Managing hand-foot-mouth disease in children: More of counseling, less of medicines

ABSTRACT

Hand, foot, and mouth disease (HFMD) is a clinical syndrome characterized by a febrile illness, followed by an oral exanthema and a macular, maculopapular, or vesicular rash of the hands, also involving palms, feet, and buttocks caused by enteroviruses of the picornaviridae family. It is a benign self-limiting disease which spreads by fecal–oral, oral–oral, and respiratory droplet contact. This case series describes cases of HFMD, presenting with typical clinical features in the North Indian region where early diagnosis and management of the condition can be carried out to halt the disease progression and prevention for the betterment of children. We came across four cases of HFMD in the month of early September to October. Their parents were health care workers, and the patients had typical symptoms and signs, except in one case, which showed extensive vesicular eruptions and crusting. All children improved at domiciliary care. Active communication and close monitoring are what is required to manage HFMD without complications. These cases infer that counseling and monitoring are an integral part in the management of HFMD.

Introduction

Hand, foot, and mouth disease (HFMD) is a clinical syndrome characterized by a febrile illness, followed by an oral exanthema and a macular, maculopapular, or vesicular rash of the hands also involving palms, feet, and buttocks caused by enteroviruses of the picornaviridae family, the most common cause being coxsackievirus A16 and Enterovirus 71. The incubation period is 3–7 days. It is a benign self-limiting disease which spreads by fecal–oral, oral–oral, and respiratory droplet contact.[1]

Case Report

Family 1: Case 1

An 18-month-old boy weighing 11 kg, the child of a postgraduate medical student, presented with a history of cough and runny nose for 6 days. After 4 days, the patient developed high-grade fever, with a peak of 102.4°F, and eruption of papular rashes all over the body. The patient experienced severe itching over the papules. The rashes started over the face and then progressed to involve the palms and then the peri-anal region. The child was fully immunized. Physical examination revealed multiple erythematous papular lesions present over the face, palms, soles, and buttocks. Some of the lesions over the anogenital region were crusted [Figure 1]. The child was having excessive salivation. A few blood-red areas, without bleeding, were seen over the hard palate, and a single rash was found on the margin of the left margin of the tongue. Considering characteristic clinical manifestation, a diagnosis of HFMD was made. Symptomatic treatment in the form of plenty of fluids, antipyretics (syp paracetamol), to control fever, antihistamines (syp fexofenadine) to reduce itching, and Zytee lotion (choline salicylate and benzalkonium chloride – RAPTAKOS, BRETT, and CO) for relieving local irritation and pain was given. After 4 days of development of rashes, the fever intensity and itching were reduced.

Figure 1.

Lesion present over the pinna of the child. Multiple erythematous lesions present over the anogenital region, few of them were crusted which resolved later without leaving scar formation

Family 1: Case 2

A 4-year-old elder sibling weighing 18 kg developed similar complaints 2 days after rashes of his younger brother started disappearing. The papulovesicular skin rashes first developed on the flexor and extensor parts of the elbow joint. He complained of fever with chills and malaise for 1 day before the onset of the cutaneous rashes. It was followed by the complaint of difficulty in eating for 1 day. The baby was having difficulty in accepting feed and was passing urine 5–6 times a day. There was no history of itching, rhinorrhea, cough, sneezing, or vomiting.

Informed consent was obtained from the parents as a part of the routine protocol before the clinical examination. On examination, the patient was febrile and had a body temperature of 101 °F. There were multiple 1–3 mm size papulovesicular skin lesions which were umblicated and were present over the skin around the elbow joint [Figure 2], the left palm, and both soles. The symptoms were mild, and the number of rashes was also less than that of his sibling.

Figure 2.

Multiple lesions present over the flexor surface of the child’s elbow

Intra-oral examination revealed multiple reddish macules measuring approximately 2 mm in diameter over the hard palate. Systemic examination was normal. The complete blood count was normal. Considering characteristic clinical manifestation and recent contact with a child suffering from HFMD, the patient was diagnosed with HFMD. The patient was advised plenty of fluids, syrup paracetamol, and Zytee oral drops. After around a week, the vesicle started forming crustations, rashes disappeared over 4–6 days without leaving scar or discoloration, and the skin returned to normal in a month.

Family 2: Case 3

A 2 years and 3 months old girl, the daughter of a doctor, complained of cough and runny nose for 2 days. After 2 days of illness, the child developed rashes over the trunk that progressed to involve the palms as well as the soles. There was no history of fever associated with illness. The baby was not able to take food orally and was irritable. On physical examination, there was redness in the oral cavity and multiple 2–4 mm size papulovesicular lesions were present on fingertips, palm, soles, and trunk. The patient was given symptomatic treatment in the form of antihistaminics, and adequate hydration was ensured. After around 10 days, the lesions started healing and slowly subsided. The child used to visit the creche from where she had acquired the illness.

Family 3: Case 4

A 4-year-old boy reported to the hospital with complaints of a 2-day history of low-grade fever for 2 days, sudden in onset with no other symptoms. After 1 day, his mother noticed two papules, one over the dorsum of his hands and one on the trunk associated with difficulty in swallowing. The patient also had itching over the rashes. On physical examination, the patient was febrile and had a body temperature of 100.6 degrees F. Multiple 2–4 mm size papulovesicular lesions were present over the skin around the elbow joint. Intra-oral examination revealed small erythematous lesions measuring approximately 1 mm in diameter over the hard palate and small ulcers in the right buccal mucosa as shown in Figure 3. The patient was diagnosed with HFMD. He was advised plenty of fluids and syrup paracetamol and calamine lotion for local application. After around a week, the vesicle started forming crustations, rashes disappeared over 4–5 days, and the skin returned to normal within a month.

