What is the treatment and prognosis for a patient with hand, foot, and mouth disease?

Hand, Foot, and Mouth Disease: Treatment and Prognosis

Hand, foot, and mouth disease is a self-limited viral illness requiring only supportive care, with most cases resolving spontaneously within 7-10 days and excellent prognosis in immunocompetent patients. 1, 2, 3

Treatment Approach

Symptomatic Management

Pain and fever control forms the cornerstone of HFMD treatment:

• Administer oral acetaminophen or NSAIDs for pain relief and fever reduction, limiting duration to avoid unnecessary medication exposure 1
• Apply benzydamine hydrochloride oral rinse or spray every 3 hours, particularly before eating, to reduce oral inflammation and pain 1
• For severe oral involvement (grade >2), consider betamethasone sodium phosphate mouthwash four times daily 1

Oral Lesion Care

Meticulous oral hygiene prevents secondary complications:

• Apply white soft paraffin ointment to lips every 2 hours to prevent drying and cracking 1
• Clean mouth daily with warm saline mouthwashes or use oral sponge for comfort 1
• Use chlorhexidine oral rinse twice daily as antiseptic measure 1
• Employ mild toothpaste and gentle oral hygiene techniques 1

Skin Manifestation Management

Intensive skin care reduces discomfort and prevents secondary infection:

• Apply moisturizing creams containing urea to hands and feet regularly 1
• Use zinc oxide in thin layers to affected areas after gentle cleansing for itchiness relief; zinc oxide achieved 50% clearance in controlled trials and can be reapplied as needed 1
• For nighttime relief, apply zinc oxide followed by loose cotton gloves to create occlusive barrier 1
• Avoid chemical agents or plasters to remove corns or calluses 1
• Do not apply zinc oxide to open or weeping lesions 1

Foot Lesion Care (When Open Sores Present)

Proper wound protection prevents secondary bacterial infection:

• Wash feet daily with careful drying, particularly between toes 1
• Avoid walking barefoot; wear appropriate cushioned footwear to protect lesions 1
• Do not soak feet in footbaths, as this induces skin maceration and worsens open sores 1
• Monitor for signs of secondary infection including increased redness, warmth, purulent drainage, or worsening pain 1
• Do not use topical antiseptic or antimicrobial dressings routinely, as these are not recommended for HFMD wound healing 1

What NOT to Do

No antiviral therapy exists for HFMD, unlike herpes simplex virus which has treatment options 1, 2

Do not treat with antibiotics unless secondary bacterial infection develops 1

Infection Control and Return to Activities

Contagion Period and Exclusion

Children can return to daycare once fever resolves and mouth sores heal, even if skin rash persists 1

• By diagnosis time, the child has likely been infectious for weeks, posing limited additional risk 1
• Exclusion based solely on healing skin lesions is unnecessary 1

Prevention Measures

Hand hygiene with soap and water is the single most important preventive measure, superior to alcohol-based sanitizers 1, 4

• Avoid sharing utensils, cups, or food with infected individuals 1, 4
• Clean and disinfect contaminated surfaces regularly, as virus remains viable on fomites for several hours 4
• Avoid close conversation within few feet of infected individuals to prevent respiratory droplet transmission 4
• Direct contact with vesicle fluid poses highest transmission risk due to extremely high viral loads 4

Prognosis

Expected Clinical Course

Excellent prognosis with spontaneous resolution in immunocompetent patients:

• Symptoms typically resolve within 7-10 days without complications 2, 3
• Fever and constitutional symptoms improve within 2-3 days 1
• Oral lesions heal within 1 week 1

Late Manifestations (Not Active Disease)

Nail changes may appear weeks after initial illness:

• Beau's lines (deep transverse nail grooves) appear approximately 1-2 months after fever onset 1, 5
• Periungual desquamation typically begins 2-3 weeks after fever onset 1, 5
• These represent delayed sequelae rather than active disease or complications 5

When to Reassess

Re-evaluate if symptoms persist beyond expected timeframe:

• Reassess after 2 weeks if lesions 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 Considerations

Immunocompromised patients require closer monitoring for severe disease 1

• Enterovirus 71 (EV-A71) associated with more severe outbreaks, especially in Asia, with potential neurological complications including encephalitis/meningitis, acute flaccid paralysis, and acute flaccid myelitis 1, 2, 6
• Severe cardiopulmonary complications possible in EV-A71 cases 2
• Coxsackievirus A6 and A10 increasingly causing infections with atypical presentations 6, 7

Critical Differential Diagnoses

Distinguish HFMD from conditions requiring different management:

• Herpes simplex virus infection (has available antiviral treatment) 1
• Drug hypersensitivity reactions (can present with palmar-plantar rash) 1
• Kawasaki disease (diffuse erythema vs. vesicular lesions) 1
• In atypical presentations: syphilis, meningococcemia, Rocky Mountain spotted fever 1