Definition

Hand-foot-and-mouth disease is a mild, contagious viral infection common in young children.

Characterized by sores in the mouth and a rash on the hands and feet, hand-foot-and-mouth disease
is most commonly caused by a coxsackievirus.

There's no specific treatment for hand-foot-and-mouth disease. You can reduce your risk of infection
from hand-foot-and-mouth disease by practicing good hygiene, such as washing your hands often and
thoroughly.

Pathophysiology
The infection occurs when a susceptible person is exposed to the virus by means of direct contact with nose and
throat discharges, saliva, vesicle fluid, or faecal material from an infected person. The virus may persist in faecal
material for up to 1 month. After contact, the virus spreads to regional lymph nodes within 24 hours and viraemia
rapidly follows, with spread of the virus to the oral mucosa and skin causing the vesicular rash. The incubation period
is 4 to 7 days; however, there may be a prodromal period of 3 to 4 days. Lesions in the mouth heal within 1 week,
and lesions on the hands and feet may last up to 10 days

Hand-foot-and-mouth disease is caused by a group of RNA viruses called enteroviruses. The most
commonly implicated enterovirus is coxsackievirus A16.1 However, coxsackieviruses A5, A9, A10, A16,
B1, and B3; human enterovirus 71 (HEV71); as well as herpes simplex viruses (HSV) can cause the
illness.

Cases are commonly spread via the fecal-oral or oral-oral route. Respiratory droplet transmission also
may occur but is less likely. Typically, the virus seeds the GI tract via the buccal mucosa or the
ileum. Over the next 72 hours (accounting for the incubation period), a viremia is established via spread
through nearby lymph nodes.2

Clinical
History

• The usual incubation period of hand-foot-and-mouth (HFM) disease is 4-6 days.

• The prodrome is associated with the following:
o Low-grade fever
o Malaise
o Anorexia
o Abdominal pain
o Sore mouth
• The prodrome precedes the development of oral lesions, followed shortly by skin lesions,
primarily on the hands and feet and occasionally on the buttocks.
Physical
Hand-foot-and-mouth disease is the most common cause of mouth sores in pediatric patients.

• Yellow ulcers surrounded by red halos characterize the oral lesions.

o These primarily occur on the labial and buccal mucosal surfaces but may be observed on
the tongue, palate, uvula, anterior tonsillar pillars, or gums. Unlike herpetic
gingivostomatitis, perioral lesions are uncommon. Coxsackie A virus also causes
herpangina, mostly described as palatal and posterior oropharyngeal lesions without any
associated exanthem.
o The oral ulcers are painful. Children younger than 5 years are predominately more
symptomatic than older patients.
• The exanthem typically involves the dorsal surfaces but frequently may include the palmar,
plantar, and interdigital surfaces of the hands and feet.
o These lesions may be asymptomatic or pruritic.
o They usually begin as erythematous macules that rapidly progress to thick-walled grey
vesicles with an erythematous base.
o In young infants, these lesions may also be observed on the trunk, thighs, and buttocks.
o The rash is usually self-limited, lasting approximately 3-6 days.
o Case reports have documented subacute, chronic, and recurring skin lesions.

Causes
The most common cause of hand-foot-and-mouth disease is infection due to the coxsackievirus A16.
The coxsackievirus belongs to a group of viruses called nonpolio enteroviruses. Other enteroviruses
sometimes cause hand-foot-and-mouth disease.

Oral ingestion is the main source of coxsackievirus infection and hand-foot-and-mouth disease. The
illness spreads by person-to-person contact with nose and throat discharges, saliva, fluid from
blisters, or the stool of someone with the infection. The virus can also spread through a mist of fluid
sprayed into the air when someone coughs or sneezes.

Hand-foot-and-mouth disease is most common in children in child care settings because of frequent
diaper changes and potty training, and because little children often put their hands in their mouths.

Although your child is most contagious with hand-foot-and-mouth disease during the first week of the
illness, the virus can remain in his or her body for weeks after the signs and symptoms are gone. That
means your child still can infect others.

Some people, particularly adults, can pass the virus without showing any signs or symptoms of the
disease.

Outbreaks of the disease are more common in summer and autumn in the United States and other
temperate climates. In tropical climates, outbreaks occur year-round.
Hand-foot-and-mouth disease isn't related to foot-and-mouth disease (sometimes called hoof-and-
mouth disease), which is an infectious viral disease found in farm animals. You can't contract hand-
foot-and-mouth disease from pets or other animals, and you can't transmit it to them.

