Hand, Foot, and Mouth Disease: Signs and Symptoms
Hand, foot, and mouth disease typically begins with fever (often the first symptom), followed by the development of painful mouth sores and a characteristic vesicular rash on the palms and soles. 1
Initial Presenting Symptoms
Fever is usually the first manifestation, typically low-grade but can exceed 102.2°F (39°C), accompanied by malaise, general discomfort, sore throat, and irritability particularly in toddlers. 1 The fever precedes the characteristic rash by 1-2 days. 2
Additional early symptoms may include:
- Respiratory symptoms such as cough and rhinitis, especially in younger children 1
- Gastrointestinal symptoms including nausea, vomiting, and diarrhea occasionally 1
- Mild sore throat that precedes the rash 2
Characteristic Rash Pattern
The hallmark exanthem begins as small pink macules that evolve into vesicular lesions with a highly characteristic distribution on palms and soles. 1 These are tender, deep-seated vesicles and papules. 2
The oral lesions manifest as:
- Painful sores in the mouth (oral mucosa) 3, 4
- Oral herpes-like lesions that typically resolve spontaneously within days 5
The skin findings include:
- Vesicles on palms of hands and soles of feet 3, 4
- Widespread exanthema beyond the classic distribution may occur, involving the legs 6
- Lesions may be asymptomatic in some cases 2
Important Clinical Distinctions
Unlike Kawasaki disease, HFMD presents with vesicular lesions rather than diffuse erythema. 1 This is a critical distinction because:
- Kawasaki disease shows diffuse erythema and edema of hands/feet, not vesicles 7
- Kawasaki disease includes bilateral conjunctival injection without exudate 7
- Kawasaki disease requires fever ≥5 days 7
Unlike chickenpox, HFMD vesicles are concentrated on hands, feet, and mouth rather than widely distributed. 1
Atypical Presentations
In children with atopic dermatitis:
- "Eczema coxsackium" may occur, where eczematous skin becomes superinfected with coxsackie virus, resembling herpes infection 4
- These atypical manifestations can mimic herpetic superinfection 4
Late Manifestations (Weeks After Initial Symptoms)
Nail changes may appear approximately 1-2 months after fever onset:
- Beau's lines (deep transverse nail grooves) 6
- Periungual desquamation typically begins 2-3 weeks after fever onset 6
- Nail shedding (onychomadesis) may occur 3, 2
Severe Complications (Rare)
With Enterovirus 71 infections, particularly in Asia, severe neurological complications can occur:
- Encephalitis/meningitis 6
- Acute flaccid myelitis 6
- Acute flaccid paralysis 6
- Cardiopulmonary complications 5
Clinical Course
Most infections are asymptomatic or present as a mild febrile illness. 3 When symptomatic, the rash typically resolves within 7 days without treatment or complications. 2 The disease is self-limiting in the vast majority of cases. 8, 5
Recurrence is rare but possible, with subsequent episodes often being milder with less severe prodromal symptoms. 2