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Dermatologic Manifestations of Hand-Foot-and-Mouth Disease Follow-up

  • Author: Brad S Graham, MD; Chief Editor: Dirk M Elston, MD  more...
 
Updated: Feb 12, 2016
 

Inpatient & Outpatient Medications

For symptomatic pain control for oral ulcers associated with hand-foot-and-mouth disease (HFMD), elixirs such as diphenhydramine (Benadryl), aluminum and magnesium hydroxide (Mylanta), and sucralfate (Carafate) can be helpful. Several times daily, the patient should swish the elixir in his or her mouth and spit it out.

The application of topical viscous lidocaine with a cotton-tipped swab several times daily can help in controlling the pain caused by oral ulcers.

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Deterrence/Prevention

Recent studies from China have shown that most of the children with hand-foot-and-mouth disease (HFMD) presented with vitamin A insufficiency, which was associated with their reduced immunity and more severe illness.[19]

Studies of large outbreaks of childhood HFMD in China have shown that risk factors for HFMD included playing with neighborhood children, visiting an outpatient medical clinic for another reason, and community exposures to crowded places. In this study, good hand-washing techniques by preschool-aged children and their caregivers had a significant protective effect against community-acquired HFMD from human enterovirus 71 infection.[20]

In a study of a large pediatric outbreak due to enterovirus 71 in China, several factors were studied to see which were predictive of increased severity in HFMD. Prior Epstein-Barr virus exposure, enterovirus 71 infection, and rural residence were associated with severe infections, while breastfeeding was a protective factor.[21]

Topical disinfectants show varied ability to inactivate the virus to prevent transmission.[16]  

On December 3, 2015, the China Food and Drug Administration approved the first inactivated enterovirus 71 whole virus vaccine for prevention of severe HFMD. However, it is still not widely available commercially worldwide.[22]

A study in 2015, looking at disinfectants to halt the spread of HFMD viruses, tested 13 commercially available products. The results showed acidic ethanol disinfectants, alkaline cleaners, and sodium hypochlorite were very effective. Neutral ethanol disinfectants, hand soaps, and quaternary ammonium compound sanitizers did not show great effect against HFMD viruses.[23]

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Complications

Dehydration occasionally occurs in children with hand-foot-and-mouth disease (HFMD).

Rarely, complications of hand-foot-and-mouth disease include meningoencephalitis, myocarditis, pulmonary edema, and death.

Desquamation of palms and soles and onychomadesis may develop after the infection.[6]

A case report in 2105 reported an adult with concurrent HFMD who also developed acute unilateral maculopathy. Empirical treatment with oral corticosteroids was commenced and the inflammation resolved, leaving a residual macular scar.[24]

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Prognosis

The prognosis for hand-foot-and-mouth disease (HFMD) is excellent; except in large epidemics caused by human enterovirus 71 in which neurologic complications and death have been reported, especially in children.

HFMD is more severe in infants and children than adults, but generally, the disease has a mild course. Coxsackie A6 often presents with more generalized involvement, as well as with more severe systemic symptoms.[25]

Enteroviral infections may also cause myocarditis, epididymitis, pneumonia, meningoencephalitis, and even death.[26] MicroRNA profiles and elevated circulating histones have been used to characterize more severe disease.[27, 28]

Rarely, disease recurs.

Infection in the first trimester may lead to spontaneous abortion or intrauterine growth retardation.

A large outbreak of HFMD in Taiwan caused by enterovirus 71 had a high mortality rate of 19.3% in the severe cases; the deaths resulted from pulmonary hemorrhage. During this outbreak, mortality rates were highest in children younger than 3 years.[29]

In a large epidemic (138 cases) of HFMD related to enterovirus 71 in Singapore, 7 fatalities occurred, most from interstitial pneumonitis or brainstem encephalitis. The report's conclusions were that in general, HFMD is a benign disease but the presence of unusual physical findings, elevated total white blood cell count, and vomiting and the absence of oral ulcers may signify a patient with higher risk of a fatal outcome.[30] Newer reports of large outbreaks of HFMD in China have shown that longer duration of fever, elevated serum C-reactive protein (CRP), and hyperglycemia are risk factors for increased severity of disease.[4]

A later study of an HFMD epidemic (14 children) in Australia, again with enterovirus 71, reported that 9 (64%) developed severe neurologic disease in which the host immune response seemed to cause most of the neurologic manifestations.[31]

In one study of an outbreak HFMD in Sarawak, Malaysia caused by human enterovirus 71, the authors identified 3 clinical risk factors to help detect children at risk for neurologic complications. Total duration of fever for 3 or more days, peak temperature elevation greater or equal to 38.5°C, and a history of lethargy all were independently associated with cerebrospinal fluid pleocytosis and neurologic disease.[32]

In an outbreak in the Republic of Korea with enterovirus 71, duration of fever longer than 4 days, peak temperature elevation greater than 39°C, vomiting, headache, neurologic signs, and serum glucose value over 100 mg/dL were all significant risk factors for neurologic complications.[33]

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Patient Education

The virus that causes hand-foot-and-mouth disease (HFMD) may be present in the patient's stool for 1 month.

The patient’s exclusion from school is generally not required.

Good hand-washing technique is necessary to reduce the potential spread of disease.

To reduce viral spreading, do no rupture blisters.

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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, Texas Dermatological Society, American Academy of Dermatology, American Society of Dermatopathology

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Michael J Wells, MD, FAAD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, 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, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

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

Disclosure: Nothing to disclose.

References
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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.
 
 
 
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