What are the management strategies for a patient with hand, foot, and mouth disease?

Management of Hand, Foot, and Mouth Disease

Hand, foot, and mouth disease requires supportive care focused on pain relief and hydration, as there are no specific antiviral treatments available for this self-limiting viral illness. 1, 2

Symptomatic Treatment

Pain and Fever Management

• Use acetaminophen or NSAIDs (ibuprofen) at the lowest effective dose for limited duration to relieve pain and reduce fever. 1, 2
• Oral lidocaine is not recommended for pain control. 2

Oral Lesion Management

For patients with painful oral ulcerations that interfere with eating or drinking:

• Apply white soft paraffin ointment to the lips every 2 hours to prevent drying and cracking. 1
• Use benzydamine hydrochloride oral rinse or spray every 3 hours, particularly before eating, to reduce inflammation and pain. 1
• Clean the mouth daily with warm saline mouthwashes for comfort. 1
• Consider chlorhexidine oral rinse twice daily as an antiseptic measure. 1
• For severe oral involvement, consider betamethasone sodium phosphate 0.5 mg dissolved in 10 mL of water as a 2-3 minute rinse-and-spit solution one to four times daily. 1
• Barrier preparations such as Gengigel mouth rinse or gel or Gelclair are helpful for pain control. 1

Dietary Modifications

• Eliminate tomatoes, citrus fruits, hot drinks, and spicy, hot, raw, or crusty foods that exacerbate oral pain. 1
• Ensure adequate fluid intake to maintain hydration and keep the mouth moist. 1, 2

Skin Lesion Management

• Apply intensive skin care to hands and feet with moisturizing creams, particularly urea-containing products. 1
• Avoid friction and heat exposure to affected areas. 1
• For itchiness, zinc oxide can be applied as a protective barrier in a thin layer after gentle cleansing; avoid applying 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

Infection Control and Prevention

Hand Hygiene

• Thorough handwashing with soap and water is the most important preventive measure and is more effective than alcohol-based hand sanitizers. 1

Environmental Cleaning

• Disinfect toys and objects that may be placed in children's mouths. 1, 2
• Avoid sharing utensils, cups, or food. 1

Isolation Precautions

• 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 not necessary, as by the time HFMD is diagnosed, the child has likely had the infection for weeks. 1
• Follow standard precautions and good hand hygiene practices in healthcare settings. 1

Monitoring and Follow-Up

Routine Cases

• Most cases resolve in 7-10 days without sequelae. 2, 3
• 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

Warning Signs Requiring Urgent Evaluation

Monitor for neurological or cardiopulmonary complications, particularly with Enterovirus 71 infections:

• Encephalitis/meningitis 1
• Acute flaccid myelitis or paralysis 1
• Circulatory failure secondary to myocardial impairment 3
• Neurogenic pulmonary edema secondary to brainstem damage 3

Special Populations

• Immunocompromised patients may experience more severe disease and should be monitored closely. 1
• Intravenous immunoglobulin should be considered for severe/complicated HFMD. 3

Diagnostic Considerations

Confirmation Testing

• Reverse transcriptase PCR (RT-PCR) targeting the 5′ non-coding region is the preferred diagnostic method. 1
• Vesicle fluid samples have high viral loads and are ideal for testing; respiratory samples and/or stool specimens can also be used. 1

Critical Differential Diagnoses

• 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
• Differentiate from Kawasaki disease (HFMD has vesicular lesions vs. diffuse erythema). 1
• Consider erythema multiforme, measles, and varicella in the differential. 2

Expected Late Manifestations

• Beau's lines (deep transverse nail grooves) may appear approximately 1-2 months after fever onset, representing a delayed sequela rather than active disease. 1
• Periungual desquamation typically begins 2-3 weeks after onset of fever. 1

Common Pitfalls to Avoid

• Do not use topical antiseptic or antimicrobial dressings routinely for HFMD foot lesions, as these are not recommended for wound healing. 1
• Do not use chemical agents or plasters to remove any associated corns or calluses. 1
• Do not prescribe antiviral medications, as none are currently approved for HFMD treatment. 2, 3