Management of hand, foot and mouth disease

Case scenario

Mrs Ng comes into the pharmacy with her 6-year-old son Max after seeing the doctor. Mrs Ng was very worried after Max developed a sore mouth and small vesicles on the soles of his feet and palms of his hands. She tells you the doctor said Max has hand, foot and mouth disease. She remembers the doctor discussed keeping Max from school, but she can’t recall for how long. Mrs Ng requests pain relief for Max and asks if you have any further advice about this condition.

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Introduction

Hand, foot and mouth disease (HFMD) is a generally mild, but contagious, viral infection caused predominantly by coxsackieviruses.^1–4 It is different to foot and mouth disease, which occurs only in animals.⁴ HFMD usually affects infants and children, but may occur in adults.^2,5 Outbreaks are more common in summer and early autumn, although they can also occur during winter.^5–9 The most characteristic presentation is lesions that develop in the mouth or on the hands and feet.^2,3,5

The pharmacist can identify signs and symptoms of HFMD, advise on strategies to reduce transmission, and act as a referral pathway, where indicated. The pharmacist can also offer supportive treatment, including pain relief and hydration solutions.

Causes and risk factors

HFMD is most often caused by coxsackievirus A6, A10 or A16, or enterovirus.^2,3,7 It is spread through oral ingestion of viral shedding from the infected person’s gut, respiratory tract, oral secretions or via direct contact with vesicle fluid.^2,3,5,8

The virus then reproduces in the pharynx and lower intestine before spreading to lymph nodes and organs (e.g. central nervous system, liver and skin).^2,5,7 Enteroviruses continue to shed in the stool for 4–8 weeks after infection.⁷

HFMD is very contagious, and school or child daycare attendance is a risk factor for transmission.³ Children who are immunocompromised have a higher risk of contracting HFMD.⁴

Clinical Features

The incubation period for HFMD is generally 3–5 days but may range between 2 and 7 days.⁴ Although often absent, occasionally a prodromal period of 3–4 days occurs, with symptoms such as low-grade fever, malaise, reduced appetite, abdominal pain, cough, arthralgia, vomiting or diarrhoea.^4,5,7,10

The most common and characteristic presentation of HFMD is the exanthem (external rash) and the oral enanthem (internal oral lesions).⁵ In up to 15% of cases, oral lesions may occur without the external rash, or the external rash may occur without the oral lesions.^4,5,8 Younger children are more likely to have both, while older children are more likely to have one or the other.⁴

The exanthem can be macular, maculopapular or vesicular (~1–10 mm diameter).⁵ This rash is not usually itchy or painful.^2,5 Vesicles have a red ‘halo’ with a clear or milky fluid inside.⁵ They later rupture to form superficial oval or linear ulcers that are grey-yellow with a red edge.² The rash can last up to 10 days and does not cause scarring.^2,4

The areas affected most characteristically are the hands and feet; however, regions on the upper thighs, arms, face, torso, genitals or buttocks can also be affected.^2,4,5 Buttock lesions are more common in infants and young children, and are commonly maculopapular.⁵ Occasionally, nail symptoms are seen (e.g. nail separation from the bed, nail shedding).^8,9

The oral enanthem may occur as ulcers, papules, macules or vesicles on the tongue, inside of the cheek, or less commonly on the lips, soft or hard palate, or tonsils.^4,5,7,10 The tongue may be red and swollen.⁴ These lesions may cause severe pain and interfere with the ability to eat and drink, and usually heal within 1 week.^3,4

HFMD caused by coxsackievirus A16 is usually mild and self-limiting, and uncomplicated HFMD has a low mortality rate (0.03–0.11%).^3,7,8 Rarely, HFMD may cause complications such as aseptic meningitis, encephalitis, Guillain-Barré syndrome, polio-like syndrome, acute cerebellar ataxia or benign intracranial hypertension due to central nervous system involvement.^2,10 Rarely, interstitial pneumonia, myocarditis or pancreatitis may occur.^3,4,5 Complications are more common with HFMD caused by enterovirus 71.⁴ Coxsackievirus A16 in a pregnant woman can rarely cause miscarriage.⁴

