Dermatologic Manifestations of Hand-Foot-and-Mouth Disease Clinical Presentation

  • Author: Brad S Graham, MD; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Mar 21, 2012
 

History

A brief prodrome of 12-36 hours duration is part of the usual presentation of hand-foot-and-mouth disease (HFMD), which consists of the following:

  • Low-grade fever with an average temperature of 38.3°C and duration of 2-3 days
  • Anorexia
  • Malaise
  • Abdominal pain
  • Sore mouth
  • Cough

In one study, 80% of the children presented with anorexia and mouth soreness. The enanthem usually precedes the exanthem that is asymptomatic, but both may occur simultaneously. The lesions on the hands and feet are present for 5-10 days. The mucosal and cutaneous lesions heal spontaneously in 5-7 days.

Next

Physical

Hand-foot-and-mouth disease (HFMD) is more severe in infants and children than adults, but generally, the disease has a mild course. Symptoms such as malaise, low-grade fever, and anorexia are often present. Occasionally, patients have high fever, marked malaise, diarrhea, and arthralgias.

Enteroviral infections may also cause myocarditis, pneumonia, meningoencephalitis, and even death. Infection in the first trimester may lead to spontaneous abortion or intrauterine growth retardation.

Rarely, disease recurs. One report describes a 15-year-old white boy with recurrent episodes of HFMD at 3 weeks and 7 months following the initial viral illness.[9] The lesions in the recurrent episodes were located in the same distribution as the initial presentation. His workup after the last case revealed an absence of immunodeficiency and a greater than 4-fold increase in coxsackievirus B titers. No serologic evidence of acute infection was identified, and titers of immunoglobulin G remained elevated for 1 year following this third episode.

Oral lesions begin as erythematous macules that evolve into 2-3 mm vesicles on an erythematous base. The vesicles are rarely observed because they rapidly become ulcerated. They are painful and may interfere with eating. The total number of ulcers averages 5-10. The vesicles may involve the palate, buccal mucosa, gingiva, and tongue. The tongue is involved in 44% of the cases, and, in addition to the ulcers, the tongue may be edematous and tender. Note the images below.

The lower lip has an ulcer with an erythematous haThe lower lip has an ulcer with an erythematous halo. The tongue has an ulcer with an erythematous halo.The tongue has an ulcer with an erythematous halo.

Cutaneous lesions are characteristic and are present in two-thirds of patients. Typically, the hands, feet, and buttocks are involved. The hands are involved more often than the feet, and the dorsal aspect of the hands and sides of the fingers are more commonly involved than the palmar surfaces. Each lesion begins as a 2-10 mm erythematous macule on which a central, gray, oval vesicle develops. The lesions are characteristically elliptical; their long axis parallels the skin lines. These lesions are asymptomatic and resolve in 3-7 days as a result of fluid resorption. Note the image below. Erythematous maculopapular eruptions may also occur on the buttocks and arms. In one report, 22% of the patients also had marked cervical or submandibular lymphadenopathy.

More recently, in large outbreaks of HFMD of children in Taiwan, 66 (51%) of coxsackievirus A6–infected patients experienced desquamation of palms and soles after the infection episode and 48 (37%) patients developed onychomadesis.[10]

A typical cutaneous lesion has an elliptical vesicA typical cutaneous lesion has an elliptical vesicle surrounded by an erythematous halo. The long axis of the lesion is oriented along the skin lines.
Previous
Next

Causes

Epidemic hand-foot-and-mouth disease (HFMD) infections are usually caused by coxsackievirus A16 or enterovirus 71.[11] In addition, sporadic cases with coxsackievirus types A4-A7, A9, A10, B1-B3, and B5 are reported. An outbreak of hand-foot-and-mouth disease in China during 2003 was caused by echovirus 19.[1]

Previous
Proceed to Differential Diagnoses
 
 
Contributor Information and Disclosures
Author

Brad S Graham, MD  Consulting Staff, Dermatology Associates of Tyler

Brad S Graham, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society of Dermatopathology, and Texas Dermatological Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Bernice R Krafchik, MBChB, FRCPC  Professor Emeritus, Department of Pediatrics, Section of Dermatology, University of Toronto

Bernice R Krafchik, MBChB, FRCPC is a member of the following medical societies: American Academy of Dermatology, American Dermatological Association, Canadian Medical Association, College of Physicians and Surgeons of Ontario, Royal College of Physicians and Surgeons of Canada, and Society for Pediatric Dermatology

Disclosure: Nothing to disclose.

Michael J Wells, MD  Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association

Disclosure: Nothing to disclose.

Edward F Chan, MD  Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania School of Medicine

Edward F Chan, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Catherine M Quirk, MD  Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania

Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD  Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

References

  1. Zhu Z, Xu WB, Xu AQ, et al. Molecular epidemiological analysis of echovirus 19 isolated from an outbreak associated with hand, foot, and mouth disease (HFMD) in Shandong Province of China. Biomed Environ Sci. Aug 2007;20(4):321-8. [Medline].

  2. Yan XF, Gao S, Xia JF, Ye R, Yu H, Long JE. Epidemic characteristics of hand, foot, and mouth disease in Shanghai from 2009 to 2010: Enterovirus 71 subgenotype C4 as the primary causative agent and a high incidence of mixed infections with coxsackievirus A16. Scand J Infect Dis. Dec 18 2011;[Medline].

  3. Yang C, Deng C, Wan J, Zhu L, Leng Q. Neutralizing antibody response in the patients with hand, foot and mouth disease to enterovirus 71 and its clinical implications. Virol J. 2011;8:306. [Medline].

