Hand, foot and mouth disease

The symptoms of hand, foot and mouth disease may show up in three phases. 

• The disease begins with a prodromal phase. Viral infections usually start with fatigue and the feeling of being unwell for a couple of days. The prodrome phase is associated with symptoms like mild fever, fatigue, malaise and loss of appetite. Patients may also experience sore throat, cough and pain in their abdominal area. 
• After the prodrome is over, patients develop numerous lesions in the mouth. These lesions may be observed on the buccal mucosa, tongue and the hard palate. Sometimes, the gums, lips, uvula and the skin around the mouth may also be affected. These lesions are macular lesions at the start, meaning they are flat and less than 1 cm in size. These macules progress to vesicles, which are small fluid-filled sacs on the skin. These vesicles then further undergo erosion. Lesions in the mouth are seen as yellow ulcerations that are surrounded by reddish haloes. Patients may complain of discomfort and pain in the mouth. They may be more severe in children less than 5 years old. 
• Lesions on the skin may also develop later on. The most common sites are the palms, soles and in the area between the toes and fingers. Initially, these lesions start as 2-5 mm erythematous (red) macules and progress to become fluid-filled sacs (vesicles) with a reddish erythematous base. Other sites where lesions can be observed include the trunk area, buttocks and the genital region of the body. The rashes may last for a week and are mainly asymptomatic. Sometimes, they can cause an itching sensation along with pain. 

The disease has the highest incidence rate in the summer and autumn months. It is more common in infants and children less than 10 years old. Adults who may develop this disease suffer from even milder symptoms as compared to children. The disease is considered to be moderately infectious and, therefore, epidemics can and have occurred in the past with a risk of transmission ranging from 10% to 30%. These epidemics mainly occurred in the southeastern part of Asia. The last major outbreak of this disease was seen in China in 2009. Outbreaks mostly occur in nurseries, schools and daycare centres. 

(Read more: Viral load)

Hand, foot and mouth disease is usually a result of infection by Group A Coxsackievirus (CA16) or enterovirus 71 (EV71). These viruses belong to the Picornaviridae family and genus Enterovirus. Transmission of this virus commonly occurs via the fecal-oral route. It may also take place after contact with skin lesions or oral droplets (through coughing or sneezing) of an infected person.

(Read more: What is droplet transmission?).

Infected patients continue to excrete the virus in their stool for a few weeks. It may take 3-5 days from exposure for the symptoms of this disease to show. This is termed as the incubation period. 

According to a lot of research that has been conducted on this disease, it is not a very serious illness. The fever (moderate to high) and the lesions resolve in a matter of 7-10 days. The painful mouth ulcers can also last for a week. Children are often uncomfortable and irritable during this time and maybe for a few days after. Rarely does the virus affect other important organs of the body like the heart, lungs and the brain. 

Doctors can diagnose hand, foot and mouth disease based on the patient profile, history and clinical examination alone. Investigations are not usually required. The virus can be isolated and identified using swabs from the throat, skin lesions or the rectum. A faecal culture may also be performed (more than one sample may be needed as sometimes the virus may not be excreted in a bowel movement). Polymerase chain reaction (PCR) allows doctors to identify the subtype of enterovirus and is the best investigation to identify the virus causing the disease. It is rarely performed though. 

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Other conditions that have to be considered when making the diagnosis for hand, foot and mouth disease include the following: 

• Herpangina: It is also caused by similar viruses with the same oral lesions. The difference in herpangina is that the lesions are restricted to the back side (posterior) of the oral cavity and that there are no skin lesions. 
• Kawasaki disease: Kawasaki disease is an illness that is associated with inflammation of the walls of blood vessels. Most commonly affects infants and children less than 5 years old. It also presents with a fever along with a rash. Patients also complain of peeling of the skin.
• Erythema multiforme: Erythema multiforme may present with a rash on the body that resembles a bullseye, which is an immune response of the skin to infections or medications. 
• Viral pharyngitis: It also causes inflammation of the back of the throat
• Gingivitis: Gingivitis is the inflammation of the gums (gingiva). 
• Herpes simplex virus (HSV)
• Herpes zoster virus

Currently, no definitive cure to destroy the virus in the body exists. The goal of treatment is to manage or reduce the symptoms and make the child feel more comfortable. The treatment protocols are the same for all age groups. 