Figure 3.

Multiple lesions were present over the fingers of the hand, trunk and hard palate

All patients were managed on a domiciliary care basis. A close monitoring of the patients was done with the help of Whatsapp messages and video conferencing. The first child was evaluated physically on day 3. The rest of the three cases were evaluated on mobile phone. Parents were anxious because children were not accepting orally and after learning that no specific treatment was available for the disease. The mother of the first case was very apprehensive because of extensive rashes over the perineum. We conducted a long counseling session with each parent and with other family members, if staying together; in one case, the grandmother was taken into confidence. Accepting parental concerns with paraphrasing, empathy, and relevant information did soothe the parents and helped reduce their anxiety. Good communication with the family also helped build confidence, and parents accepted symptomatic treatment and “no investigations”. In one case, we did ask for a complete blood count to allay the fears of the mother. All patients improved without any sequelae.

Discussion

HFMD is a common mild childhood illness caused by enteroviruses, often coxsackievirus A16 and enterovirus 71.[1] During the 2022 coronavirus disease 2019 (COVID-19) pandemic, coxsackie A16 and A6 were the primary transmitters.[2] HFMD is named after skin lesions on hands, feet, and oral mucosa. It is contagious but typically benign, with lesions clearing in 1–2 weeks.[1] Early symptoms include fever, malaise, and sore throat. Sudden erythematous papulo-vesicular eruptions, often in crops, appear on hands, feet, perioral area, knees, buttocks, and oral cavity.[1,3] Some lesions are larger vesiculobullous ones found in different body areas. Thick-skinned regions like palms and soles might lack classical vesicles, appearing as erythematous papules.[3] Improvement usually occurs in 7–10 days without complications, but in a few cases, severe cardiorespiratory and neurological involvement can arise.[1,3,4] All four cases exhibited fever and viral prodrome symptoms. Three patients had typical rash characteristics, while the youngest case had intense symptoms with numerous rashes, notably in the groin and perianal region, with some lesions merging, causing concern for the mother. Uncommon presentation rashes have been described in HFMD. Chatproedprai S et al. have reported widespread severe cutaneous eruptions, large vesicles (varicelliform), purpuric-like lesions, or Gianotti-Crosti like eruptions in an HFMD caused by Coxsackie virus-6.[5]

HFMD is primarily clinically diagnosed, distinguished from similar conditions like varicella zoster, papular urticaria, impetigo, and pompholyx by unique features for confident identification.[1,3,6] No effective antiviral therapy or vaccine exists. Highly contagious, HFMD can rapidly spread in communities.[1] HFMD treatment is mainly symptomatic: antipyretics control fever, antihistamines reduce itching, and topical anesthetics aid oral ulcers for eating.[1,3] To prevent outbreaks, curbing disease spread is essential. Enterovirus spreads feco-orally and commonly transmits among families.[3] Adults typically catch the disease-causing virus, but even if they do not exhibit any symptoms, they can pass it on to their children.[7] If two children live in the same household, their parents should be instructed to take precautions to prevent illness transmission inside the home.

Parents often mistakenly avoid water, which should be corrected. They must encourage clean bathing to prevent superinfection.[8] Advising green tea leaf baths can speed healing. Regular mouth rinsing, sterilizing utensils and baby bottles, cleaning homes, and disinfecting toys and clothes are essential precautions. Mucaine gel was recommended for pain relief, along with a diet high in soft foods like yogurt and pudding.[9] Children’s contact and toy-sharing make hand-to-mouth common. Frequent handwashing is vital to prevent spread.[10] Children with HFMD benefit from lettuce baths. Lettuce’s antibacterial, anti-inflammatory properties aid blister-like lesions. Purslane baths, rich in vitamins and anti-inflammatory substances, aid healing. Marjoram’s alkaloids offer anti-inflammatory, antiseptic effects.[10]

Strict implementation of basic protocols like monitoring the cleanliness of the hands, utensils, and drinking water and avoiding direct contact with affected people can be rewarding.[11] Restriction of the affected children from attending school or other outdoor activities is a very simple but effective strategy.[12] Parents are very anxious and worried as a result of the rapid onset of the disease, fever, difficulty in feeding, irritability, and eruption of rashes over the body with intense itching in some cases as happened in our case. Active communication with the parents, adolescents, and older children, explaining pathogenesis in simple language, and empathy and affectionate care of the child patient with special attention toward nutrition and fluid intake are enough in the majority of cases, leading to complete recovery.[13] However, in a minuscule number of patients, dehydration can occur due to poor oral intake and intravenous fluid administration may require hospital admission. Rare complications of HFMD include aseptic meningitis and encephalitis with paralysis and loss of fingers and toenails.[6,8,11] Close personal contacts, such as kissing, embracing, coming into contact with feces, touching infected surfaces, and sticking fingers in eyes, are all ways that HFMD can spread.[12] Towels, clothing, toys, and other items that are frequently shared can transmit the virus. Therefore, until the blisters dry up, children with widespread blisters should be quarantined for at least 7 days.[1]

Conclusion

We came across four cases of HFMD in the months of early September to October. Their parents were healthcare workers, and the patients had typical symptoms and signs except in one case, which showed extensive vesicular eruptions and crusting. All children improved at domiciliary care. Active communication and close monitoring are what is required to manage HFMD without complications. These cases infer that counseling and monitoring are an integral part in the management of HFMD. Close follow-up of these patients was done via Whatsapp photos, and parents were counseled during the entire phase of illness.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.