Hand Foot and Mouth Disease
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Direct answer
Hand, foot and mouth disease is a common, self-limiting enteroviral illness of young children, most often caused by Coxsackievirus A16. It presents with fever, painful mouth ulcers and vesicles on the palms, soles and buttocks, and it usually settles within about a week to ten days. The main concern is enterovirus 71, which can cause severe neurological and cardiopulmonary complications.
What you must remember
- Causative viruses: Coxsackievirus A16 is the commonest cause, and enterovirus 71 is linked with severe disease.
- Lesions: vesicles and ulcers on the palms, soles, buttocks and oral mucosa, with painful mouth ulcers that reduce feeding.
- Spread: faecal-oral and respiratory routes, with the virus shed in stool for weeks.
- Herpangina contrast: vesicles limited to the posterior pharynx, without hand or foot lesions.
- Nail changes: onychomadesis, the shedding of nails weeks later, is a recognised late, self-limiting sequela.
- Warning signs of enterovirus 71: persistent vomiting, lethargy, myoclonic jerks, limb weakness and breathing difficulty.
- Management: symptomatic care with analgesia and hydration, with no specific antiviral therapy.
- Exclusion: children stay away from school until the fever has settled and the lesions have dried.
Routine cases and the rare child who needs urgent care
A 3-year-old has three days of fever, painful mouth ulcers and spots on the palms. The steps below sort the routine cases from the rare child who needs urgent care.
- Examine the distribution: look for vesicles on the palms, soles, buttocks and oral mucosa, since this pattern makes the diagnosis clinically.
- Check hydration: painful mouth ulcers reduce intake, so assess urine output and the mucous membranes.
- Relieve pain: use paracetamol and soft fluids, and avoid acidic drinks that sting the ulcers.
- Listen for warning signs: look for persistent vomiting, lethargy, myoclonic jerks or breathing difficulty, which suggest enterovirus 71 complications.
- Refer urgently: send children with neurological or respiratory signs to a paediatric unit for monitoring, since brainstem involvement and pulmonary oedema can develop quickly.
- Advise on school and follow-up: keep the child at home until the fever settles and the lesions dry, and warn parents about nail shedding weeks later.
Where the exam tries to catch you
Questions on this topic test the distribution of lesions, the viral causes and the warning signs.
- Trap: prescribing antibiotics for the vesicular rash Correct: hand, foot and mouth disease is viral, so care is symptomatic and antibiotics are not indicated.
- Trap: confusing herpangina with hand, foot and mouth disease Correct: herpangina has posterior pharyngeal vesicles without hand or foot lesions.
- Trap: dismissing a child with fever, lethargy and myoclonus as routine hand, foot and mouth disease Correct: these signs suggest enterovirus 71 neurological involvement and need urgent referral.
- Trap: attributing nail shedding to a bacterial infection Correct: onychomadesis is a late, self-limiting sequela of the illness.
Frequently asked questions
Which virus most commonly causes hand, foot and mouth disease?
Coxsackievirus A16 is the commonest cause of hand, foot and mouth disease. Enterovirus 71 produces the same clinical picture but is more often linked with severe neurological complications. Both are enteroviruses that spread by the faecal-oral and respiratory routes.
What are the signs of enterovirus 71 complications in hand, foot and mouth disease?
Enterovirus 71 complications include persistent vomiting, lethargy, myoclonic jerks, limb weakness and breathing difficulty. Tachycardia, hypotension and pulmonary oedema are severe signs. Children with these features need urgent paediatric admission and monitoring.
How does herpangina differ from hand, foot and mouth disease?
Herpangina causes vesicles and ulcers at the back of the mouth and throat, without the hand and foot lesions of hand, foot and mouth disease. Both are enteroviral illnesses of young children. Herpangina is also managed with symptomatic care.
Is there specific treatment for hand, foot and mouth disease?
No specific antiviral treatment is established for hand, foot and mouth disease. Care is symptomatic, with analgesia, hydration and soft food. Antibiotics are not indicated for the viral illness.
Why do children lose their nails after hand, foot and mouth disease?
Children may lose their nails weeks after hand, foot and mouth disease, a condition called onychomadesis. It is a self-limiting late sequela in which the nail separates and grows out again. Parents should be told about it in advance so that it does not cause alarm.