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

Management of Hand, Foot, and Mouth Disease

Hand, foot, and mouth disease requires supportive care only—do not use corticosteroids, as they suppress the immune response needed for viral clearance and may increase risk of severe complications and death. 1

Symptomatic Treatment

Pain and Fever Management

• Use oral acetaminophen or NSAIDs for a limited duration to relieve pain and reduce fever 2
• Avoid oral lidocaine, as it is not recommended for HFMD 3

Oral Lesion Management

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

Skin Lesion Management

• Apply intensive moisturizing care with urea-containing creams to hands and feet 2, 1
• Avoid friction and heat exposure to affected areas 2
• Apply zinc oxide as a protective barrier for itchy skin lesions in a thin layer after gentle cleansing 2
• For nighttime relief, apply zinc oxide followed by loose cotton gloves to create an occlusive barrier 2
• Avoid applying zinc oxide to open or weeping lesions 2

Management of Open Sores on Feet

• Wash feet daily with careful drying, particularly between the toes 2
• Avoid walking barefoot and wear appropriate cushioned footwear to protect open lesions 2
• Do not soak feet in footbaths, as this induces skin maceration and worsens open sores 2
• Do not use topical antiseptic or antimicrobial dressings routinely, as these are not recommended for wound healing 2

Monitoring and Follow-Up

Watch for Complications

• Monitor for signs of secondary bacterial infection: increased redness, warmth, purulent drainage, or worsening pain 2
• Be vigilant for neurological complications (encephalitis/meningitis, acute flaccid paralysis, acute flaccid myelitis), particularly with enterovirus 71 2, 4, 5
• Recognize that severe cases may develop cardiopulmonary complications including pulmonary edema and myocardial impairment 4, 6

Reassessment Timeline

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

Late Manifestations

• Expect Beau's lines (deep transverse nail grooves) approximately 1-2 months after fever onset 2
• Periungual desquamation typically begins 2-3 weeks after onset of fever 2
• These represent delayed sequelae rather than active disease 2

Infection Control and Prevention

Hand Hygiene

• Thorough handwashing with soap and water is more effective than alcohol-based hand sanitizers 2
• This is the most important preventive measure 2

Environmental Measures

• Clean toys and objects that may be placed in children's mouths 2
• Disinfect potentially contaminated surfaces and fomites 3
• Avoid sharing utensils, cups, or food 2

Isolation Guidelines

• Children should avoid close contact with others until fever resolves and mouth sores heal 2
• Children can return to daycare once fever has resolved and mouth sores have healed, even if skin rash is still present 2
• Exclusion based solely on healing skin lesions is not necessary 2
• By the time HFMD is diagnosed, the child has likely had the infection for weeks, posing limited additional risk to others 2

Diagnostic Considerations

Confirm Diagnosis When Needed

• Vesicle fluid samples have high viral loads and are ideal for testing 2
• Reverse transcriptase PCR (RT-PCR) targeting the 5′ non-coding region is the preferred diagnostic method 2
• Respiratory samples and/or stool specimens can also be used 2

Critical Differential Diagnoses

• Distinguish from herpes simplex virus infection, as HSV has available antiviral treatment whereas HFMD does not 2
• Rule out drug hypersensitivity reactions, which can also present with palmar-plantar rash 2
• Differentiate from Kawasaki disease (HFMD has vesicular lesions vs. diffuse erythema) 2
• Consider syphilis, meningococcemia, and Rocky Mountain spotted fever in atypical presentations with palmar-plantar involvement 2

Special Populations

• Immunocompromised patients may experience more severe disease and should be monitored closely 2
• Most cases occur in patients younger than 10 years, though adults can be affected 3, 4

Common Pitfalls to Avoid

• Never prescribe corticosteroids for HFMD based on the presence of inflammation or fever, as they may increase the risk of severe complications and death 1
• Do not use chemical agents or plasters to remove any associated corns or calluses 2
• No specific antiviral treatment is available or recommended for HFMD 3, 7