How do I manage hand, foot, and mouth disease in a healthy child under five with fever, sore throat, and vesicular lesions on the palms, soles, and oral mucosa?

Management of Hand, Foot, and Mouth Disease in Children Under Five

For a healthy child under five with fever, sore throat, and vesicular lesions on palms, soles, and oral mucosa, provide symptomatic management with oral analgesics while immediately excluding life-threatening conditions like Rocky Mountain Spotted Fever and meningococcemia that can present similarly. 1

Critical First Step: Exclude Life-Threatening Mimics

Before settling on HFMD as your diagnosis, you must actively rule out conditions with significant mortality:

• Rocky Mountain Spotted Fever (RMSF) has a 5-10% mortality rate if untreated and can present with palmar-plantar rash, though RMSF typically shows blanching pink macules evolving to petechiae rather than vesicles, with prominent systemic toxicity 1
• Start doxycycline immediately if RMSF cannot be excluded based on clinical presentation, even in young children, as the mortality risk outweighs concerns about dental staining 2
• Meningococcemia requires emergent ceftriaxone administration, as the rash progresses rapidly within hours (not days) and presents as petechial/purpuric rather than vesicular 1
• Kawasaki disease must be considered if fever persists ≥5 days, but presents with diffuse erythema and edema of hands/feet rather than discrete vesicles, plus bilateral conjunctival injection 1

Symptomatic Treatment Protocol

Once life-threatening conditions are excluded, management focuses on comfort:

Pain and Fever Management

• Administer acetaminophen or NSAIDs for limited duration to relieve pain and reduce fever 1, 3
• Never use aspirin in children due to Reye's syndrome risk 1

Oral Lesion Care

• Apply white soft paraffin ointment to lips every 2 hours to prevent drying and cracking 1, 3
• Use benzydamine hydrochloride oral rinse or spray every 3 hours, particularly before eating, to reduce inflammation and pain 1, 3
• Apply chlorhexidine oral rinse twice daily as an antiseptic measure 1, 3
• Clean mouth with warm saline mouthwashes or oral sponge for comfort 1, 3
• For severe oral involvement, consider betamethasone sodium phosphate mouthwash four times daily 3

Skin Lesion Management

• Apply intensive moisturizing with urea-containing creams to hands and feet 1, 3
• Use zinc oxide 20% as a thin layer after gentle cleansing for itchiness, which works as a protective barrier and has immune-modulating properties 3
• Avoid friction and heat exposure to affected areas 1, 3
• Do not use chemical agents or plasters to remove lesions 1, 3

Infection Control and Return to Activities

• Hand hygiene with soap and water is more effective than alcohol-based sanitizers and represents the single most important preventive measure 1, 3
• Clean toys and objects that may be placed in children's mouths regularly 1, 3
• Children can return to daycare once fever resolves and mouth sores heal, even if skin rash persists—exclusion based solely on healing skin lesions is unnecessary 1, 3
• Avoid sharing utensils, cups, or food during the illness period 1, 3

Follow-Up and Warning Signs

• Reassess after 2 weeks if lesions are not improving with standard care 1, 3
• Re-evaluate and consider alternative diagnoses if symptoms have not resolved after 4 weeks 1, 3
• Monitor for neurological complications including encephalitis/meningitis, acute flaccid myelitis, and acute flaccid paralysis, particularly with Enterovirus 71 strains, though these are rare 1, 3

Expected Late Manifestations (Not Complications)

• Periungual desquamation typically begins 2-3 weeks after fever onset and represents a normal sequela 1, 3
• Beau's lines (deep transverse nail grooves) may appear 1-2 months after fever onset, representing delayed sequelae rather than active disease 3

Common Pitfalls to Avoid

• Do not delay doxycycline if RMSF cannot be excluded—up to 40% of RMSF patients report no tick bite history, and serology is negative in early disease 2
• Do not wait for serologic confirmation before treating suspected RMSF, as 50% of deaths occur within 9 days of illness onset 2
• Do not exclude RMSF based on geography alone—while more common in south central and south Atlantic states, cases occur nationwide 2
• Do not routinely use topical antiseptic or antimicrobial dressings for HFMD foot lesions, as these are not recommended for wound healing 3