What is the recommended management approach for a patient, including a 14-year-old, with hand, foot, and mouth disease?

Management of Hand, Foot, and Mouth Disease in a 14-Year-Old

Hand, foot, and mouth disease (HFMD) requires supportive care focused on pain relief and hydration, with most cases resolving in 7-10 days without specific antiviral therapy. 1, 2

Immediate Symptomatic Management

Pain and Fever Control

• Administer oral acetaminophen or NSAIDs (ibuprofen) for pain relief and fever reduction 1
• Avoid oral lidocaine, as it is not recommended for HFMD 2
• Continue analgesics as needed until oral lesions heal and fever resolves 1

Oral Lesion Management

• Apply white soft paraffin ointment to the lips every 2 hours to prevent drying and cracking 1
• Use warm saline mouthwashes or oral sponges for gentle cleaning daily 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
• Maintain mild oral hygiene practices to avoid further irritation 1

Skin Manifestations (Hand and Foot Lesions)

• Apply intensive moisturizing creams containing urea to hands and feet 1
• Avoid friction and heat exposure to affected areas 1
• Apply zinc oxide in a thin layer to itchy lesions after gentle cleansing; reapply as needed 1
• For nighttime relief, apply zinc oxide followed by loose cotton gloves to enhance effectiveness 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 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

Hydration Support

• Encourage adequate fluid intake, as painful oral lesions may reduce oral intake 2, 3
• Cold fluids and soft foods may be better tolerated 2

Infection Control and Return to Activities

Isolation Precautions

• The child can return to school/activities 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 1
• Avoid sharing utensils, cups, or food 1

Prevention Measures

• Handwashing with soap and water is more effective than alcohol-based hand sanitizers and is the most important preventive measure 1, 2
• Disinfect toys and objects that may contact the mouth 1
• Standard precautions and good hand hygiene should be followed 1

Monitoring and Follow-Up

Expected Course

• Lesions typically resolve in 7-10 days 2, 3
• Fever usually resolves within a few days 2

Warning Signs Requiring Urgent Re-evaluation

• Neurological symptoms including severe headache, altered mental status, weakness, or seizures (rare but serious complications, particularly with enterovirus A71) 1, 3, 4
• Signs of cardiopulmonary complications including chest pain, difficulty breathing, or rapid heart rate 3, 4
• Inability to maintain hydration due to severe oral pain 2
• Signs of secondary bacterial infection 1

Routine Follow-Up

• 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

Late Manifestations to Anticipate

Nail Changes

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

Special Considerations for Adolescents

Atypical Presentation

• Coxsackievirus A6 (CVA6) has been increasingly associated with HFMD in older children and adults 6
• CVA6 causes more severe disease with higher fever, longer duration, and more widespread skin manifestations beyond the classic distribution 1, 6
• Lesions may involve the legs and other areas beyond hands, feet, and mouth 1, 6

Differential Diagnosis

• 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
• Consider Kawasaki disease (HFMD has vesicular lesions vs. diffuse erythema) 1

What NOT to Do

• Do not use topical antiseptic or antimicrobial dressings routinely for HFMD foot lesions 1
• Do not use chemical agents or plasters to remove corns or calluses 1
• Do not prescribe antiviral medications, as none are approved for HFMD 2, 3
• Do not use oral lidocaine 2