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

Treatment of Hand, Foot, and Mouth Disease

Hand, foot, and mouth disease requires supportive care only, focusing on pain relief with acetaminophen or NSAIDs and maintaining hydration, as no specific antiviral treatment is available. 1, 2

Immediate Symptom Management

Pain and Fever Control

• Use oral acetaminophen or NSAIDs for a limited duration to relieve pain and reduce fever. 1
• Avoid oral lidocaine as it is not recommended for HFMD. 2
• Symptoms typically resolve within 7-10 days without intervention. 2, 3

Oral Lesion Care

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

Skin Manifestation Management

• Apply intensive moisturizing creams to hands and feet, particularly urea-containing products. 1
• Use zinc oxide as a protective barrier on itchy skin lesions—apply in a thin layer after gentle cleansing and reapply as needed. 1
• For nighttime relief, apply zinc oxide followed by loose cotton gloves to create an occlusive barrier. 1
• Avoid friction and heat exposure to affected areas. 1
• Do not apply zinc oxide to open or weeping lesions. 1

Open Foot Lesions

• Wash feet daily with careful drying, particularly between the toes. 1
• Avoid walking barefoot and wear appropriate cushioned footwear to protect open lesions. 1
• Do not soak feet in footbaths, as this induces skin maceration and worsens open sores. 1
• Do not use topical antiseptic or antimicrobial dressings routinely, as these are not recommended for HFMD wound healing. 1
• Do not use chemical agents or plasters to remove corns or calluses. 1

Monitoring for Complications

Red Flags Requiring Immediate Evaluation

• Monitor closely for neurological complications including encephalitis, meningitis, acute flaccid myelitis, or acute flaccid paralysis, particularly with Enterovirus 71 infections. 1
• Watch for signs of secondary bacterial infection: increased redness, warmth, purulent drainage, or worsening pain. 1
• Immunocompromised patients may experience more severe disease and require closer monitoring. 1

Follow-Up Timeline

• 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

Infection Control and Return to Activities

Prevention 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 and disinfect toys and objects that may be placed in children's mouths. 1, 2
• Avoid sharing utensils, cups, or food. 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 not necessary, as by the time HFMD is diagnosed, the child has likely had the infection for weeks and poses limited additional risk. 1
• Children should avoid close contact with others until fever resolves and mouth sores heal. 1

Critical Differential Diagnoses

Before confirming HFMD treatment, rule out:

• Herpes simplex virus infection (which has available antiviral treatment, unlike HFMD). 1
• Drug hypersensitivity reactions presenting with palmar-plantar rash. 1
• Kawasaki disease (HFMD has vesicular lesions versus diffuse erythema). 1
• In atypical presentations: syphilis, meningococcemia, Rocky Mountain spotted fever, erythema multiforme, measles, and varicella. 1, 2

Common Pitfalls to Avoid

• Do not prescribe antiviral medications—none are approved or available for HFMD treatment. 2, 3
• Do not use oral lidocaine for pain management. 2
• Do not exclude children from daycare based solely on persistent skin lesions after fever and oral lesions have resolved. 1
• Do not overlook the possibility of severe complications, particularly with EV-A71 infections which have higher complication rates than coxsackievirus A16. 3