Hand-Foot-and-Mouth Disease: Rapid Evidence Review

 

Am Fam Physician. 2019 Oct 1;100(7):408-414.

  Patient information: A handout on this topic is available at https://familydoctor.org/condition/hand-foot-and-mouth-disease.

Author disclosure: No relevant financial affiliations.

Hand-foot-and-mouth disease is caused by human enteroviruses and coxsackieviruses. Outbreaks can occur in the spring to fall and are common in North America, and most cases occur in patients younger than 10 years. Hand-foot-and-mouth disease is transmitted by fecal-oral, oral-oral, and respiratory droplet contact. Patients present with a low-grade fever, a maculopapular or papulovesicular rash on the hands and soles of the feet, and painful oral ulcerations. Lesions usually resolve in seven to 10 days; however, in rare cases, patients may have neurologic or cardiopulmonary complications. The differential diagnosis for childhood rashes and oral enanthems is broad and includes erythema multiforme, herpes, measles, and varicella. Treatment is supportive and directed toward hydration and pain relief as needed with acetaminophen or ibuprofen. Oral lidocaine is not recommended, and antiviral treatment is not available. The best methods to prevent the spread of hand-foot-and-mouth disease are handwashing and disinfecting potentially contaminated surfaces and fomites.

Hand-foot-and-mouth disease is a common viral disease that presents in primary care. This article presents a brief summary and review of the etiology, clinical features, diagnosis, prognosis, and evidence for the care of patients with hand-foot-and-mouth disease.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

The diagnosis of hand-foot-and-mouth disease should be based on presentation of a maculopapular or papulovesicular rash on the hands and soles of the feet and painful oral ulcerations.7

C

Expert opinion from the Centers for Disease Control and Prevention

Supportive care should be used to treat hand-foot-and-mouth disease. Weight-based acetaminophen or ibuprofen may be used to treat fever and pain, but oral lidocaine is not recommended.7,39,40

C

Consensus opinion (acetaminophen/ibuprofen); small randomized controlled trial and case report (lidocaine)

Handwashing decreases the risk of transmitting hand-foot-and-mouth disease.8,42

C

Disease-oriented, retrospective studies


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

The diagnosis of hand-foot-and-mouth disease should be based on presentation of a maculopapular or papulovesicular rash on the hands and soles of the feet and painful oral ulcerations.7

C

Expert opinion from the Centers for Disease Control and Prevention

Supportive care should be used to treat hand-foot-and-mouth disease. Weight-based acetaminophen or ibuprofen may be used to treat fever and pain, but oral lidocaine is not recommended.7,39,40

C

Consensus opinion (acetaminophen/ibuprofen); small randomized controlled trial and case report (lidocaine)

Handwashing decreases the risk of transmitting hand-foot-and-mouth disease.8,42

C

Disease-oriented, retrospective studies


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

Epidemiology

  • Hand-foot-and-mouth disease was first described after an outbreak in Canada in the 1950s.1 It is caused by picornaviruses, specifically human enteroviruses and coxsackieviruses.2

  • The most common viruses that cause hand-foot-and-mouth disease are enterovirus 71 and coxsackievirus A16.2 Currently, hand-foot-and-mouth disease is not listed as a notifiable condition in the United States by the Centers for Disease Control and Prevention; however, it has been a reportable illness in the Western Pacific region, where there are more severe outbreaks.35

  • Coxsackievirus A6 can cause severe disease manifestations with atypical lesions such as vesicles, bullae, and scabs on the trunk, extremities, and face.6

  • Spring to fall seasonal outbreaks of hand-foot-and-mouth disease are typical in North America and temperate zones.7,8 Years can pass between cyclical epidemics, during which time the pool of unexposed children increases.1

  • Outbreaks of hand-foot-and-mouth disease are possible during the winter, and some are associated with coxsackievirus A6.2 Year-round outbreaks are common in tropical zones.8

  • Most cases occur in patients younger than 10 years,1 and the largest incidence is within the first five years of life.9

  • Health care professionals working with

The Authors

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AARON SAGUIL, MD, MPH, FAAFP, is an associate dean in recruitment and admissions, and is an associate professor in the Department of Family Medicine at F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Md....

SHAWN F. KANE, MD, FAAFP, FACSM, is an associate professor in the Department of Family Medicine at the University of North Carolina in Chapel Hill.

REBECCA LAUTERS, MD, is a staff member of the Eglin Family Medicine Residency, 96th Medical Group, Eglin Air Force Base, Fla.

MICHAEL G. MERCADO, MD, FAAFP, is the head of the Department of Family Medicine at the Naval Hospital, Bremerton, Wash., and is an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences.

Address correspondence to Aaron Saguil, MD, MPH, FAAFP, Brooke Army Medical Center, USUHS Medicine, 3551 Roger Brooke Dr., Fort Sam Houston, TX 78234 (email: asaguil@usuhs.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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