What is the management for Hand, Foot, and Mouth Disease (HFMD)?

Management of Hand, Foot, and Mouth Disease (HFMD)

HFMD management is entirely supportive, focusing on symptom relief with oral analgesics, maintaining hydration, and preventing transmission through hand hygiene, as there are no specific antiviral therapies approved for this self-limited viral illness. 1

Symptomatic Treatment

Pain and Fever Management

• Use acetaminophen or NSAIDs for a limited duration to relieve pain and reduce fever 1
• These medications address both constitutional symptoms and discomfort from oral and skin lesions 1

Oral Lesion Management

For mild to moderate oral involvement:

• 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 practices 1

For more severe oral involvement:

• 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
• Consider betamethasone sodium phosphate mouthwash four times daily for severe oral involvement 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 20% can be applied as a protective barrier to soothe inflamed areas and reduce itching 1
• Apply in a thin layer after gentle cleansing of affected areas 1
• Avoid applying 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

Diagnostic Considerations

Vesicle fluid samples have the highest viral loads and are ideal for testing, with reverse transcriptase PCR (RT-PCR) targeting the 5′ non-coding region being the preferred diagnostic method. 1

Alternative samples include respiratory specimens and stool samples, both suitable for RT-PCR diagnosis 1

Critical Differential Diagnoses to Exclude

• Herpes simplex virus infection: This is crucial to distinguish because HSV has available antiviral treatment whereas HFMD does not 1
• Kawasaki disease: HFMD has vesicular lesions versus diffuse erythema 1
• Drug hypersensitivity reactions, which can also present with palmar-plantar rash 1
• In atypical presentations with palmar-plantar involvement, consider syphilis, meningococcemia, and Rocky Mountain spotted fever 1

Prevention and Transmission Control

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

Additional measures:

• Environmental cleaning, particularly of toys and objects that may be placed in children's mouths 1
• Avoid sharing utensils, cups, or food 1
• Children should avoid close contact with others until fever resolves and mouth sores heal 1
• Standard precautions and good hand hygiene practices should be followed in healthcare settings 1

Return to Daycare/School Criteria

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 1
• By the time HFMD is diagnosed, the child has likely had the infection for weeks, posing limited additional risk to others 1

Monitoring for Complications

Neurological Complications (Rare but Serious)

Be vigilant for signs of severe disease, particularly with Enterovirus 71 (EV-A71):

• Encephalitis/meningitis 1, 2
• Acute flaccid myelitis (AFM) 1
• Acute flaccid paralysis (AFP) 1
• Severe respiratory symptoms such as pulmonary edema 2

EV-A71 is associated with more severe outbreaks, especially in Asia 1, 2

Special Populations

• Immunocompromised patients may experience more severe disease and should be monitored closely 1

Late Manifestations (Not Active Disease)

• Beau's lines (deep transverse nail grooves) may appear approximately 1-2 months after fever onset 1
• Periungual desquamation typically begins 2-3 weeks after onset of fever 1
• These represent delayed sequelae rather than active disease and require no specific treatment 1

Follow-Up and Re-Evaluation

• If evidence of infection has not resolved after 4 weeks, re-evaluate and consider alternative diagnoses 1
• Reassess after 2 weeks if lesions are not improving with standard care 1

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
• Do not confuse HFMD with chemotherapy-induced hand-foot syndrome, which requires different treatments such as high-potency steroids 3
• Do not use alcohol-based hand sanitizers as the primary prevention method; soap and water handwashing is more effective 1