What is the management and treatment for a patient with Hand-foot-and-mouth disease?

Management of Hand, Foot, and Mouth Disease

Hand, foot, and mouth disease (HFMD) is a self-limited viral illness requiring only supportive care in most cases, with treatment focused on pain relief, hydration, and monitoring for rare but serious neurological complications. 1

Immediate Assessment and Diagnosis

Rule out serious mimics first: Distinguish HFMD from herpes simplex virus infection (which has antiviral treatment options), Kawasaki disease (which presents with diffuse erythema rather than vesicular lesions), and drug hypersensitivity reactions. 1 In atypical presentations with palmar-plantar involvement, also consider syphilis, meningococcemia, and Rocky Mountain spotted fever. 1

Diagnostic confirmation: Vesicle fluid samples have the highest viral loads and are ideal for reverse transcriptase PCR (RT-PCR) testing targeting the 5′ non-coding region. 1 Respiratory samples or stool specimens can also be used when vesicle fluid is unavailable. 1

Symptomatic Treatment

Pain and Fever Management

• Use oral acetaminophen or NSAIDs for limited duration to relieve pain and reduce fever. 1
• Avoid aspirin in children due to Reye's syndrome risk. 2, 3

Oral Lesion Management

• 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 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 Manifestations (Hand and Foot Lesions)

• Apply intensive moisturizing creams to hands and feet, particularly urea-containing products. 1
• Avoid friction and heat exposure to affected areas. 1
• Do not use chemical agents or plasters to remove corns or calluses. 1
• For itchiness, apply zinc oxide 20% in a thin layer after gentle cleansing of affected areas, which can be repeated as needed. 1 For nighttime relief, apply zinc oxide followed by loose cotton gloves to create an occlusive barrier. 1
• Avoid applying zinc oxide 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 induces skin maceration and worsens 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
• Do not use topical antiseptic or antimicrobial dressings routinely, as these are not recommended for wound healing in HFMD. 1

Prevention and Infection Control

Hand hygiene is the most important preventive measure: Thorough handwashing with soap and water is more effective than alcohol-based hand sanitizers. 1 Environmental cleaning, particularly of toys and objects that may be placed in children's mouths, is crucial. 1

Isolation guidelines: Children should avoid close contact with others until fever resolves and mouth sores heal, 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

Avoid sharing utensils, cups, or food. 1

Monitoring and Follow-Up

Watch for severe complications: Enterovirus 71 (EV-A71) is associated with more severe outbreaks, particularly in Asia, and can cause neurological complications including encephalitis/meningitis, acute flaccid myelitis, and acute flaccid paralysis. 1, 2 Circulatory failure secondary to myocardial impairment and neurogenic pulmonary edema secondary to brainstem damage are the main causes of death. 4

Immunocompromised patients require closer monitoring as they may experience more severe disease. 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

Anticipate late manifestations: Beau's lines (deep transverse nail grooves) may appear approximately 1-2 months after fever onset, and periungual desquamation typically begins 2-3 weeks after onset of fever. 1, 5 These represent delayed sequelae rather than active disease and require no specific treatment.

Common Pitfalls to Avoid

• Do not confuse HFMD with herpes simplex virus infection, particularly in children with atopic dermatitis who may develop "eczema coxsackium" resembling herpetic superinfection. 6
• Do not prescribe antiviral therapy, as there are no approved antiviral agents for HFMD treatment, unlike HSV infections. 1, 4
• Do not restrict return to daycare based solely on persistent skin lesions after fever and mouth sores have healed. 1