What is the recommended management for hand, foot, and mouth disease (HFMD)?

Management of Hand, Foot, and Mouth Disease

Hand, foot, and mouth disease requires supportive care only, focusing on pain relief and hydration, as there are no approved antiviral treatments available. 1, 2

Symptomatic Treatment

Pain and Fever Management

• Use oral acetaminophen or NSAIDs (such as ibuprofen) for a limited duration to relieve pain and reduce fever. 1, 2
• Oral lidocaine is not recommended for pain management. 2

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
• 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
• Use mild toothpaste and gentle oral hygiene practices. 1

Skin Manifestations (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 itchiness, zinc oxide can be applied as a protective barrier after gentle cleansing of affected areas; application can be repeated as needed. 1
• Avoid applying zinc oxide to open or weeping lesions. 1

Management of Open Sores on Feet

• 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 can induce skin maceration and worsen open sores. 1
• Monitor for signs of secondary bacterial infection including increased redness, warmth, purulent drainage, or worsening pain. 1
• Treat any secondary bacterial infections that develop. 1

Prevention and Infection Control

Hand Hygiene

• Thorough handwashing with soap and water is more effective than alcohol-based hand sanitizers and is the most important preventive measure. 1

Environmental Measures

• Disinfect toys and objects that may be placed in children's mouths. 1, 2
• Avoid sharing utensils, cups, or food. 1

Isolation Precautions

• 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. 1
• In healthcare settings, follow standard precautions and good hand hygiene practices. 1

Monitoring and Follow-Up

Routine Cases

• Lesions usually resolve in 7 to 10 days without sequelae. 2, 3
• 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

Severe Disease Monitoring

• Immunocompromised patients may experience more severe disease and should be monitored closely. 1
• Watch for neurological complications such as encephalitis/meningitis, acute flaccid myelitis, or acute flaccid paralysis, particularly with Enterovirus 71 infections. 1
• Monitor for cardiopulmonary complications including circulatory failure secondary to myocardial impairment and neurogenic pulmonary edema. 3
• Intravenous immunoglobulin should be considered for severe/complicated HFMD. 3

Late Manifestations

Expected Sequelae

• Beau's lines (deep transverse nail grooves) may appear approximately 1-2 months after fever onset, representing a delayed sequela rather than active disease. 1
• Periungual desquamation typically begins 2-3 weeks after onset of fever. 1

Diagnostic Considerations

Differential Diagnosis

• 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

Confirmatory Testing

• Reverse transcriptase PCR (RT-PCR) targeting the 5′ non-coding region is the preferred diagnostic method. 1
• Vesicle fluid samples have high viral loads and are ideal for testing. 1
• Respiratory samples and/or stool specimens can also be used for diagnosis. 1

Special Populations

Atypical Presentations

• Children with atopic dermatitis may develop "eczema coxsackium," in which eczematous skin is superinfected with coxsackie virus, resembling herpes infection. 4
• Widespread exanthema beyond the classic distribution (hands, feet, mouth) may occur, involving the legs. 1