Hand-foot-mouth diseaseMANAGEMENT

INFECTIOUS DISEASE PRESENTATIONS · 12 SECTIONS

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532 items

☷ Legend

01Approach to the Critical Patient/attcp54

Initial Stabilization

›Immediate priorities

›Airway patency

›Stridor

›Drooling with inability to handle secretions

›Breathing status

›Work of breathing

›Hypoxemia

›Circulation and perfusion

›Capillary refill delay

›Hypotension

›Neurologic status

›Altered mental status

›Seizure

›Dehydration risk

›Unable to tolerate oral fluids

›Reduced urine output

›Escalation triggers

›If toxic appearance, sepsis pathway

›Blood cultures

›Broad spectrum antibiotics per local protocol

›If respiratory distress or hypoxemia, resuscitation bay

›Supplemental oxygen

›Chest imaging based on exam

›If neurologic signs, emergent pediatric or neurology consult

›Concern for enterovirus neurologic complication

›Consider ICU

›Infection control

›Contact precautions

›Gloves and gown for direct contact

›Dedicated equipment when feasible

›Droplet precautions if prominent respiratory symptoms

›Surgical mask for close contact

›Cohorting if outbreak setting

›Hand hygiene emphasis

›Soap and water after diapering

›Alcohol based hand rub for routine use

Key Decision Points

›Severity stratification

›Uncomplicated HFMD

›Normal mental status

›Adequate oral intake

›Moderate dehydration risk

›Pain limiting intake

›Mild clinical dehydration

›High risk or complicated disease

›Dehydration with failed oral rehydration

›Neurologic symptoms

›Cardiopulmonary symptoms

›Diagnostic posture

›Clinical diagnosis in typical cases

›Oral enanthem with extremity rash pattern

›Known exposure or daycare cluster

›Targeted testing in atypical or severe cases

›Alternate diagnosis concern

›Complication concern

02History/hx42

Symptom Pattern and Timeline

›Core history elements

›Symptom onset day

›Fever duration

›Rash onset relative to fever

›Oral pain

›Refusal to drink

›Refusal to eat

›Rash description

›Vesicles

›Painful lesions

›Exposure context

›Daycare or school attendance

›Household contact illness

Hydration and Complication Screen

›Intake and output

›Oral fluid intake

›Ability to swallow

›Vomiting

›Urine output

›Wet diapers count

›Dark urine

›Red flag symptoms

›Neurologic

›Headache

›Neck stiffness

›Myoclonus or tremor

›Ataxia

›Respiratory

›Shortness of breath

›Persistent tachypnea

›Cardiac

›Chest pain

›Palpitations

›Host factors

›Age under 2 years

›Higher dehydration risk

›Limited oral reserve

›Immunocompromised state

›Transplant

›Chemotherapy

›Pregnancy status in adolescents

›Third trimester symptoms

›Close household exposure

03Physical Exam/exam60

Vitals and Hydration

›Global assessment

›Toxic appearance

›Lethargy

›Poor perfusion

›Fever pattern

›Persistent high fever

›Afebrile

›Hydration status

›Mucous membranes

›Dry mouth

›Saliva pooling

›Tears

›Present

›Absent

›Capillary refill

›Normal

›Prolonged

›Heart rate relative to fever

›Disproportionate tachycardia

›Normal

›Weight based comparison when available

›Recent weight loss

›Baseline weight unknown

Skin and Oropharynx

›Lesion characterization

›Oral enanthem

›Vesicles and ulcers on buccal mucosa

›Posterior oropharyngeal lesions

›Extremity rash distribution

›Palms

›Soles

›Typical additional sites

›Buttocks

›Perioral skin

›Severity markers

›Uncontrolled drooling

›Unable to manage secretions

›Dehydration risk

›Extensive blistering

›Coxsackie A6 pattern concern

›Secondary infection risk

Neurologic and Cardiopulmonary

›Neurologic exam

›Mental status