Diagnosis

HFMD is often diagnosed clinically based on the appearance and location of the rash, and history of contact with HFMD. Where diagnosis is uncertain, a medical practitioner can take scrapings from vesicles or a biopsy to differentiate HFMD from other conditions such as varicella-zoster or herpes simplex virus.² Depending on severity, polymerase chain reaction (PCR) may be used to confirm the diagnosis and differentiate between coxsackievirus and enterovirus as the causative pathogen.² 

There are many potential differential diagnoses for HFMD, including other conditions associated with oral lesions, and those with maculopapular or vesicular rashes.⁵ If there is any doubt or concerns, or any systemic or alarm symptoms are present, the patient should be referred to a medical practitioner for assessment.^7,11  Infants, pregnant persons and those who are immunocompromised should all be referred for assessment.^2,4,13 Specialised references should be utilised when necessary.

Alarm symptoms to consider include^{4,5,7,11–14}:

• presence of headache, stiff neck or sensitivity to light
• a rash that differs in presentation to expected (e.g. non-blanching or pin prick size spots)
• neurologic, respiratory or cardiopulmonary symptoms
• persistent fever, or moderate to severe systemic symptoms
• inability to replace fluids orally
• signs of dehydration.

HFMD differs from chickenpox in that chickenpox vesicles typically present on the entire body and are very itchy.^3,4

Herpes simplex lesions are painful ulcers on the lips or genitals and are commonly associated with a prodromal phase (e.g. itching, tingling).³ In a patient with aphthous mouth ulcers, there are no systemic symptoms (unless associated with an underlying systemic disease), and the ulcers are present only on the mucosal surface of the mouth.^3,5,15,16

Management

Treatment is supportive, and the pharmacist can offer advice and recommendations to manage symptoms. No antiviral medicines can treat HFMD, and no vaccine is currently available.^7–9 The patient is often acutely ill for 10–14 days, and the majority or patients will recover without sequelae.²

Pain and fever can be managed with paracetamol or ibuprofen.^2,7 Aspirin should be avoided in children under 16 years due to the risk of Reye’s syndrome.⁴ Lidocaine should be avoided in children to treat painful mouth ulcers, as evidence supporting use is lacking.^7,8 Steroids should be avoided, as these can increase the risk of severe HFMD.^2,8

The patient should be kept adequately hydrated and monitored for signs of dehydration. If the patient is dehydrated, or fluids can’t be replaced orally, they should be referred for assessment and potential intravenous fluids.⁴ If the patient develops neurologic or cardiopulmonary symptoms, they should be referred to hospital.⁴

Hot, spicy, salty or acidic food and drinks may cause a stinging sensation in the mouth and should be avoided. Cold drinks (e.g. water, milk) are more soothing in patients with mouth ulcers.⁴

Vesicles should not be ‘popped’ but left to heal on their own.

Prevention

Good hand hygiene (i.e. regular hand washing) helps prevent HFMD transmission.⁴ Caregivers should be reminded to wash their hands after changing nappies in a child with HFMD due to continued viral shedding in stools.⁴

Any surfaces or personal items (e.g. cups, cutlery) that may be contaminated with oral secretions or faeces should be disinfected and cleaned regularly.^5,7,9

Individuals with HFMD should avoid contact with those who are immunosuppressed to reduce the risk of serious illness.²

Children with HFMD should be excluded from school, daycare and other group settings, and infected adults should not attend work until the vesicles have dried and no new lesions are appearing, as they are likely still contagious.^3,6

Local state and territory public health websites have information on specific exclusion periods.

Knowledge to practice

Pharmacists are a useful point of care for parents and patients with HFMD. The pharmacist can identify signs and symptoms of HFMD and refer the patient when needed. They can recommend appropriate supportive care, such as analgesia and provide non-pharmacological advice. Additionally, the pharmacist can provide advice on how to reduce transmission, such as hygiene practices and appropriate cleaning of personal items and surfaces.

