Hand, Foot and Mouth Disease

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Hand, foot and mouth disease (HFMD)\: common self-limiting viral illness in children caused by coxsackie or enterovirus.
Aetiology\: most commonly caused by coxsackie A virus (CA16) and enterovirus (EV71); transmitted through faecal-oral,
oral-oral, and respiratory droplet contact.
Risk factors\: contact with an infected person, children under 10 (especially under four), poor hygiene, attendance at
daycare or school.
Symptoms\: prodrome of low-grade fever, malaise, loss of appetite; non-pruritic rash starting as a red macule, developing
into grey vesicles on oral mucosa, hands, and feet.
Clinical
trunk, buttocks, and genitals.
Important examination steps\: assess hydration status, neurological exam for neck sti
Di
measles, pemphigus vulgaris, Stevens-Johnson syndrome, varicella.
Investigations\: generally, none required; PCR of throat, vesicle, or rectal swab can subtype the organism but not routine.
Management\: supportive with hydration, soft diet, analgesia (paracetamol/ibuprofen), good hand hygiene; no exclusion
criteria but patients are infective until blisters resolve.
Complications\: excellent prognosis with self-resolution in 7-10 days, potential for superinfection with skin
dehydration, rare complications include meningitis and cardiorespiratory failure.
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A comprehensive topic overview

Introduction

Hand, foot and mouth disease (HFMD) is a common self-limiting viral illness in children. 1
or enterovirus and generally has good clinical outcomes.
2,3
It is usually caused by coxsackie

Aetiology

The two most common causative organisms of HFMD are coxsackie A virus (CA16) and enterovirus (EV71).
1,4
HFMD is commonly transmitted through the faecal-oral route. However, it can also be transmitted via oral-oral and
respiratory droplet contact.
2,4

Risk factors

The most signi
10 (especially under the age of four) and families/carers of children in this age group. This is because outbreaks usually
spread within pre-schools, schools and households.
3
Poor hygiene, especially whilst toileting, is another risk factor to consider.
2Clinical features
History
Typical symptoms of HFMD include\:
1,2,3
A prodrome of low-grade fever, malaise, loss of appetite for 1-2 days prior to lesions appearing
A non-pruritic rash that starts as a red macule and then develops into a grey vesicle a
and feet (including palms and soles)
Other important areas to cover in the history include\:
1,3
Age\: usually a
Attendance at a daycare or school
Contact with known infectious persons\: either as a classmate or carer
Pregnancy\: HFMD in the last trimester can have considerable risks to the newborn
Clinical examination
Typical clinical
4
Low-grade fever
Rash a
and genitals in some cases (Figures 1 and 2)
Figure 1. Typical
5
Figure 2. The rash of hand foot and mouth disease.
6Other 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 sti

Di

It is important to dirashes of childhood (Table 1).
Table 1. Causes of rashes in childhood and di
3,4
Condition Atopic dermatitis
Behcet syndrome
Bullous impetigo
Erythema multiforme
Herpangina
Herpes (simplex or zoster)
Measles
Pemphigus vulgaris
Stevens-Johnson syndrome Varicella
Clinical features di
Tends to be a chronic condition without any prodromal
features of HFMD. Additionally, a
in the high-risk age group, as opposed to palms, soles
and mouth
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
Caused by S t a p h y l o c o c c u s a u r e u s ; lesions present as
bullae that rupture then dry and scale, which primarily
a
Often secondary to infection with herpes simplex virus or
M y c o p l a s m a p n e u m o n i a e ; lesions appear as two
concentric rings with a dusky central zone that primarily
a
Caused by the Coxsackie virus with lesions solely
a
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 con
pathology and consider involving local child protection
services if there is a suspicion of abuse
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
A potentially life-threatening di
bullae and erosions of the lips, tongue, buccal mucosae
and oro-pharynx
Delayed drug reaction with concurrent fever
Appears as a generalised pruritic rash starting on the face
and trunk and spreading to the rest of the bodyInvestigations
Generally, there are no investigations required for 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.
2,3

Diagnosis

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

Management

HFMD requires supportive management. 1,2,3,4
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. 1,2
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 bene
2
HFMD is not a reportable or noti
that patients are infective until blisters have resolved.
2,3

Complications

HFMD has an excellent prognosis with self-resolution after 7-10 days in the majority of cases.
1,4
A common complication is superinfection with skin
antibiotic therapy.
2
Another potential complication is dehydration due to the painful oral ulcers or stomatitis reducing oral intake.
2, 4
Rarer complications include meningitis and cardiorespiratory failure.
4
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.
4

References

Frydenberg and Starr. H a n d , f o o t a n d m o u t h d i s e a s e . 2003. Available from\: [LINK]
General Practice, 8e. C h a p t e r 8 6 \: C o m m o n c h i l d h o o d i n f e c t i o u s d i s e a s e s ( i n c l u d i n g s k i n e r u p t i o n s ) . John Murtagh’s Available from\: [LINK]
2022.
Tidy et al. H a n d , F o o t a n d M o u t h D i s e a s e . 2021. Available from\: [LINK]
Saguil et al. H a n d-F o o t-a n d-M o u t h D i s e a s e \: R a p i d E v i d e n c e R e v i e w . BruceBlaus. H a n d F o o t a n d M o u t h D i s e a s e . Licence\: [CC BY-SA 4.0]
2019. Available from\: [LINK]
KlatschmohnAcker. H a n d F o o r a n d M o u t h D i s e a s e A d u l t 3 6 y r s . Licence\: [CC BY-SA 3.0]

Reviewer

Dr Keith Hamd MBBS, FRACGP, DCH
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