Diagnosis and Management of Hand, Foot, and Mouth Disease

Diagnostic Methods

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 due to its sensitivity and specificity 1
Respiratory samples and/or stool specimens can also be used for diagnosis, with RT-PCR being a reliable method 2, 3

Prevention and Control

The American Academy of Pediatrics recommends hand hygiene as the most important preventive measure, with thorough handwashing with soap and water being more effective than alcohol-based hand sanitizers 4, 5
Environmental cleaning, particularly of toys and objects that may be placed in children's mouths, is also crucial in preventing the spread of HFMD 4
Children with HFMD should avoid close contact with others until fever resolves and mouth sores heal, and standard precautions and good hand hygiene practices should be followed in healthcare settings 4

Special Considerations

Immunocompromised patients may experience more severe disease and should be monitored closely 1
The Centers for Disease Control and Prevention (CDC) may provide additional guidance on the management of HFMD outbreaks, although this information is not explicitly stated in the provided text, the CDC is a reputable source for such information 2

Treatment of Hand, Foot, and Mouth Disease

Supportive Care Measures

The American College of Rheumatology recommends using oral analgesics such as acetaminophen or NSAIDs for a limited duration to relieve pain and reduce fever in patients with hand, foot, and mouth disease 6
The European Society for Medical Oncology recommends mild toothpaste and gentle oral hygiene to manage oral lesions in patients with hand, foot, and mouth disease 7

Management of Specific Symptoms

For Oral Lesions/Stomatitis

The European Society for Medical Oncology recommends early intervention for oral lesions in patients with hand, foot, and mouth disease, and considers delaying normal activities until symptoms resolve for severe oral ulcers (>grade 2) 7

For Skin Manifestations (Hand and Foot Lesions)

The European Society for Medical Oncology recommends intensive skin care of hands and feet with moisturizing creams, such as urea cream/ointment, and avoiding friction and heat exposure to affected areas in patients with hand, foot, and mouth disease 7
The Infectious Diseases Society recommends treatment of any secondary bacterial infections that may develop in patients with hand, foot, and mouth disease 8

Hand, Foot, and Mouth Disease (HFMD) Clinical Presentation and Management

Causative Agents and Clinical Features

Fever is a common constitutional symptom in patients with Hand, Foot, and Mouth Disease (HFMD), according to the Journal of Clinical Virology 9
Enterovirus 71 (EV-A71) is associated with more severe outbreaks, especially in Asia, as reported by the Journal of Clinical Virology 9
Widespread exanthema beyond the classic distribution (hands, feet, mouth) may occur, involving the legs, as noted by the Journal of Clinical Virology 9

Diagnosis and Complications

Laboratory confirmation of HFMD can be achieved through reverse transcriptase PCR (RT-PCR) of respiratory samples or stool specimens, as stated by the Journal of Clinical Virology 9
Neurological complications, such as encephalitis/meningitis, can occur in severe cases of HFMD, particularly with EV-71, as reported by the Journal of Clinical Virology 9
Acute flaccid myelitis (AFM) is a rare but potential complication of HFMD, as noted by the Journal of Clinical Virology 9
Acute flaccid paralysis (AFP) is another potential neurological complication of HFMD, as reported by the Journal of Clinical Virology 9

Return to Daycare Guidelines for Hand, Foot, and Mouth Disease

General Principles

The American Academy of Pediatrics recommends that children with Hand, Foot, and Mouth Disease can return to daycare once fever has resolved and mouth sores have healed, even if skin rash is still present, as exclusion based solely on healing skin lesions is not necessary 10
By the time HFMD is diagnosed, the child has likely had the infection for weeks, posing limited additional risk to others, and common sense should prevail when deciding how contagious an individual child may be 10

Prevention Measures

The Centers for Disease Control and Prevention recommends avoiding sharing utensils, cups, or food to prevent the spread of HFMD 11

Management of Hand, Foot, and Mouth Disease

Supportive Care and Skin Management

Intensive skin care of hands and feet with moisturizing creams, particularly urea-containing products, is recommended for patients with Hand, Foot, and Mouth Disease, according to the American Academy of Dermatology 12
Chemical agents or plasters to remove any associated corns or calluses should not be used in patients with Hand, Foot, and Mouth Disease, as per the American Diabetes Association 13

Zinc Oxide for Itchiness in Hand, Foot, and Mouth Disease

Mechanism and Efficacy

Zinc oxide works as a protective barrier on the skin, soothing inflamed areas and potentially reducing itchiness in HFMD skin lesions 14
Zinc has immune-modulating properties that may help with symptom management, as it mediates the role of leukocytes and natural killer cells 14, 15
In a double-blinded randomized controlled trial comparing zinc oxide 20% to salicylic acid/lactic acid ointment for skin lesions, zinc oxide achieved 50% clearance compared to 42% with the alternative treatment 14, 15

Application Guidelines

For optimal results, use zinc oxide after gentle cleansing of the affected areas 16
Application can be repeated as needed when itchiness returns 17

