How should hand‑foot‑mouth disease in a child be managed, including supportive care, isolation period, warning signs, and when it is safe to return to school?

Management of Hand, Foot, and Mouth Disease in Children

Hand, foot, and mouth disease (HFMD) is a self-limited viral illness requiring supportive care focused on pain control and hydration, with children able to return to school once fever resolves and mouth sores heal, even if skin lesions persist. 1

Supportive Care Measures

Pain and Fever Management

• Administer acetaminophen or ibuprofen for pain relief and fever reduction during the acute phase, particularly in the first 24-48 hours when symptoms are most severe 1, 2
• For infants under 6 months, consider nonnutritive sucking with a pacifier to reduce pain-related distress from oral lesions 1
• Administer 2 mL of 25% sucrose solution by syringe (1 mL per cheek) for infants younger than 6 months during particularly painful events such as feeding attempts 1
• Avoid oral lidocaine as it is not recommended for HFMD 2

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 oral sponges for daily mouth cleaning and comfort 1
• Apply benzydamine hydrochloride oral rinse or spray every 3 hours, particularly before eating, to reduce inflammation and pain 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
• Eliminate acidic foods (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 Lesion Care

• Apply intensive moisturizing creams containing urea to hands and feet to soothe inflamed areas 1
• Use zinc oxide in a thin layer on itchy lesions after gentle cleansing; this can be repeated as needed and provides a protective barrier with immune-modulating properties 1
• Avoid chemical agents or plasters to remove corns or calluses 1
• For nighttime relief, apply zinc oxide followed by loose cotton gloves to create an occlusive barrier 1

Foot Care for Open Sores

• Wash feet daily with careful drying, particularly between the toes, to prevent secondary complications 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
• Monitor for signs of secondary bacterial infection including increased redness, warmth, purulent drainage, or worsening pain 1

Isolation and Return to School Guidelines

Children can return to daycare or school once fever has resolved and mouth sores have healed, even if the skin rash is still present. 1 Exclusion based solely on healing skin lesions is unnecessary because by the time HFMD is diagnosed, the child has likely been shedding virus for weeks, posing limited additional risk to others 1.

Infection Control Measures

• Emphasize thorough handwashing with soap and water as the most important preventive measure; this is more effective than alcohol-based hand sanitizers 1, 2
• Clean and disinfect toys and objects that may be placed in children's mouths 1
• Avoid sharing utensils, cups, or food to prevent spread 1
• Children should avoid close contact with others until fever resolves and mouth sores heal 1

Warning Signs Requiring Re-evaluation

Neurological Complications

• Watch for signs of encephalitis/meningitis: severe headache, neck stiffness, altered mental status, or seizures, particularly with enterovirus A71 infections 1, 3
• Monitor for acute flaccid paralysis or acute flaccid myelitis: sudden onset of limb weakness or paralysis 1
• These complications are more common in severe cases, especially in Asia with EV-A71 outbreaks 1, 3

Cardiopulmonary Complications

• Assess for signs of myocardial impairment: chest pain, shortness of breath, or signs of heart failure 3
• Watch for neurogenic pulmonary edema: rapid breathing, respiratory distress, or hypoxia 3
• These are the main causes of death in severe HFMD cases 3

Signs of Secondary Infection

• Increased redness, warmth, purulent drainage, or worsening pain at skin lesion sites suggests bacterial superinfection requiring antibiotic treatment 1

Dehydration

• Monitor for decreased urine output, dry mucous membranes, lethargy, or sunken fontanelle in infants, as painful oral lesions may limit fluid intake 2, 3

Follow-up Recommendations

• 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
• Expect Beau's lines (deep transverse nail grooves) approximately 1-2 months after fever onset as a delayed sequela rather than active disease 1
• Periungual desquamation typically begins 2-3 weeks after onset of fever 1

Critical Differential Diagnoses

Distinguish HFMD from herpes simplex virus infection, as HSV has available antiviral treatment whereas HFMD does not 1. Also consider:

• Erythema multiforme: target lesions versus vesicles 2
• Varicella: more widespread distribution and different vesicle morphology 2, 4
• Eczema herpeticum in children with atopic dermatitis: may mimic "eczema coxsackium" (HFMD superinfection of eczematous skin) 5
• Drug hypersensitivity reactions: can present with palmar-plantar rash 1
• Kawasaki disease: diffuse erythema versus vesicular lesions 1

Special Populations

Immunocompromised patients may experience more severe disease and should be monitored closely 1. For severe or complicated HFMD, intravenous immunoglobulin should be considered and has been recommended by several national and international guideline committees 3.

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 school based solely on persistent skin lesions after fever and oral lesions have resolved 1
• Do not prescribe antiviral medications, as none are currently approved or available for HFMD treatment 2, 3
• Do not overlook atypical presentations caused by Coxsackievirus A6, including widespread exanthema, Gianotti-Crosti-like eruptions, or vesiculobullous lesions 4, 5