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BASICS

Description

  • Common clinical syndrome caused by multiple enterovirus serotypes.
  • Characteristic oral enanthem and exanthem on hands, feet, and sometimes other areas.
  • Rash can be macular, maculopapular, or vesicular.
  • Synonym: herpangina (when limited to oral mucosa and posterior pharynx).

Epidemiology

  • Self-limiting, resolves in 7–10 days.
  • Moderately contagious; spread via contact with nasal secretions, saliva, blister fluid, stool.
  • Most contagious during first week of illness; virus can shed for weeks post symptoms, especially in stool.
  • Incubation: 3–7 days.
  • Most common in children <5 years, especially in daycare settings.
  • Occurs worldwide; outbreaks mostly in Southeast Asia.
  • Vertical transmission possible.

Etiology and Pathophysiology

  • Not related to animal foot-and-mouth disease.
  • Transmitted fecal-oral and by contact with skin/oral secretions.
  • Caused by enteroviruses: most commonly coxsackievirus A16 and enterovirus 71.
  • Other serotypes: coxsackie A5, A7, A9, A10, B2, B5.
  • Enterovirus 71 linked to more severe disease.

Prevention

  • Handwashing, especially during food handling and diaper changes.
  • Exclusion from group settings during illness with open lesions.
  • Pregnant women should avoid contact with infected persons.
  • Vaccines (monovalent and polyvalent) under investigation with promising results.

DIAGNOSIS

History

  • Prodrome: 1–2 days of fever, anorexia, malaise, abdominal pain, URI symptoms.
  • Rash often follows prodrome.
  • Rash: maculopapular on hands, feet, mouth; oral lesions may precede skin rash.
  • Fever lasts 3–4 days; sore throat common.
  • History of sick contacts common.

Physical Exam

  • Oral enanthem: tender vesicles → ulcers on buccal mucosa, tongue sides, palate; last up to 1 week.
  • Skin: 3–5 mm painful vesicles, mostly on dorsal fingers/toes; may also involve palms, soles, buttocks, groin.
  • Adults less likely to have cutaneous lesions.
  • Nail dystrophies common, lasting weeks post infection.
  • Watch for CNS symptoms (rare but serious).

Differential Diagnosis

  • Herpetic gingivostomatitis
  • Aphthous stomatitis
  • Scabies
  • Chickenpox
  • Measles, Rubella, Scarlet fever, Roseola infantum, Fifth disease
  • Other enteroviral infections
  • Kawasaki disease
  • Viral pharyngitis
  • Varicella
  • Rickettsial infections
  • Behcet syndrome
  • Pemphigus vulgaris
  • Stevens-Johnson syndrome

Diagnostic Tests

  • Clinical diagnosis usually sufficient.
  • Viral culture or PCR from oral lesions, vesicles, throat, stool, CSF if needed.
  • PCR especially for enterovirus 71 suspicion.

TREATMENT

General Measures

  • Symptomatic care.
  • Isolation to prevent spread.

Medications

  • Pain and fever relief: ibuprofen or acetaminophen.
  • Avoid "magic mouthwash" with lidocaine; not superior and has systemic risks.
  • No specific antivirals.

Pediatric Considerations

  • Avoid aspirin due to Reye syndrome risk.

Admission Criteria

  • CNS involvement or autonomic dysregulation.
  • Dehydration with inability to maintain oral hydration.

ONGOING CARE

Diet

  • Encourage cold liquids (ice cream, popsicles).
  • Avoid acidic, salty, spicy foods to reduce oral pain.

COMPLICATIONS

  • Dehydration (due to painful oral ulcers).
  • CNS involvement (aseptic meningitis; rising incidence).
  • Enterovirus 71 associated with severe CNS disease.
  • Cardiopulmonary: myocarditis, pneumonitis, pulmonary edema.
  • Nail dystrophies and desquamation (Beau lines).

Clinical Pearls

  • Most common from May to October.
  • Children <5 years have more severe symptoms.
  • HFMD is the leading cause of mouth sores in pediatric patients.
  • Careful handwashing essential to reduce spread.
  • Nail changes can persist weeks after resolution.

References

  1. Saguil A, Kane SF, Lauters R, et al. Hand-foot-and-mouth disease: rapid evidence review. Am Fam Physician. 2019;100(7):408-414.
  2. Zhu P, Ji W, Li D, et al. Current status of hand-foot-and-mouth disease. J Biomed Sci. 2023;30(1):15.
  3. Hopper SM, McCarthy M, Tancharoen C, et al. Topical lidocaine to improve oral intake in children with painful infectious mouth ulcers: a blinded, randomized, placebo-controlled trial. Ann Emerg Med. 2014;63(3):292-299.