What are the presentation and treatment guidelines for pediatric patients with hand foot mouth disease?

Pediatric Hand, Foot, and Mouth Disease: Presentation and Treatment

Clinical Presentation

Hand, foot, and mouth disease (HFMD) is a common viral illness in children under 5 years characterized by fever, painful oral ulcers, and vesicular rash on the palms, soles, and buttocks, typically resolving in 7-10 days without complications. 1, 2

Classic Features

• Fever is a common initial symptom 1
• Oral enanthem presents as painful ulcers and vesicles in the mouth 2
• Exanthem appears as asymptomatic vesicular lesions on palms and soles 2
• Buttocks involvement is frequently seen 3
• Widespread distribution may extend beyond classic sites to involve the legs 1

Atypical Presentations

• Eczema coxsackium can occur in children with atopic dermatitis, mimicking herpes simplex virus superinfection 4
• Periungual desquamation typically begins 2-3 weeks after fever onset 1
• Beau's lines (deep transverse nail grooves) may appear 1-2 months after fever onset as a delayed sequela 1

Severe Disease Warning Signs

Children under 3 years with EV-A71 infection and disease duration less than 3 days require heightened vigilance for progression to severe disease. 5

Critical indicators of deterioration include:

• Persistent hyperthermia 5
• Neurological involvement (encephalitis, meningitis, acute flaccid paralysis) 1, 5
• Worsening respiratory rate and rhythm 5
• Circulatory dysfunction 5
• Elevated peripheral WBC count 5
• Elevated blood glucose 5
• Elevated blood lactic acid 5

Causative Agents

• Coxsackievirus A16 causes most mild cases 2
• Enterovirus A71 (EV-A71) is associated with more severe outbreaks, particularly in Asia, with higher complication rates including neurogenic pulmonary edema and myocardial impairment 1, 2

Diagnostic Approach

Clinical Diagnosis

Most cases are diagnosed clinically based on characteristic presentation 3

Laboratory Confirmation

• RT-PCR of vesicle fluid is the preferred diagnostic method due to high viral loads and optimal sensitivity 1
• Respiratory samples or stool specimens can also be used for RT-PCR testing 1

Critical Differential Diagnoses

Distinguish HFMD from herpes simplex virus infection, as HSV has available antiviral treatment whereas HFMD does not. 1

Additional differentials to consider:

• Drug hypersensitivity reactions 1
• Kawasaki disease (HFMD has vesicular lesions vs. diffuse erythema) 1
• Syphilis, meningococcemia, and Rocky Mountain spotted fever in atypical presentations 1

Treatment Guidelines

Supportive Care (Primary Management)

Given the self-limited nature of most cases, treatment is mainly symptomatic and supportive, with most children recovering in 7-10 days without sequelae. 2

Pain and Fever Management

• Acetaminophen or NSAIDs for limited duration to relieve pain and reduce fever 1

Oral Lesion Management

• Gentle oral hygiene with mild toothpaste 1
• Warm saline mouthwashes or oral sponge for comfort 1
• Benzydamine hydrochloride oral rinse or spray every 3 hours, particularly before eating 1
• Chlorhexidine oral rinse twice daily as antiseptic 1
• Betamethasone sodium phosphate mouthwash four times daily for severe oral involvement 1
• White soft paraffin ointment to lips every 2 hours to prevent drying and cracking 1

Skin Lesion Management

• Intensive moisturizing with urea-containing creams for hands and feet 1
• Avoid friction and heat exposure to affected areas 1
• Zinc oxide can be applied as a protective barrier to soothe inflamed areas and reduce itchiness 1
• Apply zinc oxide in thin layers after gentle cleansing, avoiding open or weeping lesions 1

Foot Care for Open Sores

• Wash feet daily with careful drying, particularly between the toes 1
• Avoid walking barefoot and wear appropriate cushioned footwear 1
• Do not soak feet in footbaths, as this induces maceration 1
• Monitor for secondary infection (increased redness, warmth, purulent drainage, worsening pain) 1
• Avoid topical antiseptic or antimicrobial dressings routinely, as these are not recommended 1

Severe/Complicated Disease

Intravenous immunoglobulin (IVIG) should be considered for severe or complicated HFMD and has been recommended by several national and international guideline committees. 2

Medications to Avoid

• No specific antiviral agents are currently approved for HFMD treatment 2
• Ribavirin, suramin, and other agents remain investigational 2

Monitoring and Follow-Up

• Reassess after 2 weeks if lesions are not improving with standard care 1
• Re-evaluate after 4 weeks if evidence of infection has not resolved and consider alternative diagnoses 1
• Immunocompromised patients require closer monitoring due to risk of more severe disease 1

Infection Control and Return to Activities

Prevention Measures

Hand hygiene with thorough handwashing using soap and water is the most important preventive measure and is more effective than alcohol-based hand sanitizers. 1

Additional measures:

• Environmental cleaning of toys and objects that may be placed in children's mouths 1
• Avoid sharing utensils, cups, or food 1

Return to Daycare/School

Children can return to daycare 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 unnecessary 1
• By the time HFMD is diagnosed, the child has likely been infectious for weeks, posing limited additional risk 1
• Standard precautions and good hand hygiene should be followed in healthcare settings 1

Common Pitfalls

• Do not use chemical agents or plasters to remove corns or calluses on affected feet 1
• Do not routinely use topical antimicrobials for foot lesions 1
• Do not delay recognition of severe disease in high-risk children (under 3 years, EV-A71 infection, disease duration <3 days) 5
• Do not confuse with herpes simplex virus, especially in children with atopic dermatitis presenting with eczema coxsackium 4