prescribe antiviral therapy, as there is no generally recommended or approved antiviral treatment for typical HFMD. 2, 3 While drugs such as ribavirin, suramin, and others have emerged as potential candidates, none are currently approved. 3

Special Considerations

Severe Cases

In rare severe HFMD cases (primarily associated with EV-A71), treatment may encompass mechanical ventilation and additional application of antiviral agents such as ribavirin, though this is not standard practice. 2 Intravenous immunoglobulin should be considered for severe/complicated HFMD. 3

Associated Complications

Be aware that nail dystrophies (Beau's lines or nail shedding/onychomadesis) can occur weeks after initial symptom onset, particularly with coxsackievirus A6. 4