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 requires supportive care focused on pain relief and hydration, as there are no approved antiviral treatments for this self-limited viral illness. 1, 2

Symptomatic Treatment

Pain and Fever Management

• Use oral acetaminophen or NSAIDs for pain relief and fever reduction 1, 2
• Continue analgesics as needed until symptoms resolve, typically within 7-10 days 3, 2
• Avoid oral lidocaine due to lack of evidence supporting its use 2

Oral Lesion Care

• Apply white soft paraffin ointment to 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 mouth daily with warm saline mouthwashes 1
• Apply 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 water as a rinse-and-spit solution 1-4 times daily 1
• Use barrier preparations such as Gengigel mouth rinse or Gelclair for additional pain control 1

Dietary Modifications

• Eliminate tomatoes, citrus fruits, hot drinks, and spicy, hot, raw, or crusty foods that exacerbate oral pain 1
• Encourage ample fluid intake to maintain hydration and keep the mouth moist 1
• This is critical as painful oral lesions may lead to decreased oral intake, particularly in young children 2

Skin Manifestation Management

Hand and Foot Lesions

• Apply intensive moisturizing care with urea-containing creams to hands and feet 1
• Use zinc oxide as a protective barrier to soothe inflamed areas and reduce itchiness 1
• Apply zinc oxide in a thin layer after gentle cleansing, repeating as needed when itchiness returns 1
• For nighttime relief, apply zinc oxide followed by loose cotton gloves to create an occlusive barrier 1
• Avoid friction and heat exposure to affected areas 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 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

Severe Disease Management

Indications for Escalated Care

• Consider intravenous immunoglobulin for severe or complicated HFMD, particularly with neurological or cardiopulmonary involvement 3
• This is especially important for enterovirus A71 infections, which carry higher complication rates including meningoencephalitis, myocarditis, and neurogenic pulmonary edema 3, 4
• Immunocompromised patients require close monitoring as they may experience more severe disease 1

Infection Control and Return to Activities

Prevention Measures

• Hand hygiene with soap and water is the most important preventive measure and is more effective than alcohol-based sanitizers 1
• Disinfect toys and objects that may be placed in children's mouths 1, 2
• Avoid sharing utensils, cups, or food 1

Return to Daycare/School

• Children can return 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 shedding virus for weeks, posing limited additional risk 1

Follow-Up and Monitoring

Expected Course

• Most cases resolve within 7-10 days without sequelae 3, 2
• Reassess after 2 weeks if lesions are not improving with standard care 1
• If evidence of infection persists after 4 weeks, re-evaluate and consider alternative diagnoses 1

Late Manifestations to Anticipate

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

Critical Differential Diagnoses

Distinguish HFMD from herpes simplex virus infection, as HSV has available antiviral treatment whereas HFMD does not 1, 2. Also consider drug hypersensitivity reactions, Kawasaki disease (which presents with diffuse erythema rather than vesicular lesions), erythema multiforme, measles, and varicella 1, 2.

Common Pitfalls

• 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
• Recognize that "eczema coxsackium" in children with atopic dermatitis may mimic herpetic superinfection 4