What is the management approach for a child 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, with most cases resolving in 7-10 days without intervention. 1, 2

Symptomatic Treatment

Pain and Fever Management

• Use acetaminophen or ibuprofen for pain relief and fever reduction 1, 2
• Avoid oral lidocaine as it is not recommended for oral lesions 2
• No antiviral agents are currently approved for HFMD treatment 3, 2

Oral Lesion Care

• Apply white soft paraffin ointment to lips every 2 hours to prevent drying and cracking 1
• Use warm saline mouthwashes or oral sponges for gentle cleaning 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 water as a rinse-and-spit solution 1-4 times daily 1
• Barrier preparations such as Gengigel mouth rinse/gel or Gelclair help with 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

Skin Care for Hand and Foot Lesions

• Apply intensive moisturizing creams, particularly urea-containing products, to hands and feet 1
• Use zinc oxide as a protective barrier for itchy lesions, applying in thin layers after gentle cleansing 1
• For nighttime relief, apply zinc oxide followed by loose cotton gloves to enhance effectiveness 1
• Avoid applying zinc oxide to open or weeping lesions 1
• Do not use chemical agents or plasters to remove corns or calluses 1

Foot Care for Open Sores

• Wash feet daily with careful drying, particularly between 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

Monitoring for Complications

Warning Signs Requiring Close Observation

• Monitor for neurological complications including meningoencephalitis, brainstem encephalitis, acute flaccid paralysis, and acute flaccid myelitis, particularly with Enterovirus 71 infections 1, 4
• Watch for fever, vomiting, myoclonic jerks, seizures, headache, and convulsions as indicators of severe neurological involvement 4
• Circulatory failure from myocardial impairment and neurogenic pulmonary edema from brainstem damage are the main causes of death 3

Special Populations

• Immunocompromised patients may experience more severe disease and require closer monitoring 1
• Enterovirus 71 (EV-A71) is associated with more severe outbreaks, especially in Asia, with higher complication rates than Coxsackievirus A16 1, 3

Secondary Infection Surveillance

• Monitor for signs of secondary bacterial infection including increased redness, warmth, purulent drainage, or worsening pain 1
• Treat any secondary bacterial infections that develop 1

Severe/Complicated Disease Management

For severe or complicated HFMD, intravenous immunoglobulin should be considered and has been recommended by several national and international guideline committees. 3

• Glucocorticoid therapy is commonly used alongside IVIG for severe neurological complications 4
• 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

Prevention and Infection Control

Hand Hygiene

• Thorough handwashing with soap and water is more effective than alcohol-based hand sanitizers and is the most important preventive measure 1, 2
• Disinfect toys and objects that may be placed in children's mouths 1

Isolation and Return to Activities

• 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
• Avoid sharing utensils, cups, or food 1
• In healthcare settings, follow standard precautions and good hand hygiene practices 1

Diagnostic Considerations

Differential Diagnosis

• 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 differentials include erythema multiforme, measles, and varicella 2

Diagnostic Testing

• Vesicle fluid samples have high viral loads and are ideal for testing, with reverse transcriptase PCR (RT-PCR) targeting the 5′ non-coding region being the preferred diagnostic method 1
• Respiratory samples and/or stool specimens can also be used for RT-PCR diagnosis 1

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, 5
• 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 exclude children from daycare based solely on the presence of healing skin lesions 1
• Do not overlook atypical presentations in children with atopic dermatitis, where "eczema coxsackium" may resemble herpetic superinfection 5