What are the management strategies for hand foot mouth disease?

Management of Hand, Foot, and Mouth Disease

Hand, foot, and mouth disease requires supportive care focused on pain control, hydration, and preventing transmission, as there are no specific antiviral treatments available. 1, 2

Immediate Symptomatic Management

Pain and Fever Control

• Administer acetaminophen or NSAIDs (ibuprofen) for pain relief and fever reduction in all symptomatic patients 1, 2
• For oral pain specifically, use benzydamine hydrochloride oral rinse or spray every 2-4 hours, which provides both anti-inflammatory and analgesic effects for painful mouth ulcers 3
• Apply the benzydamine particularly before eating to facilitate oral intake 3
• Avoid viscous lidocaine in children due to safety concerns; reserve it only for cases where benzydamine provides inadequate control 3

Oral Lesion Care

• Perform warm saline mouthwashes daily to reduce bacterial colonization and promote healing 3
• Apply white soft paraffin ointment to the lips every 2 hours to prevent drying and cracking 1, 3
• Use chlorhexidine oral rinse (0.2%) twice daily as an antiseptic measure to prevent secondary infection 3
• For severe oral involvement, consider betamethasone sodium phosphate mouthwash 1-4 times daily as a rinse-and-spit solution 1, 3
• Apply mucoprotectant mouthwashes (such as Gelclair) three times daily to protect ulcerated surfaces 3

Skin Lesion Management

• Apply intensive moisturizing care to hands and feet using urea-containing creams to manage skin manifestations 1
• For itchy lesions, zinc oxide 20% can be applied as a protective barrier after gentle cleansing, repeated as needed 1
• Avoid applying zinc oxide to open or weeping lesions 1
• Do not use chemical agents or plasters to remove corns or calluses during active disease 1

Management of Open Foot Sores

• Wash feet daily with careful drying, particularly between toes 1
• Avoid walking barefoot and ensure appropriate cushioned footwear to protect 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

Hydration and Nutrition

• Ensure adequate fluid intake to maintain hydration, especially when oral intake is compromised by painful mouth sores 2, 4
• Avoid painful stimuli including citrus fruits, tomatoes, hot drinks, and spicy or crusty foods 1

Infection Control and Prevention

Hand Hygiene (Most Critical Preventive Measure)

• Thorough handwashing with soap and water is more effective than alcohol-based hand sanitizers for preventing HFMD transmission 1, 2
• Implement handwashing after diaper changes, before food preparation, and after contact with potentially contaminated surfaces 1

Environmental Measures

• Disinfect toys and objects that may be placed in children's mouths regularly 1, 2
• Clean potentially contaminated surfaces and fomites thoroughly 2
• Avoid sharing utensils, cups, or food 1

Isolation Guidelines

• Children can return to daycare once fever has resolved and mouth sores have healed, even if skin rash persists 1
• Exclusion based solely on healing skin lesions is unnecessary, as viral shedding occurs before diagnosis and continues for weeks 1
• In healthcare settings, follow standard precautions and maintain good hand hygiene practices 1

Monitoring for Complications

Red Flags Requiring Urgent Evaluation

• Monitor for neurological complications including encephalitis, meningitis, acute flaccid myelitis, or acute flaccid paralysis, particularly with Enterovirus A71 infections 1, 4
• Watch for signs of cardiopulmonary complications including circulatory failure secondary to myocardial impairment or neurogenic pulmonary edema 4
• Immunocompromised patients require closer monitoring as they may experience more severe disease 1

Follow-Up Timing

• Most cases resolve in 7-10 days without intervention 2, 4
• Reassess after 2 weeks if lesions are not improving with standard care 1
• Re-evaluate after 4 weeks if evidence of infection has not resolved and consider alternative diagnoses 1

Treatment of Secondary Infections

• If candidal infection develops, treat with nystatin oral suspension or miconazole oral gel, particularly in children with prolonged mouth sores or those on corticosteroid therapy 3
• Treat any secondary bacterial infections that develop in skin lesions 1

Critical Differential Diagnoses to Exclude

• Distinguish from herpes simplex virus infection, as HSV has available antiviral treatment whereas HFMD does not 1
• Rule out drug hypersensitivity reactions, which can present with similar palmar-plantar rash 1
• Consider Kawasaki disease (HFMD has vesicular lesions versus diffuse erythema), syphilis, meningococcemia, and Rocky Mountain spotted fever in atypical presentations 1

What NOT to Do

• Do not use antiviral medications, as none are approved for HFMD treatment 2, 4
• Avoid routine topical antiseptic or antimicrobial dressings for foot lesions 1
• Do not start interdental cleaning during active disease if not previously practiced, as it can break the epithelial barrier 1