›Irritability

›Lethargy

›Meningeal signs

›Neck stiffness

›Photophobia

›Cerebellar findings

›Ataxia

›Tremor or myoclonus

›Respiratory and cardiac exam

›Work of breathing

›Retractions

›Grunting

›Auscultation

›Crackles

›Wheeze

›Perfusion

›Cool extremities

›Mottling

04Differential Diagnosis/ddx36

Vesicular Rash With Oral Lesions

›Mimics and alternatives

›Herpangina

›Posterior pharyngeal vesicles predominance

›Minimal hand and foot rash

›Primary HSV gingivostomatitis

›Diffuse gingival inflammation

›Perioral grouped vesicles

›Varicella

›Trunk predominant lesions

›Lesions in multiple stages

›Impetigo bullous

›Honey crusting

›Localized lesions

›Eczema herpeticum

›Atopic dermatitis background

›Monomorphic punched out lesions

›Erythema multiforme

›Target lesions

›Medication or infection trigger

›Stevens Johnson syndrome

›Mucosal involvement severity

›Systemic toxicity

›Mpox

›Deep seated umbilicated lesions

›Exposure risk context

High Consequence Diagnoses to Exclude

›Dangerous rash syndromes

›Meningococcemia

›Petechiae or purpura

›Rapid progression

›Kawasaki disease

›Conjunctivitis

›Strawberry tongue

›Extremity swelling

›Toxic shock syndrome

›Hypotension

›Multisystem involvement

05Laboratory Tests/lt42

Routine Testing Strategy

›Typical uncomplicated cases

›No routine laboratory tests

›Clinical diagnosis

›Self limited course

›Focus on hydration assessment

›Oral intake trial response

›Urine output trend

Dehydration and Severe Illness Evaluation

›Dehydration concern

›Basic metabolic panel for moderate to severe dehydration

›Sodium abnormalities

›Potassium abnormalities

›Glucose point of care for poor intake or lethargy

›Hypoglycemia

›Stress hyperglycemia

›Serum ketones when prolonged poor intake

›Starvation ketosis

›Alternate diagnosis consideration

›Systemic toxicity concern

›Complete blood count when bacterial infection concern

›Neutrophilia

›Thrombocytopenia

›C reactive protein when inflammatory differential broad

›Limited specificity

›Trend support only

›Blood cultures if sepsis concern

›Before antibiotics when feasible

›Do not delay stabilization

Neurologic or Cardiac Complication Workup

›CNS involvement concern

›Lumbar puncture studies when meningitis encephalitis concern

›Cell count and differential

›Protein

›Glucose with paired serum glucose

›CSF enterovirus PCR when available

›Supports enterovirus etiology

›Does not exclude alternate pathogens

›Myocarditis concern

›Troponin if chest pain or arrhythmia

›Myocardial injury marker

›Requires clinical correlation

›BNP or NT proBNP if heart failure signs

›Volume status interpretation challenge

›Adjunct only

06Diagnostic Tests/dt45

Scoring Systems

›Clinical risk and monitoring tools

›Dehydration severity clinical assessment

›Mild

›Thirst

›Slightly dry mucosa

›Moderate

›Decreased tears

›Sunken eyes

›Reduced urine output

›Severe

›Lethargy

›Weak pulses

›Prolonged capillary refill

›Pediatric early warning approach when admitted

›Heart rate trend

›Respiratory rate trend

›Mental status trend

MRI

›Neuro complication imaging

›Brain MRI indications

›Myoclonus

›Ataxia

›Persistent altered mental status

›Brainstem encephalitis features

›Brainstem lesions

›Cerebellar involvement

›Spine MRI indications

›Acute flaccid weakness

›Reflex changes

›Time sensitive neuro evaluation

›Head CT indications

›Altered mental status with focal deficit

›Concern for intracranial process before lumbar puncture

›Limitations

›Low sensitivity for early brainstem encephalitis

›Radiation risk in pediatrics

Ultrasound (or US)

