What is the management approach for a pediatric patient presenting with suspected hand, foot, and mouth disease (HFMD)?

Management of Hand, Foot, and Mouth Disease

Hand, foot, and mouth disease (HFMD) is a self-limiting viral illness requiring supportive care only—focus on pain control, hydration, and parent counseling about the benign course, with return to daycare once fever resolves and mouth sores heal. 1

Immediate Clinical Assessment

When evaluating a patient with suspected HFMD, look for these specific diagnostic features:

• Classic triad: Fever, oral ulcers/vesicles, and vesicular rash on palms, soles, and buttocks 1, 2
• Incubation period: 3-10 days before symptom onset 3
• Progression: Fever and sore throat appear first, followed 1-2 days later by the characteristic rash 3
• Atypical presentations: Widespread exanthema beyond classic distribution (legs, arms) may occur, particularly with coxsackievirus A6 1, 4

Critical Differential Diagnoses to Exclude

Before confirming HFMD, rule out these conditions that require different management:

• Herpes simplex virus: This is crucial because HSV has antiviral treatment options whereas HFMD does not 1
• Kawasaki disease: Look for diffuse erythema rather than vesicular lesions 1
• Drug hypersensitivity reactions: Can present with palmar-plantar rash 1
• In atypical presentations: Consider syphilis, meningococcemia, and Rocky Mountain spotted fever 1

Diagnostic Testing (When Needed)

Most cases are diagnosed clinically, but laboratory confirmation may be warranted in outbreak settings or severe cases:

• Preferred method: RT-PCR of vesicle fluid (highest viral load) targeting the 5' non-coding region 1
• Alternative samples: Respiratory samples or stool specimens 1

Treatment Protocol

Pain and Fever Management

• First-line: Acetaminophen or NSAIDs for limited duration to relieve pain and reduce fever 1
• Avoid aspirin in children due to Reye's syndrome risk (general medical knowledge)

Oral Lesion Management (Stepwise Approach)

Mild cases:

• Apply white soft paraffin ointment to lips every 2 hours to prevent drying and cracking 1
• Warm saline mouthwashes or oral sponge for comfort 1
• Mild toothpaste and gentle oral hygiene 1

Moderate cases:

• Benzydamine hydrochloride oral rinse or spray every 3 hours, particularly before eating 1
• Chlorhexidine oral rinse twice daily as antiseptic 1
• Barrier preparations such as Gengigel mouth rinse/gel or Gelclair for pain control 1

Severe oral involvement:

• Betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water as 2-3 minute rinse-and-spit solution 1-4 times daily 1
• Dilute mouthwashes by 50% if they cause discomfort 1

Dietary modifications:

• Eliminate tomatoes, citrus fruits, hot drinks, and spicy/hot/raw/crusty foods 1
• Encourage ample fluid intake to maintain hydration and keep mouth moist 1

Skin Manifestations Management

For hands and feet:

• Intensive moisturizing with urea-containing creams 1
• Avoid friction and heat exposure to affected areas 1
• Do not use chemical agents or plasters to remove corns/calluses 1

For itchiness:

• Apply zinc oxide 20% cream in thin layer after gentle cleansing 1
• Reapply as needed when itchiness returns 1
• For nighttime relief, apply zinc oxide followed by loose cotton gloves to create occlusive barrier 1
• Avoid applying to open or weeping lesions 1

For open sores on feet:

• Wash feet daily with careful drying, particularly between toes 1
• Avoid walking barefoot; wear appropriate cushioned footwear 1
• Do not soak feet in footbaths as this induces maceration and worsens open sores 1
• Do not use topical antiseptic or antimicrobial dressings routinely 1

Secondary Infection Monitoring

• Watch for increased redness, warmth, purulent drainage, or worsening pain 1
• Treat any secondary bacterial infections that develop 1

Special Populations

Immunocompromised patients:

• May experience more severe disease and require close monitoring 1

Severe cases (primarily EV-71 in Asia):

• Watch for neurological complications: encephalitis/meningitis, acute flaccid myelitis, acute flaccid paralysis 1
• Severe respiratory symptoms including pulmonary edema 3
• May require mechanical ventilation and consideration of ribavirin 3

Infection Control and Return to Activities

Prevention measures:

• Hand hygiene with soap and water is the single most important preventive measure—more effective than alcohol-based sanitizers 1, 5
• Clean and disinfect toys and objects that may be placed in children's mouths 1
• Avoid sharing utensils, cups, or food 1, 5
• Avoid close contact with others until criteria for return are met 1

Return to daycare/school criteria:

• Child 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 not necessary 1
• By the time HFMD is diagnosed, the child has likely been shedding virus for weeks, posing limited additional risk 1

Follow-Up and Expected Course

Typical timeline:

• Symptoms usually last less than 1 week 2
• Most cases are benign and self-limiting 3, 6

Delayed sequelae (reassure parents these are benign):

• Periungual desquamation typically begins 2-3 weeks after fever onset 1
• Beau's lines (nail grooves) or nail shedding may appear 1-2 months after fever onset 1, 4

When to reassess:

• If lesions not improving after 2 weeks with standard care 1
• If evidence of infection has not resolved after 4 weeks, re-evaluate and consider alternative diagnoses 1

Common Pitfalls to Avoid

• Do not prescribe antiviral therapy—no generally recommended antiviral exists for HFMD 3
• Do not exclude children from daycare based on skin lesions alone if fever resolved and mouth sores healed 1
• Do not rely solely on alcohol-based hand sanitizers—soap and water is superior 1, 5
• Do not use aggressive wound care products on foot lesions 1

Key Counseling Points

Active communication and close monitoring are integral to managing HFMD without complications 6. Reassure parents that:

• This is a self-limiting disease with excellent prognosis in most cases 6, 7
• Nail changes weeks later are expected and benign 1, 4
• The child has likely been contagious before diagnosis, so isolation after symptom onset has limited benefit 1