  4. Chang LY, King CC, Hsu KH, et al. Risk factors of enterovirus 71 infection and associated hand, foot, and mouth disease/herpangina in children during an epidemic in Taiwan. Pediatrics. Jun 2002;109(6):e88. [Medline]. [Full Text].

  5. Chong CY, Chan KP, Shah VA, et al. Hand, foot and mouth disease in Singapore: a comparison of fatal and non-fatal cases. Acta Paediatr. Oct 2003;92(10):1163-9. [Medline].

  6. Yu JG, Liu YD, Qiao LY, Wang CJ. [Epidemiological study and clinical analysis of 931 children with hand foot and mouth disease in Yantai]. Zhonghua Shi Yan He Lin Chuang Bing Du Xue Za Zhi. Oct 2011;25(5):374-6. [Medline].

  7. McMinn P, Stratov I, Nagarajan L, Davis S. Neurological manifestations of enterovirus 71 infection in children during an outbreak of hand, foot, and mouth disease in Western Australia. Clin Infect Dis. Jan 15 2001;32(2):236-42. [Medline].

  8. Ooi MH, Wong SC, Mohan A, et al. Identification and validation of clinical predictors for the risk of neurological involvement in children with hand, foot, and mouth disease in Sarawak. BMC Infect Dis. Jan 19 2009;9:3. [Medline]. [Full Text].

  9. Sutton-Hayes S, Weisse ME, Wilson NW, Ogershok PR. A recurrent presentation of hand, foot, and mouth disease. Clin Pediatr (Phila). May 2006;45(4):373-6.

  10. Wei SH, Huang YP, Liu MC, Tsou TP, Lin HC, Lin TL. An outbreak of coxsackievirus A6 hand, foot, and mouth disease associated with onychomadesis in Taiwan, 2010. BMC Infect Dis. 2011;11:346. [Medline].

  11. Lee TC, Guo HR, Su HJ, Yang YC, Chang HL, Chen KT. Diseases caused by enterovirus 71 infection. Pediatr Infect Dis J. Oct 2009;28(10):904-10. [Medline].

  12. Tsao KC, Chang PY, Ning HC, et al. Use of molecular assay in diagnosis of hand, foot and mouth disease caused by enterovirus 71 or coxsackievirus A 16. J Virol Methods. Apr 2002;102(1-2):9-14. [Medline].

  13. Zhang X, Yan HP, Huang C, et al. [The etiology and clinical manifestations of 70 patients with hand-foot-mouth disease]. Zhonghua Yu Fang Yi Xue Za Zhi. Oct 2009;43(10):872-4. [Medline].

  14. Li J, Chen F, Liu T, Wang L. MRI Findings of Neurological Complications in Hand-Foot-Mouth Disease by Enterovirus 71 Infection. Int J Neurosci. Feb 20 2012;[Medline].

  15. Yang Y, Wang H, Gong E, et al. Neuropathology in 2 cases of fatal enterovirus type 71 infection from a recent epidemic in the People's Republic of China: a histopathologic, immunohistochemical, and reverse transcription polymerase chain reaction study. Hum Pathol. Apr 22 2009;[Medline].

  16. Yang Y, Zhang L, Fan X, Qin C, Liu J. Antiviral effect of geraniin on human enterovirus 71 in vitro and in vivo. Bioorg Med Chem Lett. Mar 15 2012;22(6):2209-11. [Medline].

  17. Liu J, Yang Y, Xu Y, Ma C, Qin C, Zhang L. Lycorine reduces mortality of human enterovirus 71-infected mice by inhibiting virus replication. Virol J. 2011;8:483. [Medline].

  18. Faulkner CF, Godbolt AM, DeAmbrosis B, Triscott J. Hand, foot and mouth disease in an immunocompromised adult treated with aciclovir. Australas J Dermatol. Aug 2003;44(3):203-6. [Medline].

  19. Toida M, Watanabe F, Goto K, Shibata T. Usefulness of low-level laser for control of painful stomatitis in patients with hand-foot-and-mouth disease. J Clin Laser Med Surg. Dec 2003;21(6):363-7. [Medline].

  20. Chen S, Yang Y, Yan X, Chen J, Yu H, Wang W. Influence of vitamin A status on the antiviral immunity of children with hand, foot and mouth disease. Clin Nutr. Dec 22 2011;[Medline].

  21. Ruan F, Yang T, Ma H, Jin Y, Song S, Fontaine RE. Risk factors for hand, foot, and mouth disease and herpangina and the preventive effect of hand-washing. Pediatrics. Apr 2011;127(4):e898-904. [Medline].

  22. Hood AF, Mihm MC. Hand-foot-and-mouth disease. In: Fitzpatrick TB, Austen KF, Wolff K, Eisen AZ, Freedberg IM, eds. Dermatology in General Medicine. 4th ed. New York, NY: McGraw-Hill; 1993:2521-3.

  23. Hurwitz S. The exanthematous diseases of childhood. In: Hurwitz, ed. Clinical Pediatric Dermatology: A Textbook of Skin Disorders of Childhood and Adolescence. 2nd ed. Philadelphia, Pa: WB Saunders; 1993:359-61.

 
Previous
Next
 
The lower lip has an ulcer with an erythematous halo.
The tongue has an ulcer with an erythematous halo.
A typical cutaneous lesion has an elliptical vesicle surrounded by an erythematous halo. The long axis of the lesion is oriented along the skin lines.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.