Hand, foot and mouth disease

hand foot and mouth · HFMD · coxsackie · enterovirus rash

A self-limiting enteroviral illness where the mouth ulcers, not the rash, decide whether the child can go home.

DISCHARGEBand B

Red flags

Dehydration from refusal to drink - this, not the rash, is the reason children are admitted
Drowsiness, irritability, limb jerks or unsteadiness - enteroviral meningoencephalitis, rare but described
A neonate or very young infant - lower threshold for admission
Immunosuppression, or eczema with widespread involvement - consider eczema coxsackium and reassess for eczema herpeticum
Severe or atypical widespread blistering - reconsider the diagnosis

Recognise

On light skin

Small grey-white oval vesicles on an erythematous base on the hands, feet and buttocks, with shallow yellow-grey mouth ulcers surrounded by a red halo.

On brown and black skin

The erythematous halo around each vesicle is often not visible in brown and black skin, so the lesions may read simply as pale grey-white or skin-coloured oval blisters on an unremarkable background. The vesicle itself and its distinctive oval shape are tone-independent - look for the shape and the site rather than for surrounding redness, and examine the sides of the fingers and toes where lesions are easy to overlook. Mouth ulcers are unaffected by skin pigment. Post-inflammatory hyperpigmentation at the sites is common afterwards, as is nail shedding weeks later, and neither indicates ongoing infection.

In any skin tone

Distribution is the diagnosis: hands, feet, mouth and often the nappy area
Lesions are characteristically oval rather than round
Painful mouth ulcers, which are usually what limits drinking
Mild fever and a generally well child
Nail shedding may follow weeks later and is harmless - warn parents

Distribution

Oval vesicles on the palms, soles, and sides of the fingers and toes, with painful ulcers in the mouth. Often also the buttocks and around the nappy area, particularly in infants.

Photographs

Hand, foot and mouth disease on the sole of a child with brown skin. Scattered dull red-brown oval macules follow the skin creases. The plan — Hand, foot and mouth disease on the sole of a child with brown skin. Scattered dull red-brown oval macules follow the skin creases. **The plantar surface is naturally much paler than the rest of this child's skin**, which is why the lesions remain visible here when the same eruption on the trunk may not be - so always look at palms, soles and mouth, which are the sites where colour change survives pigmentation.
Fitzpatrick IV (Fitzpatrick type estimated from the photograph, not stated by the source) · Rajeshodayanchal · Wikimedia Commons - Hand-foot-and-mouth-disease-Aatmeya.jpg · CC BY-SA 4.0

Provenance for every photograph in this library: image licences. How much of the corpus still has no darker-skin photograph: skin tone coverage.

Mimics

Chickenpox (varicella) — Chickenpox lesions are in crops at different stages across the whole body, not concentrated on hands, feet and mouth
Eczema herpeticum — In a child with eczema, widespread vesicles must raise eczema herpeticum, which needs aciclovir urgently
Erythema multiforme major — Both give acral lesions with mouth involvement; EM major has target lesions and is more unwell
Impetigo — Perioral lesions can look similar, but impetigo crusts with a golden appearance and is not vesicular in the same distribution

What to do in the ED

Assess hydration and the ability to drink - this determines disposition
Analgesia before anything else; adequate pain relief is what allows a child to drink and go home
In a child with eczema, examine the eczematous skin specifically and consider eczema herpeticum, which is a different and urgent diagnosis
No antibiotics and no antivirals - this is a self-limiting viral illness
Advise on fluids: cold drinks, ice lollies, and small frequent volumes
Exclusion from school or nursery is not routinely required once the child is well enough to attend; follow UKHSA advice
Warn about nail shedding and post-inflammatory pigment change so that neither prompts a re-attendance

Disposition

DISCHARGE

Discharge with analgesia and fluid advice. Admit for dehydration, inability to drink despite adequate analgesia, or any neurological feature.

Safety-netting

Give regular pain relief, because a comfortable child will drink. Return if the child will not drink at all, is passing much less urine, has no tears when crying, or has a dry mouth. Return immediately if they become drowsy, unusually irritable, unsteady, or develop jerking movements. Nails may loosen or fall off a few weeks later - this is harmless and they grow back.

Sources

Open this entry in the interactive tool