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Hand-Foot-and-Mouth Disease
Lee J. Herskowitz, DO, MBA
image BASICS
  • Common acute viral illness affecting mostly children
  • Characterized by vesicles on the buccal mucosa and tongue and peripherally distributed small, tender cutaneous lesions on the hands, feet, buttocks, and (less commonly) genitalia
  • Group A coxsackieviruses are the most common causative agent (1).
  • Synonym(s): herpangina (when affecting oral mucosa and posterior pharynx)
  • Self-limiting illness resolves in 7 to 10 days.
  • Moderately contagious
  • Infection is spread by direct contact with nasal discharge, saliva, blister fluid, or stool.
  • Infected individuals are most contagious during the 1st week of the illness. Some exposed individuals (especially adults) may be asymptomatic but still contagious.
  • The viruses that cause hand-foot-and-mouth disease (HFM) can persist for weeks after symptoms have resolved, most commonly in stool, allowing transmission following resolution of symptoms.
  • The incubation period is 3 to 7 days (1).
  • Children <5 years of age are most commonly affected, especially in day care facilities (1,2).
  • Can occur as isolated cases, outbreaks, or epidemics
  • Occurs worldwide
  • Mother-to-fetus transmission is possible.
  • Most large outbreaks occur in Southeast Asia.
  • HFMS is not the same as foot (hoof) and mouth found in cattle, and there is no cross species infectious concern (3).
  • Transmission by the fecal-oral route or contact with skin lesions or oral secretions; caused by viruses that belong to the Enterovirus genus and replicated in the GI tract (3)
  • Most commonly coxsackievirus A16
  • Also coxsackieviruses A5, A7, A9, A10, B2, B5, and Enterovirus 71
  • Hand washing, especially around food handling or diaper changes
  • Exclusion of children from group settings during the first few days of the illness in the presence of open lesions in the mouth or on the skin may reduce the spread of infection.
  • Hand hygiene measures are effective in reducing transmission.
  • Pregnant woman should avoid contact with infected individuals.
  • Tender vesicles or ulcers on buccal mucosa, sides of tongue, and palate
  • Begin as small red papules and evolve into vesicles and then ulcerations
  • May persist for up to 1 week
  • Cutaneous vesicles 3 to 5 mm in diameter start as painful maculopapular eruptions, occur typically on dorsal aspect of fingers and toes.
  • May also occur on the palms, soles, buttocks, and groin
  • Adults are less likely to have cutaneous findings.
  • Herpes simplex
  • Herpes zoster
  • Scarlet fever
  • Roseola infantum
  • Fifth disease
  • Other enteroviral infections
  • Kawasaki disease
  • Viral pharyngitis
  • Varicella
  • Rickettsial infection (RFSF)
Typically clinically diagnosed
Initial Tests (lab, imaging)
Culture for responsible virus (virus isolation) can be obtained from oral lesions, cutaneous vesicles, nasopharyngeal swabs, stool, and CSF, although not typically performed. PCR of throat swabs and vesicle fluid is the most efficient test if enterovirus 71 is suspected (3).

  • Symptomatic
  • Avoid spicy or acidic foods to limit oral pain.
  • Numbing sprays or cautious use of viscous lidocaine can be used for oral pain, especially for pharyngitis (use oral topical analgesics)
  • IV fluids may be required in more severe cases of dehydration.
  • Symptomatic care using ibuprofen or acetaminophen for pain from oral ulcers or fever
  • Soothing mouthwashes (“MAGIC MOUTHWASH”) can be compounded by the parents or pharmacy containing equal amounts of viscous lidocaine, diphenhydramine, and Maalox. Instruct to swish and spit (caution in young children due to risk of lidocaine toxicity).
Pediatric Considerations
Avoid aspirin use in treating febrile illness in children.
  • Patients with CNS manifestations or autonomic dysregulation should require hospitalization.
  • Admit those with dehydration unable to maintain adequate oral hydration.
  • Encourage cold liquids (e.g., ice cream, popsicles) to prevent dehydration.
  • Avoid acidic, salty, and spicy foods, as they will increase pain.
1. Centers for Disease Control and Prevention. Hand, Foot, and Mouth Disease (HFMD). http://www.cdc.gov/hand-foot-mouth/
2. Centers for Disease Control and Prevention. Notes from the field: severe hand, foot, and mouth disease associated with coxsackievirus A6-Alabama, Connecticut, California, and Nevada, November 2011-February 2012. MMWR Morb Mortal Wkly Rep. 2012;61(12):213-214.
3. A Guide to Clinical Management and Public Health Response for Hand, Foot and Mouth disease (HFMD) World Health Organization: Western Pacific Region. http://www.wpro.who.int/publications/docs/GuidancefortheclinicalmanagementofHFMD.pdf
  • B08.4 Enteroviral vesicular stomatitis with exanthem
  • B34.1 Enterovirus infection, unspecified
  • B08.5 Enteroviral vesicular pharyngitis
Clinical Pearls
  • Most common: May to October
  • Children <5 years of age tend to have worse symptoms than older children.
  • Hand-foot-and-mouth disease is the most common cause of mouth sores in pediatric patients.
  • Usually self-limiting, resolving in 7 to 10 days
  • Careful handwashing to limit dissemination.