Hand, foot and Mouth
Definition: Hand, foot and mouth disease is an acute viral illness which is characterised by vesicular eruptions in the mouth and papulovesicular lesions of the distal limbs (do not confuse with foot and mouth disease of animals which is caused by a different virus). It is usually mild and self-limiting.
When to suspect:
Examine the rash: Macules and papules of the hands/feet usually follow the oral lesions. Typically 2-5mm sparse erythematous often with a central greyish vesicle. Sides of fingers and dorsum of the hands, margins of the heels are more frequently affected. Frequently elliptical running parrallel to the skin lines. Buttocks and groin may also be affected. Lesions can be asymptomatic or painful.
Examine the mouth: scattered ulcerative lesions of the oral cavity occur within 1-2 days, typically begin as 2-8cm erythematous macules and papules and appear on the hard palate, tongue and buccal mucosa, and can be on the lips and pharynx. Lesions progress rapidly to vesicles which readily erode leaving shallow yellow-grey ulcers surrounded by erythematous halo.
Ask about - prodromal symptoms which may last 12-36 hours, early symptoms are fever, malaise, loss of appetite, cough, abdominal pain, sore mouth, rarely vomiting.
Lab investigations such as swabs are not usually required in primary care due to the self-limiting nature of the illness.
Typically presents with mild illness - sore throat, with or without low grade fever, tender lesions in the mouth (enanthem) and/or a rash on the body (exanthem)
Differential diagnosis
Chickenpox
Erythema multiforma/Stevens-johnson syndrome
Aphthous ulcers
Viral pharyngitis
Herpes stomatitis
Kawasaki disease
Herpangina
Pompholyx eczema
Gingivitis
Lichen planus
Behcet's disease
Traumatic ulcers
Pemphigus vulgaris or oral bullous pemphigoid
Management
Do not prescribe antiviral medication.
Pregnant women who have suspected hand, foot and mouth disease (or been in contact) should be generally managed as for non-pregnant, however if immunocompromised or within 3 weeks of delivery seek specialist advise as investigation to confirm diagnosis may be required.
Do not prescribe antibiotics unless secondary infection is suspected.
Follow up is not routinely require but ensure to provide safety netting.
Advise on measures to prevent transmission - general hygiene such as hand washing, covering nose/mouth when sneezing/coughing, take care with handling nappies/tissues, use of hot cycle to wash soiled clothes, bedding and towels, cups/utensils/towels should not be shared, blisters should not be pierced. Pregnant women should avoid close contact. Child do not need to be excluded for infection control purposes but should not attend if they are too unwell.
Use clinical judgement about onward referral using 2-week wait pathway if oral ulcers are persistent.
Self-care measures: Adequate fluid intake, soft diet may be required, use of Paracetamol/Ibuprofen if required to reduce pain or fever.
Provide reassurance in typical symptoms that hand, foot and mouth disease is usually a self-limiting illness.
Arrange emergency admission if there are symptoms/signs of central nervous system involvement - persistent/severe headache or fever, myoclonus with sleep disturbance, confusion/weakness/lethargy/drowsiness/irritability/ generalized seizures/coma.