What is the management approach for a patient presenting with Hand, Foot, and Mouth Disease (HFMD) in winter?

Management of Hand, Foot, and Mouth Disease in Winter

Hand, Foot, and Mouth Disease (HFMD) in winter requires the same supportive care approach as in other seasons, but clinicians must remain vigilant for respiratory complications that peak during colder months and can precipitate more severe disease. 1, 2

Core Management Principles

Symptomatic Treatment

• Administer oral acetaminophen or NSAIDs for pain relief and fever reduction for a limited duration. 1 These are the primary analgesics recommended for HFMD management.
• Apply benzydamine hydrochloride oral rinse or spray every 3 hours, particularly before eating, to reduce inflammation and oral pain. 1
• Use chlorhexidine oral rinse twice daily as an antiseptic measure for oral lesions. 1
• For severe oral involvement, consider betamethasone sodium phosphate mouthwash four times daily. 1

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
• Use mild toothpaste and gentle oral hygiene techniques. 1
• Oral lidocaine is not recommended for HFMD management. 2

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
• For itchiness, apply zinc oxide 20% cream in a thin layer after gentle cleansing of affected areas, which can be repeated as needed. 1
• Do not use chemical agents or plasters to remove corns or calluses. 1

Foot Lesion Care (When Open Sores Present)

• Wash feet daily with careful drying, particularly between the toes, to prevent secondary complications. 1
• Avoid walking barefoot and ensure appropriate cushioned footwear to protect open lesions. 1
• Do not soak feet in footbaths, as this induces skin maceration and worsens open sores. 1
• Monitor for signs of secondary bacterial infection including increased redness, warmth, purulent drainage, or worsening pain. 1

Winter-Specific Considerations

Respiratory Infection Vigilance

• Respiratory infections peak during colder months and can precipitate cardiovascular stress and worsen HFMD outcomes. 3 This is particularly relevant since severe HFMD cases can involve respiratory complications including pulmonary edema. 4, 5
• Monitor closely for fever escalation, respiratory symptoms, or signs of systemic involvement beyond typical HFMD presentation. 4, 5

Neurological Complication Monitoring

• Watch for sudden onset of high fever, severe headache, vomiting, myoclonic jerks, seizures, or altered consciousness—these indicate potential meningoencephalitis or brainstem encephalitis, which occur in approximately 70% of neurological complications. 5
• Enterovirus 71 (EV-A71) is associated with more severe outbreaks and neurological sequelae, particularly in Asian regions. 1, 4, 5
• Acute flaccid myelitis and acute flaccid paralysis are rare but potential complications requiring immediate evaluation. 1

Diagnostic Approach

When to Confirm Diagnosis

• Reverse transcriptase PCR (RT-PCR) targeting the 5′ non-coding region is the preferred diagnostic method when confirmation is needed. 1
• Vesicle fluid samples have the highest 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

Infection Control and Prevention

Hand Hygiene (Most Important)

• Thorough handwashing with soap and water is more effective than alcohol-based hand sanitizers for preventing HFMD spread. 1
• Disinfect toys and objects that may be placed in children's mouths. 1, 2

Isolation Guidelines

• 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.
• By the time HFMD is diagnosed, the child has likely had the infection for weeks, posing limited additional risk to others. 1
• Avoid sharing utensils, cups, or food. 1

Follow-Up and Monitoring

Reassessment Timeline

• Lesions typically resolve in 7-10 days. 2, 6
• 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

Late Complications

• Nail changes (onychomadesis) may occur up to 2 months after initial symptoms, particularly with coxsackievirus A6. 4, 7

Special Populations

Immunocompromised Patients

• May experience more severe disease and require closer monitoring. 1

Severe Cases Requiring Advanced Treatment

• For severe/complicated HFMD with neurological involvement, intravenous immunoglobulin should be considered and has been recommended by several national and international guideline committees. 6, 5
• Glucocorticoid therapy is commonly used in conjunction with IVIG for severe neurological complications. 5
• Mechanical ventilation may be necessary for respiratory complications. 4

Common Pitfalls to Avoid

• Do not routinely use topical antiseptic or antimicrobial dressings for HFMD foot lesions, as these are not recommended for wound healing. 1
• No antiviral treatment is currently available or approved for HFMD. 1, 2, 6 While drugs such as ribavirin have been used in severe cases, no specific antiviral agents are approved. 4, 6
• Do not confuse HFMD with conditions requiring specific antiviral therapy (HSV) or urgent intervention (Kawasaki disease). 1