›Point of care applications in complications

›Lung ultrasound for respiratory deterioration

›B lines consistent with pulmonary edema

›Pleural effusion assessment

›Focused cardiac ultrasound for myocarditis concern

›Global systolic function

›Pericardial effusion

›Volume status adjunct

›IVC variability interpretation limits in children

›Clinical correlation required

07Disposition/dispo42

Level of Care Decisions

›Discharge criteria

›Adequate oral hydration

›Successful oral fluid challenge

›Caregiver able to continue oral rehydration

›No red flag symptoms

›No neurologic signs

›No respiratory distress

›Reliable follow up

›Primary care access

›Caregiver return precautions understood

›Admission criteria

›Moderate to severe dehydration

›Failed oral rehydration

›IV fluids required

›Uncontrolled pain limiting intake

›Persistent refusal of fluids

›Recurrent vomiting

›Complication concern

›Altered mental status

›Suspected meningitis encephalitis

›Suspected myocarditis

›ICU criteria

›Cardiopulmonary instability

›Hypoxemia

›Shock

›Severe neurologic disease

›Seizure

›Brainstem signs

›Transfer criteria

›Need for pediatric ICU not available

›Escalating respiratory support

›Continuous vasoactive infusions

Return to School or Childcare Considerations

›Attendance guidance

›Afebrile

›No fever without antipyretics

›Fever resolved at least 24 hours

›Able to participate

›Energy adequate for routine activities

›Pain controlled

›No uncontrolled drooling

›Secretions manageable

›Oral lesions not causing constant drool

08Treatment/t72

Supportive Care Core

›Mainstay management

›Hydration strategy

›Oral rehydration solution for mild dehydration

›Frequent small volumes for oral pain

›Analgesia and antipyresis

›Acetaminophen oral

›Dose 15 mg per kg every 4 to 6 hours

›Maximum 75 mg per kg per day

›Ibuprofen oral age over 6 months

›Dose 10 mg per kg every 6 to 8 hours

›Maximum 40 mg per kg per day

›Oral comfort measures

›Cool liquids

›Popsicles

›Pruritus management when needed

›Cetirizine oral

›Age based dosing per local formulary

›Sedation counseling

›Diphenhydramine oral

›Avoid in very young infants unless clinician directed

›Paradoxical agitation risk

Hydration Protocols

›Oral rehydration pathway

›Mild dehydration

›Oral rehydration solution 5 to 10 mL every 1 to 2 minutes

›Escalate volume as tolerated

›Moderate dehydration

›Oral rehydration solution 10 to 20 mL every 5 minutes

›Reassess hydration status every 30 minutes

›Antiemetic support when vomiting limits rehydration

›Ondansetron oral disintegrating tablet

›Weight based dosing per local protocol

›Single dose then oral rehydration trial

›IV fluid pathway

›If moderate to severe dehydration with failed oral rehydration, initiate IV isotonic fluid

›Normal saline bolus 20 mL per kg

›Reassessment after each bolus

›Repeat bolus based on perfusion and hydration

›Maintenance fluids after resuscitation

›Isotonic maintenance per pediatric protocol

›Electrolyte monitoring if ongoing losses

Medications to Avoid

›Safety prohibitions

›Oral lidocaine preparations

›Seizure risk with toxicity

›Aspiration risk from numbing

›Aspirin in children

›Reye syndrome risk

›Use acetaminophen or ibuprofen instead

Secondary Infection and Dermatologic Care

›Skin care

›Gentle cleansing

›Mild soap and water

›Avoid lesion de roof

›Barrier protection for diaper area lesions

›Zinc oxide

›Frequent diaper changes

›Bacterial superinfection concern

›Localized impetigo treatment

›Mupirocin topical

›Apply thin layer 2 to 3 times daily

›Duration 5 days

›Cellulitis concern

›Oral antibiotics per local pediatric pathway

›Culture if purulence present

Severe EV71 Associated Complications

›Specialist guided management

›Suspected brainstem encephalitis

›ICU monitoring

›Airway protection planning

›IVIG consideration in severe neurologic disease

›Evidence base primarily observational

›Infectious disease consult

›Milrinone consideration for autonomic instability and neurogenic pulmonary edema patterns

