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Hand, Foot and Mouth Disease

Hand, Foot and Mouth Disease

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Introduction

Hand, foot and mouth disease (HFMD) is a common, self-limiting viral illness that generally has good clinical outcomes, usually caused by coxsackie or enterovirus, and most commonly affects children under the age of 10, particularly under the age of four.

Aetiology

The two most common causative organisms of HFMD are coxsackie A virus (CA16) and enterovirus (EV71). HFMD can be transmitted through the faecal-oral route, as well as oral-oral and respiratory droplet contact.

Risk factors

The most significant risk factor for HFMD is contact with an infected person, and the most at-risk groups are children under the age of 10 (particularly under the age of four), as well as their families and carers, due to outbreaks usually spreading within pre-schools, schools and households. Poor hygiene, especially whilst toileting, is another risk factor to consider.

Clinical features

History

Typical symptoms of HFMD include: a prodrome of low-grade fever, malaise and loss of appetite 1-2 days prior to the rash, a non-pruritic rash that starts as a red macule and develops into a grey vesicle affecting the oral mucosa, hands and feet (including palms and soles). Other important areas to cover in the history include age, attendance at a daycare or school, contact with known infectious persons and pregnancy (as HFMD in the last trimester can have considerable risks to the newborn).

Clinical examination

Typical clinical findings in HFMD include low-grade fever and a rash affecting the mucous membranes of the mouth, palms and soles primarily, with extension to the trunk, buttocks and genitals in some cases.

Hand Foot and Mouth Disease (HFMD)

Hand Foot and Mouth Disease (HFMD) is a common viral illness, primarily affecting children under the age of 10.

It is usually caused by a group of viruses known as enteroviruses. The most common of these are Coxsackie virus A16 and Enterovirus 71.

The most classic symptom of HFMD is a rash of flat, red spots and/or small blisters, which typically appears first on the hands and feet, the palms and soles (Figure 2).

Other important examination steps include:

  • A general assessment of hydration status: dehydration can be a complication of HFMD due to reduced oral intake
  • Neurological exam, with an assessment of neck stiffness: meningitis is a rare complication of HFMD

Differential diagnoses

It is important to differentiate HFMD from other rashes of childhood (Table 1).

Table 1. Causes of rashes in childhood and differentiating from HFMD.

ConditionClinical features differentiating from HFMDAtopic dermatitis Tends to be a chronic condition without any prodromal features of HFMD. Additionally, affects flexures in children in the high-risk age group, as opposed to palms, soles and mouth

Behcet syndrome

Would tend to have additional arthralgia, with vascular and neurologic lesions. Persistent greater than the 7-10 days of HFMD and would require further investigation Bullous impetigo Caused by Staphylococcus aureus; lesions present as bullae that rupture then dry and scale, which primarily affect the trunk as opposed to the hands and feet Erythema multiforme Often secondary to infection with herpes simplex virus or Mycoplasma pneumoniae; lesions appear as two concentric rings with a dusky central zone that primarily affects the trunk, limbs and face Herpangina Caused by the Coxsackie virus with lesions solely affecting the oral cavity Herpes (simplex or zoster) Associated fever, pruritic lesions, and often distributed either in the oral or genital cavity. Herpetic gingivostomatitis can also mimic the stomatitis of HFMD. If herpes is suspected, it is important to confirm via pathology and consider involving local child protection services if there is a suspicion of abuse Measles Associated fever, cough and coryza, with Koplik spots (white spots in buccal mucosa) often present. The maculopapular rash of measles starts on the head and spreads distally Pemphigus vulgaris A potentially life-threatening differential that presents as bullae and erosions of the lips, tongue, buccal mucosae and oro-pharynx Stevens-Johnson Syndrome Delayed drug reaction with concurrent fever

Varicella

Varicella appears as a generalised pruritic rash starting on the face and trunk and spreading to the rest of the body.

Investigations

Generally, there are no investigations required for Hand, Foot and Mouth Disease (HFMD) as it is a clinical diagnosis. A PCR of a throat, vesicle or rectal swab can be used to subtype the causative organism, but this is not routinely performed.

Diagnosis

The diagnosis of HFMD is clinical, based on history, clinical examination and risk factors.

Management

HFMD requires supportive management. This includes good hydration, a soft diet and simple analgesia (paracetamol/ibuprofen). It is important to reassure the parents, provide education about the condition, and review the child in 48 hours.

It is important to maintain good hand hygiene practices. This is very important in children who still use nappies or are not toilet trained, as viral particles can persist in faecal matter for up to six weeks after infection.

There is no evidence that topical analgesics such as lidocaine are beneficial.

HFMD is not a reportable or notifiable disease. There are no exclusion criteria for children although it is important to note that patients are infective until blisters have resolved.

Complications

HFMD has an excellent prognosis with self-resolution after 7-10 days in the majority of cases.

A common complication is superinfection with skin flora, most commonly Staphylococcus aureus, which may require antibiotic therapy.

Another potential complication is dehydration due to the painful oral ulcers or stomatitis reducing oral intake.

Rarer complications include meningitis and cardiorespiratory failure.

HFMD in pregnancy

Another important consideration is the maternal contraction of HFMD in the third trimester. Foetal infection increases the risk of meningoencephalitis, thrombocytopenia, disseminated intravascular coagulopathy, cardiomyopathy and hepatitis in the newborn.

Key points

  • HFMD is a common, self-limiting viral illness of childhood that requires supportive management.
  • The most common causative organisms of HFMD are coxsackie A virus (CA16) and enterovirus (EV71).
  • A history of age less than 10 years old, a known sick contact, a prodrome of 1-2 days in conjunction with a rash that affects the mucous membranes of the mouth, and the skin of palms and soles is highly suggestive of HFMD.
  • Diagnosis is clinical and no investigations are routinely required.
  • Supportive management is the mainstay of treatment. Reassure the parents and review the child at 48 hours.
  • Common complications include superinfections with skin flora and dehydration.
  • Maternal HFMD can result in serious complications in the neonate.

References

Reviewer: Dr Keith Hamd MBBS, FRACGP, DCH - General Practitioner

Editor: Dr Chris Jefferies

  • Frydenberg and Starr. Hand, Foot and Mouth Disease. 2003. Available from: LINK
  • John Murtagh's General Practice, 8e. Chapter 86: Common Childhood Infectious Diseases (including Skin Eruptions). 2022. Available from: LINK
  • Tidy et al. Hand, Foot and Mouth Disease. 2021. Available from: LINK
  • Saguil et al. Hand-Foot-and-Mouth Disease: Rapid Evidence Review. 2019. Available from: LINK
  • BruceBlaus. Hand Foot and Mouth Disease. Licence: CC BY-SA 4.0
  • KlatschmohnAcker. Hand Foot and Mouth Disease Adult 36yrs. Licence: CC BY-SA 3.0

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