What is the recommended treatment for hand, foot, and mouth disease (HFMD) in patients with mild symptoms, particularly in high-risk populations like young children or immunocompromised individuals?

Hand, Foot, and Mouth Disease: Treatment Recommendations

For mild hand, foot, and mouth disease in young children and immunocompromised patients, provide supportive care with oral analgesics (acetaminophen or NSAIDs) for pain and fever control, maintain hydration, and monitor closely for neurological complications—particularly in high-risk populations where enterovirus 71 can cause severe disease. 1

Supportive Care Measures

The cornerstone of HFMD management is symptomatic relief, as no specific antiviral therapy is approved for routine use. 1, 2

Pain and Fever Management

• Use acetaminophen or NSAIDs for a limited duration to relieve pain and reduce fever 1
• These medications address both constitutional symptoms and discomfort from oral and skin lesions 1

Oral Lesion Management

• 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 or use an oral sponge for comfort 1
• Use chlorhexidine oral rinse twice daily as an antiseptic measure 1
• For more severe oral involvement, consider betamethasone sodium phosphate mouthwash four times daily 1
• Barrier preparations such as Gengigel mouth rinse or gel or Gelclair are helpful for pain control 1

Dietary Modifications

• Eliminate foods such as tomatoes, citrus fruits, hot drinks, and spicy, hot, raw, or crusty foods that can exacerbate oral pain 1
• Drink ample fluids to keep the mouth moist and prevent dehydration 1
• This is particularly critical in young children who may refuse oral intake due to painful mouth sores 2

Skin Manifestation Management

Hand and Foot Lesions

• Apply intensive skin care with moisturizing creams, particularly urea-containing products 1
• Avoid friction and heat exposure to affected areas 1
• For itchiness, zinc oxide 20% can be applied as a protective barrier on the skin, soothing inflamed areas 1
• Apply zinc oxide in a thin layer after gentle cleansing of the affected areas 1
• Avoid applying zinc oxide to open or weeping lesions 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 can induce skin maceration and worsen open sores 1
• Monitor for signs of secondary infection, including increased redness, warmth, purulent drainage, or worsening pain 1
• Treat any secondary bacterial infections that may develop 1

Special Considerations for High-Risk Populations

Immunocompromised Patients

• Immunocompromised patients may experience more severe disease and should be monitored closely 1
• While the evidence does not provide specific protocols for immunocompromised patients, heightened vigilance for complications is warranted given their increased vulnerability

Young Children (Under 5 Years)

• Children younger than 5 years are most commonly affected and require careful monitoring 2
• Enterovirus 71 (EV-A71) is associated with more severe outbreaks and neurological complications, particularly in Asia 1, 3
• Neurological complications such as encephalitis/meningitis can occur in severe cases, particularly with EV-71 1
• Acute flaccid myelitis (AFM) and acute flaccid paralysis (AFP) are rare but potential complications 1
• Circulatory failure secondary to myocardial impairment and neurogenic pulmonary edema secondary to brainstem damage are the main causes of death 2

Severe Disease Management

For severe or complicated HFMD with neurological or cardiopulmonary involvement, intravenous immunoglobulin should be considered and has been recommended by several national and international guideline committees. 2

• In severe HFMD cases, suitable treatment also encompasses mechanical ventilation 3
• Additional application of antiviral agents such as ribavirin may be considered in severe cases, though no specific antiviral agents are approved for routine treatment 3, 2

Diagnostic Confirmation

• 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 diagnosis 1
• Distinguish HFMD 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

Prevention and Infection Control

• Hand hygiene is the most important preventive measure, with thorough handwashing with soap and water being more effective than alcohol-based hand sanitizers 1
• Environmental cleaning, particularly of toys and objects that may be placed in children's mouths, is crucial 1
• Avoid sharing utensils, cups, or food 1
• Children with HFMD should avoid close contact with others until fever resolves and mouth sores heal 1
• Standard precautions and good hand hygiene practices should be followed in healthcare settings 1

Return to Daycare Guidelines

• 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 1
• By the time HFMD is diagnosed, the child has likely had the infection for weeks, posing limited additional risk to others 1

Follow-Up and Monitoring

• 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
• Be aware of late manifestations: Beau's lines (deep transverse nail grooves) may appear approximately 1-2 months after fever onset 1
• Periungual desquamation typically begins 2-3 weeks after onset of fever 1
• Nail changes such as shedding may follow HFMD after a latency period 4

Critical 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
• Recognize atypical manifestations in children with atopic dermatitis, including 'eczema coxsackium', which may mimic herpetic superinfection 4, 5
• Be vigilant for coxsackievirus A6-associated HFMD, which can affect adults and present with more severe symptoms and widespread exanthema beyond classic distribution 1, 5