Conclusion

HFMD is usually mild and self-limiting and occurs mainly in young children. No specific treatment is available, however supportive care for symptoms is recommended when needed. The skin rash resolves without scarring, and generally no follow-up or monitoring is required.

Online patient information resources are available on HFMD, including:

• Local state and territory public health websites
• The Royal Children’s Hospital Melbourne fact sheet: Hand, foot and mouth disease.

Key points

• Hand, foot and mouth disease is a very contagious, generally mild, self-limiting disease that mainly occurs in children.
• Common symptoms of HFMD can include a skin rash that may be vesicular on the feet and/or hands and/or oral symptoms including ulcers.
• Treatment of HFMD is supportive; no specific medicines or vaccines are available.
• Good hand hygiene and regular cleaning helps to prevent transmission.

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References 

1. Therapeutic Guidelines. 2023. Sore throat; [updated 2022 Aug]. At: https://tgldcdp.tg.org.au/viewTopic?etgAccess=true&guidelinePage=Antibiotic&topicfile=sore-throat&guidelinename=Antibiotic&sectionId=toc_d1e47#toc_d1e47
2. Guerra AM, Orille E, Waseem M. Hand, foot and mouth disease. 2022. At: www.ncbi.nlm.nih.gov/books/NBK431082/
3. Vo TT, Mayeaux EJ, Bienvenu SN. The color atlas and synopsis of family medicine. New York: McGraw-Hill Education; 2019.
4. Ogboli MI. BMJ Best Practice. Hand-foot-and-mouth disease. London: BMJ Publishing Group; 2021.
5. UpToDate. Romero J. Hand foot and mouth disease and herpangina; [updated 2022 Mar 28]. At: www.uptodate.com/contents/hand-foot-and-mouth-disease-and-herpangina
6. Shah A, Sobolewski B, Mittiga MR. The atlas of emergency medicine. New York: McGraw-Hill Education; 2021.
7. Saguil A, Kane SF, Lauters R, et al. Hand-foot-and-mouth disease: rapid evidence review. Am Fam Physician 2019;100(7):408–14.
8. Nassef C, Ziemer C, Morrell DS. Hand-foot-and-mouth disease: a new look at a classic viral rash. Curr Opin Pediatr 2015;27(4):486–91.
9. Repass GL, Palmer WC, Stancampiano FF. Hand, foot, and mouth disease: identifying and managing an acute viral syndrome. Cleve Clin J Med 2014;81(9):537–43.
10. Cohen JI. Harrison’s principles of internal medicine. New York: McGraw-Hill Education; 2022.
11. NSW Health. Hand, foot and mouth disease fact sheet. 2022. At: www.health.nsw.gov.au/Infectious/factsheets/Pages/handfootmouth.aspx
12. The Royal Children’s Hospital Melbourne. Hand, food and mouth disease. 2018. At: www.rch.org.au/kidsinfo/fact_sheets/hand_foot_and_mouth_disease/
13. CDC (Centers for Disease Control and Prevention). Complications of Hand, Foot and Mouth Disease. 2023. At: www.cdc.gov/hand-foot-mouth/about/complications.html
14. Victorian State Government Department of Health. Hand, foot and mouth disease. 2015. At: www.health.vic.gov.au/infectious-diseases/hand-foot-and-mouth-disease
15. DermNet. Aphthous Ulcer. 2021. At: https://dermnetnz.org/topics/aphthous-ulcer
16. UpToDate. Lodi G. Oral Lesions; [updated 2023 Oct 4]. At: www.uptodate.com/contents/oral-lesions

Our author

Jeanie Misko (she/her) BPharm, PGDipPharm, MPharm (Clin Pharm), PGDipOncology, GradCertBusiness (Econ), GradCertHlthEcon, FSHP, FANZCAP (MedInfo, MedsMgmt) is an experienced clinical pharmacist and Medicines Information Senior Pharmacist at Fiona Stanley Hospital in Perth.

Our reviewer

Hana Numan (she/her) BPharm (NZ), PGDipClinPharm (NZ), MPS (NZ)