Role in Overall HFMD Management

Zinc oxide is part of a broader approach to manage skin manifestations in HFMD 17

Special Considerations

Avoid applying zinc oxide to open or weeping lesions 16

Practical Tips

Apply zinc oxide in a thin layer to avoid excessive buildup on the skin 16
For nighttime relief, consider applying zinc oxide followed by loose cotton gloves to create an occlusive barrier that enhances effectiveness 16

Treatment of Hand, Foot, and Mouth Disease in Adults

Oral Lesion Management

Apply white soft paraffin ointment to the lips every 2 hours to prevent drying and cracking, and use mild oral hygiene practices, according to the British Journal of Dermatology guidelines 18
Clean the mouth daily with warm saline mouthwashes or use an oral sponge for comfort, as recommended by the British Journal of Dermatology 18
Apply benzydamine hydrochloride oral rinse or spray every 3 hours, particularly before eating, to reduce inflammation and pain, as suggested by the British Journal of Dermatology 18
Use chlorhexidine oral rinse twice daily as an antiseptic measure, according to the British Journal of Dermatology guidelines 18
Consider betamethasone sodium phosphate mouthwash four times daily for more severe oral involvement, as recommended by the British Journal of Dermatology 18

Management of Hand, Foot, and Mouth Disease with Open Sores on Feet

Wound Protection and Hygiene

Washing feet daily with careful drying, particularly between the toes, is recommended to prevent secondary complications 19
Avoiding walking barefoot and wearing appropriate cushioned footwear can protect open lesions 19
Not soaking feet in footbaths is advised, as this can induce skin maceration and worsen open sores 20

Monitoring and Follow-Up

Monitoring for signs of secondary infection, including increased redness, warmth, purulent drainage, or worsening pain, is crucial 20, 21
Reassessing after 2 weeks is recommended if lesions are not improving with standard care 22

Common Pitfalls to Avoid

Not using topical antiseptic or antimicrobial dressings routinely for HFMD foot lesions is recommended, as these are not recommended for wound healing 23

Hand, Foot, and Mouth Disease Management

Introduction to HFMD Treatment

The Centers for Disease Control and Prevention implies that hand, foot, and mouth disease caused by herpes simplex virus has antiviral treatment options, whereas HFMD does not 24

Diagnostic Considerations

It is crucial to distinguish hand, foot, and mouth disease from herpes simplex virus, as the latter has available antiviral treatment options, according to the MMWR Recommendations and Reports 24

Follow-Up and Re-Evaluation of Hand, Foot, and Mouth Disease

Monitoring and Re-Assessment

If evidence of infection has not resolved after 4 weeks, re-evaluate and consider alternative diagnoses, as recommended by the Diabetes/Metabolism Research and Reviews 25

Hand, Foot, and Mouth Disease: Clinical Presentation and Management

Diagnostic Approach

The Centers for Disease Control and Prevention recommends distinguishing from herpes simplex virus infection, as HSV has available antiviral treatment whereas HFMD does not, and also rule out drug hypersensitivity reactions, which can also present with palmar-plantar rash 26

Critical Differential Diagnoses

The MMWR Recommendations and Reports suggests to differentiate from Kawasaki disease, as HFMD has vesicular lesions vs. diffuse erythema, and also consider syphilis, meningococcemia, and Rocky Mountain spotted fever in atypical presentations with palmar-plantar involvement 26

Hand, Foot, and Mouth Disease Complications

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, according to the American Heart Association 27
Periungual desquamation typically begins 2-3 weeks after onset of fever, as reported in Circulation 27

Treatment of Oral Lesions in Hand, Foot, and Mouth Disease

Topical Treatments for Severe Oral Involvement

Barrier preparations such as Gengigel mouth rinse or gel or Gelclair are helpful for pain control, according to the British Journal of Dermatology 28
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 for more severe oral involvement, as recommended by the British Journal of Dermatology 28
Dilution of mouthwashes (by 50%) may be necessary to reduce discomfort, as suggested by the British Journal of Dermatology 28

Dietary Modifications

Eliminate foods such as tomatoes, citrus fruits, hot drinks, and spicy, hot, raw, or crusty foods that can exacerbate oral pain, as advised by the Annals of Oncology 29
Drink ample fluids to keep the mouth moist, as recommended by the Annals of Oncology 29

Non‑Pharmacologic Pain Management in Infants with Hand‑Foot‑and‑Mouth Disease

Supportive Measures

Nonnutritive sucking with a pacifier reduces pain‑related distress when used together with systemic analgesia in infants suffering from oral lesions of HFMD. [Pediatrics] 30
A 2 mL dose of 25 % sucrose solution administered by syringe (1 mL per cheek) provides analgesia for infants younger than 6 months during especially painful events such as feeding attempts. [Pediatrics] 30

Critical Diagnostic Considerations for Severe Oral Involvement

Differential Diagnosis

Severe oral involvement accompanied by systemic symptoms must be distinguished from Stevens‑Johnson syndrome/toxic epidermal necrolysis, which require urgent specific treatment rather than supportive care for HFMD. 31