What is the recommended treatment for a pediatric patient with hand, foot, and mouth disease (HFMD) who also presents with a rash on their chest?

Hand, Foot, and Mouth Disease with Chest Rash: Treatment Approach

A rash extending to the chest in hand, foot, and mouth disease represents a widespread exanthema pattern that is well-documented and does not change the supportive management approach—treatment remains symptomatic with oral analgesics, intensive skin care with moisturizing creams, and gentle oral hygiene. 1

Understanding the Rash Distribution

• Widespread exanthema beyond the classic hand-foot-mouth distribution is a recognized variant of HFMD, with studies showing that 87.6% of confirmed cases have skin lesions on sites other than the typical locations 2
• The chest, along with legs, arms, trunk, and buttocks, can be involved in what is termed "generalized exanthema," occurring in approximately 41.5% of confirmed HFMD cases 2
• This widespread pattern occurs with both coxsackievirus A6 and A16, so the presence of chest lesions does not indicate a more severe viral strain 2

Core Treatment Strategy

Pain and Fever Management

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

Skin Care for All Affected Areas (Including Chest)

• Apply intensive moisturizing care with urea-containing creams to all affected skin areas, including the chest rash 1
• Avoid friction and heat exposure to affected areas 1
• For itching specifically, zinc oxide can be applied in a thin layer after gentle cleansing, repeated as needed when itchiness returns 1
• Do not apply zinc oxide to open or weeping lesions 1

Oral Lesion Management

• Use mild toothpaste and gentle oral hygiene practices 1
• Apply white soft paraffin ointment to lips every 2 hours to prevent drying and cracking 1
• Clean the mouth daily with warm saline mouthwashes 1
• For more severe oral involvement, consider benzydamine hydrochloride oral rinse or spray every 3 hours, particularly before eating 1

Monitoring for Complications

• Watch for signs of secondary bacterial infection: increased redness, warmth, purulent drainage, or worsening pain 1
• Monitor for neurological symptoms (severe headache, altered mental status, meningismus) which can occur in severe cases, particularly with enterovirus 71 1
• Reassess after 2 weeks if lesions are not improving with standard care 1

Important Caveats

• Do not use chemical agents or plasters to remove associated skin changes 1
• Do not use topical antiseptic or antimicrobial dressings routinely, as these are not recommended for HFMD lesions 1
• Avoid soaking affected areas in footbaths or similar treatments, as this can induce skin maceration 1
• The disease is self-limited and typically resolves in 7-10 days without sequelae 3

When to Consider Alternative Diagnoses

• If fever persists with prominent cardiac dysfunction, shock, or gastrointestinal symptoms in the context of recent COVID-19 exposure, consider multisystem inflammatory syndrome in children (MIS-C), which can present with similar rash patterns but requires different management 4
• Rule out herpes simplex virus infection, as HSV has available antiviral treatment whereas HFMD does not 1
• Consider drug hypersensitivity reactions in the differential diagnosis 1

Return to Activities

• Children can return to daycare once fever has resolved and mouth sores have healed, even if the chest rash or other skin lesions are still present 1
• Exclusion based solely on healing skin lesions is not necessary 1