The treatment protocol includes the following: 

• Treat the fever: Fever can make children miserable. Doctors may prescribe paracetamol or ibuprofen; they can help in two major ways. They bring the temperature down and they act as painkillers, which helps in reducing the soreness in the mouth. Children may require these medications in the form of syrups or flavoured tablets. These medications should not be used if the patient does not have any fever or pain. Another way to reduce the temperature is to remove the clothes and warm bedding. Windows should be opened and fans should be used if needed. Cold sponging should not be done in a child with fever as it causes narrowing of the blood vessels under the skin (vasoconstriction) if the water is too cold. This decreases loss of heat which gets trapped inside the body. Cold sponging may also be uncomfortable for your child. (Read more: First aid for viral fever)
• Hydration: A major part of the treatment of any viral infection is plenty of fluids. Hydration prevents the lack of fluids in the body that is termed as dehydration. It may be difficult to take fluids orally in case of soreness of the mouth. Hence, patients should be given paracetamol or ibuprofen if they are finding it difficult to accept oral intake due to pain. After the pain reduces, patients should be encouraged to drink some water. In case you are breastfeeding your child, it should continue as breast milk is the ideal form of hydration for infants. You can even increase the number of feeds to allow more fluid to enter your child’s body. (Read more: Dehydration in children)
• Treating the soreness of your child’s mouth: Try to give your child semi-solid food such as mashed potatoes, ice cream and soups that are easy to eat with a sore mouth. Some treatment for oral ulcers do exist but their effectiveness has not yet been established. These treatments may include the following : 
  • Lidocaine gels: Lidocaine is a local anaesthetic that acts by numbing the affected area. They are suitable for children. 
  • Benzydamine mouthwash or spray: It is safe to use in spray formulations for children above the age of 5 years. Children above the age of 12 years can also use mouthwash. 
  • Choline salicylate gel: Not suitable for children less than 16 years of age or pregnant women. 
  • Saline rinse: Can be prepared with a warm solution of water and salt. Only use this if your child is old enough to spit it and not swallow it. 
  • Painkillers: Paracetamol and ibuprofen can be used to reduce the soreness caused due to lesions in the mouth. 

Your general practitioner may refer you to a specialist in the following situations : 

• If your child exhibits any signs of severe dehydration such as extreme lethargy, dry oral mucosa and sunken eyes. Your child may need to be admitted to the hospital in such a situation. 
• If your child demonstrates any neurologic signs like jerking (myoclonic) and intense headaches or clinical features of encephalitis like loss of consciousness.
• If the oral lesions are persistent and are not resolving spontaneously. 

According to a lot of research that has been conducted on this disease, it is not a very serious illness. The fever (moderate to high) and the lesions resolve in a matter of 7-10 days. The painful mouth ulcers can also last for a week. Children are often uncomfortable and irritable during this time and maybe for a few days after. Rarely does the virus affect other important organs of the body like the heart, lungs and the brain. 

Sometimes, certain complications may occur in patients suffering from hand, foot and mouth disease. They may include the following: 

• Infection of skin after intense scratching 
• Meningitis (inflammation of the meninges) may occur in case of neurological involvement
• Failure of the cardiopulmonary system

Most patients recover completely from the disease. Clinical features start improving within 3-4 days with skin and mouth lesions completely disappearing in a week or two. 

Hand, foot and mouth disease is an infectious disease. The incubation period of the disease is 3-5 days. The virus is expelled into the air after a diseased person coughs or sneezes. It can also be transmitted by touching the infected fluid oozing out of the skin lesions of patients. You should encourage your child to maintain good hygiene to prevent contracting the virus or passing it onto somebody else. The following steps can be taken: 

• It is essential that the child washes their hands properly after going to the toilet.
• The child should keep his or her mouth and nose completely covered if coughing or sneezing. 
• They should wipe their mouth and nose with clean disposable tissue paper. 
• If you are handling nappies, wipes or tissues, you should be very careful and ensure that you wash your hands after touching any of them.
• Soiled bedding, towels and clothes should be washed with hot water manually or in the washing machine. 
• Teach your child to avoid the sharing of cups, utensils, clothes and towels with anyone when there is a risk of them or someone else being sick. This should continue for a few weeks after the infection is over.
• If your child has the disease, tell them not to pop the blisters. The fluid inside them is infectious. 

It is important to note that there are no complications that can occur in the development of the fetus if you are pregnant and have been in contact with someone who has hand, foot and mouth disease. While unlikely, if one does develop hand, foot and mouth disease three weeks before the expected delivery date, they should speak to a specialist as there may be a risk of passing the virus to the newborn. Most cases of the disease in newborns are mild but sometimes it could lead to severe infection.

(Read more: Pregnancy)