›ICU protocol dosing only

›Cardiology and critical care oversight

09Special Populations/sp31

Pregnancy

›Pregnancy considerations

›Maternal disease in adolescents and adults

›Usually self limited

›Hydration priority

›Fetal risk counseling

›Limited evidence for major congenital risk

›Emphasis on fever control and hydration

›Medication safety

›Acetaminophen preferred antipyretic

›NSAID avoidance in third trimester

Geriatric

›Older adult considerations

›Atypical presentation

›Less prominent rash

›Higher complication concern with comorbidity

›Dehydration vulnerability

›Baseline renal impairment

›Polypharmacy considerations

›Alternate diagnoses threshold

›Drug eruption

›Bullous pemphigoid

Pediatrics

›Pediatric specifics

›Highest incidence age under 5 years

›Daycare clusters common

›Household spread common

›Dehydration monitoring priority

›Wet diaper frequency

›Oral intake targets

›Return to school or childcare guidance

›Afebrile

›No uncontrolled drooling

›Able to participate

10Background/b52

Epidemiology

›Population patterns

›Typical age distribution

›Predominantly children under 5 years

›Adolescents and adults possible

›Seasonal pattern

›Summer and early fall peaks in many regions

›Year round transmission possible

›Outbreak settings

›Childcare centers

›Schools

›Clinical course expectations

›Incubation period

›Typically 3 to 6 days

›Exposure to symptom onset variability

›Illness duration

›Lesions typically resolve within 7 to 10 days

›Prolonged course possible with extensive disease

Pathophysiology

›Virology and transmission

›Causative agents

›Coxsackievirus A16

›Enterovirus 71

›Coxsackievirus A6

›Transmission routes

›Fecal oral

›Respiratory droplets

›Direct contact with vesicle fluid

›Viral shedding

›Respiratory shedding early

›Stool shedding for weeks

›Complication mechanisms

›Dehydration

›Odynophagia limiting intake

›Fever related insensible losses

›Neuroinvasive disease in EV71

›Brainstem encephalitis

›Acute flaccid paralysis

›Neurogenic pulmonary edema patterns in severe EV71

›Autonomic dysregulation

›Rapid respiratory decompensation

Therapeutic Considerations

›Evidence framing

›Supportive care as standard of care

›Hydration and pain control as primary interventions

›Self limited viral illness in most cases

›Antivirals

›No routinely recommended antiviral therapy

›Management remains symptomatic

›Evidence based cautions

›Oral lidocaine not recommended

›Aspiration and toxicity risks

›Severe EV71 disease

›ICU supportive management central

›IVIG and inotrope strategies based on limited evidence and regional protocols

11Patient Discharge Instructions/pdi46

copy discharge instructions

›Home care plan

›Fluids frequently

›Small sips every few minutes

›Oral rehydration solution preferred if intake low

›Pain and fever control

›Acetaminophen or ibuprofen as directed by clinician

›No aspirin

›Mouth pain strategies

›Cold drinks

›Popsicles

›Skin care

›Keep lesions clean and dry

›Avoid picking blisters

›Infection spread reduction

›Handwashing with soap and water after diaper changes

›Do not share cups or utensils

›Clean high touch surfaces

›Return now or go to emergency department

›Dehydration signs

›No urine for 8 hours

›Very dry mouth

›No tears when crying

›Breathing problems

›Fast breathing

›Working hard to breathe

›Neurologic symptoms

›Severe headache

›Stiff neck

›Trouble walking

›Seizure

›Persistent fever

›Fever lasting more than 3 days

›Fever with worsening appearance

›Worsening rash

›Rapid spreading bruising like spots

›Signs of skin infection with increasing redness or pus

›Return to school or childcare

›Fever free

›No fever for 24 hours

›No fever medicines needed

›Well enough for normal activities

›Drinking adequately

›Comfortable with pain control

›No uncontrolled drooling

›Able to manage secretions

›Mouth sores not causing constant drool

12References/r10

Key Sources

›Clinical guidance sources

›Centers for Disease Control and Prevention hand foot and mouth disease overview and return to school guidance updated May 7 2024

›American Academy of Pediatrics Red Book section on modes of spread and school attendance guidance for HFMD

›American Academy of Pediatrics HealthyChildren hand foot and mouth disease guidance updated Dec 15 2025

›American Academy of Family Physicians hand foot and mouth disease rapid evidence review 2019

›Public Health Agency of Canada information sheet on HFMD related to enterovirus 71 updated Jul 19 2017

›Complication evidence sources

›Huang CC et al Neurologic complications in children with enterovirus 71 infection New England Journal of Medicine 1999

›Lee KY review of enterovirus 71 neurologic complications and management recommendations 2016

›StatPearls Hand Foot and Mouth Disease NCBI Bookshelf updated 2023

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