What is the management 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 supportive care focused on pain relief, hydration, and preventing transmission—no antiviral therapy is available or indicated. 1, 2

Immediate Symptomatic Management

Pain and Fever Control

• Use oral analgesics such as acetaminophen or NSAIDs (ibuprofen) at the lowest effective dose for limited duration to relieve pain and reduce fever. 1, 2
• Avoid oral lidocaine due to lack of evidence and safety concerns. 2

Oral Lesion Management

For mild to moderate oral involvement:

• Apply white soft paraffin ointment to the lips every 2 hours to prevent drying and cracking. 1
• Clean the 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 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/gel or Gelclair are helpful for pain control. 1
• Dilute mouthwashes by 50% if they cause discomfort. 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—this is critical as dehydration is the primary complication requiring medical intervention. 1, 3

Skin Manifestation Management

Hand and Foot Lesions

• Apply intensive skin care with moisturizing creams, particularly urea-containing products (urea cream/ointment). 1
• Avoid friction and heat exposure to affected areas. 1
• For itchiness, apply zinc oxide 20% in a thin layer after gentle cleansing; this can be repeated as needed and provides a protective barrier with immune-modulating properties. 1
• Avoid applying zinc oxide to open or weeping lesions. 1
• For nighttime relief, apply zinc oxide followed by loose cotton gloves to create an occlusive barrier. 1

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—treat secondary infections if they develop. 1
• Do not use topical antiseptic or antimicrobial dressings routinely as these are not recommended for HFMD wound healing. 1

Infection Control and Prevention

Transmission Prevention

• 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
• Clean and disinfect toys and objects that may be placed in children's mouths. 1
• Avoid sharing utensils, cups, or food. 1
• Children should avoid close contact with others until fever resolves and mouth sores heal. 1

Return to Daycare/School Criteria

• Children can return to daycare once fever has resolved and mouth sores have healed, even if skin rash is still present—exclusion based solely on healing skin lesions is unnecessary. 1
• By the time HFMD is diagnosed, the child has likely been shedding virus for weeks, posing limited additional risk to others. 1

Monitoring and Follow-Up

Expected Clinical Course

• Lesions typically resolve in 7-10 days without sequelae. 2, 3
• If symptoms have not resolved after 4 weeks, re-evaluate and consider alternative diagnoses. 1
• Reassess after 2 weeks if lesions are not improving with standard care. 1

Late Manifestations (Not Requiring Treatment)

• 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

Red Flags Requiring Urgent Evaluation

• Monitor immunocompromised patients closely as they may experience more severe disease. 1
• Watch for neurological complications (encephalitis/meningitis, acute flaccid myelitis, acute flaccid paralysis), particularly with Enterovirus 71 (EV-A71), which is associated with more severe outbreaks. 1, 3
• Circulatory failure secondary to myocardial impairment and neurogenic pulmonary edema secondary to brainstem damage are the main causes of death in severe cases. 3

Diagnostic Considerations

When Laboratory Confirmation is Needed

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

Critical Differential Diagnoses to Exclude

• 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 syphilis, meningococcemia, and Rocky Mountain spotted fever in atypical presentations with palmar-plantar involvement. 1
• Other differential diagnoses include erythema multiforme, measles, and varicella. 2

Common Pitfalls to Avoid

• Do not prescribe antiviral therapy—none is available or indicated for HFMD. 2, 3
• Do not use oral lidocaine for pain control. 2
• Do not use chemical agents or plasters to remove corns or calluses associated with HFMD lesions. 1
• Do not routinely apply topical antiseptic or antimicrobial dressings to HFMD foot lesions. 1
• Active communication and close monitoring are integral to managing HFMD without complications—counseling parents about the self-limited nature and expected course is essential. 4