What are the typical presentation, supportive management, isolation duration, and prevention strategies for hand‑foot‑and‑mouth disease in children in Australia?

Hand, Foot, and Mouth Disease in Australia

Children with hand, foot, and mouth disease (HFMD) can return to daycare once fever has resolved and mouth sores have healed, even if skin rash persists, as exclusion based solely on healing skin lesions is unnecessary. 1

Clinical Presentation

Initial Symptoms

• Fever is typically the first symptom, usually low-grade but can exceed 39°C (102.2°F), accompanied by general malaise and irritability 2
• Respiratory symptoms such as cough and rhinitis may occur, particularly in younger children 2
• The characteristic vesicular rash appears 1-2 days after fever onset 2

Disease Progression

• Oral lesions develop first as small red spots that progress to painful vesicles and ulcers on the tongue, gums, and inside of the cheeks 2
• Skin lesions present as a maculopapular or papulovesicular rash on the hands and soles of the feet 3
• Fever usually subsides within 3-4 days 2
• Oral ulcers may persist for 7-10 days and can cause significant discomfort leading to decreased oral intake 2
• Lesions typically resolve completely in 7-10 days 3

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

Supportive Management

Pain and Fever Control

• Use oral acetaminophen or NSAIDs for a limited duration to relieve pain and reduce fever 1
• Avoid oral lidocaine, as it is not recommended 3

Oral Lesion Management

• Apply white soft paraffin ointment to the lips every 2 hours to prevent drying and cracking 1
• Use warm saline mouthwashes or an oral sponge for comfort 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 of water as a 2-3 minute rinse-and-spit solution one to four times daily 1
• Barrier preparations such as Gengigel mouth rinse or gel or Gelclair are helpful for pain control 1

Dietary Modifications

• Eliminate tomatoes, citrus fruits, hot drinks, and spicy, hot, raw, or crusty foods that can exacerbate oral pain 1
• Encourage ample fluid intake to keep the mouth moist and prevent dehydration 1

Skin Care

• Apply intensive moisturizing creams to hands and feet, particularly urea-containing products 1
• For itchiness, apply zinc oxide in a thin layer after gentle cleansing of affected areas; can be repeated as needed 1
• Avoid applying zinc oxide to open or weeping lesions 1
• For nighttime relief, consider applying zinc oxide followed by loose cotton gloves to create an occlusive barrier 1

Foot Lesion Management (if open sores present)

• 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

Isolation Duration and Return to Daycare

The American Academy of Pediatrics recommends that children can return to daycare once fever has resolved and mouth sores have healed, even if skin rash is still present. 1 By the time HFMD is diagnosed, the child has likely had the infection for weeks, posing limited additional risk to others 1.

Key Points:

• Exclusion based solely on healing skin lesions is not necessary 1
• Children should avoid close contact with others until fever resolves and mouth sores heal 1

Prevention Strategies

Hand Hygiene (Most Important)

• Thorough handwashing with soap and water is more effective than alcohol-based hand sanitizers and is the most important preventive measure 1

Environmental Measures

• Clean toys and objects that may be placed in children's mouths 1
• Disinfect potentially contaminated surfaces and fomites 3
• Avoid sharing utensils, cups, or food 1

Healthcare Settings

• Follow standard precautions and good hand hygiene practices 1

Warning Signs Requiring Urgent Evaluation

Seek immediate medical attention if the child develops:

• Persistent high fever 2
• Lethargy or unusual irritability 2
• Severe headache or stiff neck 2
• Respiratory distress 2
• Signs of dehydration from poor oral intake 2

These may indicate rare but serious complications such as meningitis, encephalitis, acute flaccid paralysis, or neurogenic pulmonary edema, particularly with Enterovirus 71 infections 2, 4, 5.

Diagnostic Considerations

When to Consider Testing

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

Important Differential Diagnoses

• Distinguish from herpes simplex virus infection, as HSV has available antiviral treatment whereas HFMD does not 1
• Rule out Kawasaki disease, which presents with persistent high fever, diffuse erythema (not vesicular lesions), conjunctival injection, strawberry tongue, and cervical lymphadenopathy 2
• Consider drug hypersensitivity reactions, which can also present with palmar-plantar rash 1
• Differentiate from erythema multiforme, which has target lesions with central clearing typically on extensor surfaces 2

Follow-Up

• Reassess after 2 weeks if lesions are not improving with standard care 1
• Re-evaluate after 4 weeks if evidence of infection has not resolved and consider alternative diagnoses 1
• Monitor for secondary bacterial infections that may require antibiotic treatment 1

Special Considerations

• Immunocompromised patients may experience more severe disease and should be monitored closely 1
• No specific antiviral therapy is available for HFMD 3, 5
• Atypical manifestations may occur in children with atopic dermatitis, including "eczema coxsackium" which can resemble herpes infection 6