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

Management of Hand, Foot, and Mouth Disease

Hand, foot, and mouth disease (HFMD) is managed with supportive care focused on pain relief and hydration, as there are no specific antiviral treatments available for this self-limited viral illness. 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
• Avoid oral lidocaine, as it is not recommended for HFMD. 2
• Pain control is particularly important given the painful oral ulcerations that can interfere with eating and drinking. 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 Manifestation 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, zinc oxide can be applied as a protective barrier after gentle cleansing of affected areas, repeated as needed. 1
• Apply zinc oxide in a thin layer; for nighttime relief, consider applying followed by loose cotton gloves to create an occlusive barrier. 1
• Do not use chemical agents or plasters to remove corns or calluses. 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
• Avoid applying zinc oxide to open or weeping lesions. 1

Hydration and Nutrition

• Ensure adequate hydration, as painful oral ulcerations may reduce oral intake. 2, 3
• Treatment is directed toward maintaining hydration and providing pain relief as needed. 2

Monitoring and Follow-Up

Signs Requiring Re-evaluation

• Monitor for signs of secondary bacterial infection, including increased redness, warmth, purulent drainage, or worsening pain. 1
• 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 Indicators

• Watch for neurological complications such as encephalitis, meningitis, acute flaccid myelitis, or acute flaccid paralysis, particularly with Enterovirus 71 (EV-A71). 1
• Be vigilant for cardiopulmonary complications in severe cases. 2, 4
• Immunocompromised patients may experience more severe disease and should be monitored closely. 1

Infection Control and Prevention

Hand Hygiene

• Handwashing with soap and water is the most important preventive measure and is more effective than alcohol-based hand sanitizers. 1
• Disinfect potentially contaminated surfaces and fomites, particularly toys and objects that may be placed in children's mouths. 1, 2

Isolation Precautions

• Children with HFMD 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
• 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. 1

Diagnostic Considerations

Confirmation 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

Important 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
• Other differentials include erythema multiforme, measles, and varicella. 2

Special Considerations

Atypical Presentations

• Atypical manifestations may occur in children with atopic dermatitis, including "eczema coxsackium," which resembles herpes infection. 5, 6
• Widespread exanthema beyond the classic distribution (hands, feet, mouth) may occur, involving the legs. 1
• Coxsackievirus A6 (CVA6) can cause atypical presentations including Gianotti-Crosti-like eruptions, petechial/purpuric eruption, and vesiculobullous exanthema. 6

Late Manifestations

• 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
• Nail shedding may follow HFMD after a latency period. 5

Common Pitfalls to Avoid

• Do not use topical antiseptic or antimicrobial dressings routinely for HFMD foot lesions, as these are not recommended for wound healing. 1
• Do not prescribe antiviral treatment, as none is available for HFMD. 1, 2
• Do not use oral lidocaine for pain management. 2

Treatment of Secondary Infections

• Treat any secondary bacterial infections that may develop. 1