Risk factors
Hand-foot-and-mouth disease primarily affects children younger than age 10. Children in child care
centres are especially susceptible to outbreaks of hand-foot-and-mouth disease because the infection
spreads by person-to-person contact, and young children are the most susceptible.

Children usually develop immunity to hand-foot-and-mouth disease as they get older by building
antibodies after exposure to the virus that causes the disease. However, it's possible for adolescents
and adults to get the disease.

Complications
The most common complication of hand-foot-and-mouth disease is dehydration. The illness can
cause sores in the mouth and throat, making swallowing painful and difficult. Watch closely to make
sure your child consumes adequate amounts of fluids during the course of the illness. If dehydration is
severe, intravenous (IV) fluids may be necessary.

Hand-foot-and-mouth disease is usually a minor illness causing only a few days of fever and relatively
mild signs and symptoms. However, a rare and sometimes serious form of the coxsackievirus can
involve the brain and cause other complications:

• Viral meningitis. This is an infection and inflammation of the membranes (meninges) and
cerebrospinal fluid surrounding the brain and spinal cord. Viral meningitis is usually mild and often
clears on its own.

• Encephalitis. This severe and potentially life-threatening disease involves brain inflammation
caused by a virus. Encephalitis is rare.

Tests and diagnosis

Your doctor will likely be able to distinguish hand-foot-and-mouth disease from other types of viral
infections by evaluating:

• The age of the affected person

• The pattern of signs and symptoms

• The appearance of the rash or sores

A throat swab or stool specimen may be taken and sent to the laboratory to determine which virus
caused the illness. However, your doctor probably won't need this type of testing to diagnose hand-
foot-and-mouth disease.
Treatments and drugs
There's no specific treatment for hand-foot-and-mouth disease. Signs and symptoms of hand-foot-
and-mouth disease usually clear up in seven to 10 days.

A topical oral anesthetic may help relieve the pain of mouth sores. Over-the-counter pain
medications other than aspirin, such as acetaminophen (Tylenol, others) or ibuprofen (Advil, Motrin,
others) may help relieve general discomfort.

Lifestyle and home remedies

Certain foods and beverages may irritate blisters on the tongue or in the mouth or throat. Try these
tips to help make blister soreness less bothersome and eating and drinking more tolerable:

• Suck on ice pops or ice chips

• Eat ice cream or sherbet
• Drink cold beverages, such as milk or ice water
• Avoid acidic foods and beverages, such as citrus fruits, fruit drinks and soda
• Avoid salty or spicy foods
• Eat soft foods that don't require much chewing
• Rinse your mouth with warm water after meals

If your child is able to rinse without swallowing, rinsing the inside of his or her mouth with warm salt
water may be soothing. Mix 1/2 teaspoon (2.5 milliliters) of salt with 1 cup (240 milliliters) of warm
water. Have your child rinse with this solution several times a day, or as often as needed to help
reduce the pain and inflammation of mouth and throat sores caused by hand-foot-and-mouth disease.

Prevention
Certain precautions can help to reduce the risk of infection with hand-foot-and-mouth disease:

• Wash hands carefully. Be sure to wash your hands frequently and thoroughly, especially after
using the toilet or changing a diaper, and before preparing food and eating. When soap and water
aren't available, use hand wipes or gels treated with germ-killing alcohol.

• Disinfect common areas. Get in the habit of cleaning high-traffic areas and surfaces first with
soap and water, then with a diluted solution of chlorine bleach, approximately 1/4 cup (60
milliliters) of bleach to 1 gallon (3.79 liters) of water. Child care centers should follow a strict
schedule of cleaning and disinfecting all common areas, including shared items such as toys, as
the virus can live on these objects for days. Clean your baby's pacifiers often.

• Teach good hygiene. Be a positive role model by showing your children how to practice good
hygiene and how to keep themselves clean. Explain to them why it's best not to put their fingers,
hands or any other objects in their mouths.

• Isolate contagious people. Because hand-foot-and-mouth disease is highly contagious, people

with the illness should limit their exposure to others while they have active signs and symptoms.
Keep children with hand-foot-and-mouth disease out of child care or school until fever is gone and
mouth sores have healed. If you have the illness, stay home from work.