Hand, foot and mouth disease

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Not to be confused with Foot-and-mouth disease or Hand-foot syndrome.
Hand, foot and mouth disease
Hand Foot Mouth Disease.png
Typical lesions around the mouth of an 11-month-old boy
Classification and external resources
Specialty Infectious disease
ICD-10 B08.4
ICD-9-CM 074.3
DiseasesDB 5622
MedlinePlus 000965
eMedicine derm/175
Patient UK Hand, foot and mouth disease
MeSH D006232

Hand, foot and mouth disease (HFMD) is a common human syndrome caused by highly contagious intestinal viruses. HFMD is typically characterized by a mild fever followed by a rash of flat discolored spots and bumps that may blister, involving the skin of the hands, feet, mouth, and occasionally the buttocks and genitalia.[1][2][3] HFMD mainly affects infants and children, but can occasionally occur in adults.[3]

Coxsackievirus A16 is the most common cause of HFMD.[4] Enterovirus 71 (EV-71) is the second-most common cause.[4] Many other strains of coxsackievirus and enterovirus can also be responsible.[4][5] The viruses that cause HFMD are spread through direct contact with the mucus, saliva, or feces of an infected person. HFMD often occurs in small epidemics in nursery schools or kindergartens, usually during the summer or autumn months.[3] Signs and symptoms normally appear 3–6 days after exposure to the virus.[6] The rash generally goes away on its own in about a week, and most cases require no treatment other than symptomatic relief.[7] No antiviral treatment or vaccine is currently available for HFMD, but development efforts are underway.[8]

HFMD should not be confused with foot-and-mouth disease (also known as hoof-and-mouth disease) which affects livestock. Foot-and-mouth disease is caused by a different picornavirus which almost never infects humans.[9][10]

Signs and symptoms[edit]

Rash on palms of the hands.
Rash on hand and feet of a 36-year-old man
Rash on the soles of a child's feet

Common constitutional signs and symptoms of the HFMD include fever, nausea, vomiting, feeling tired, generalized discomfort, loss of appetite, and irritability in infants and toddlers. Skin lesions frequently develop in the form of a rash of flat discolored spots and bumps which may be followed by vesicular sores with blisters on palms of the hands, soles of the feet, buttocks, and sometimes on the lips.[11] The rash is rarely itchy for children,[6] but can be extremely itchy for adults.[12] Painful facial ulcers, blisters, or lesions may also develop in or around the nose or mouth.[3][13][14] HFMD usually resolves on its own after 7–10 days.[13]


The viruses that cause the disease are of the Picornaviridae family. Coxsackievirus A16 is the most common cause of HFMD.[4] Enterovirus 71 (EV-71) is the second-most common cause.[4] Many other strains of coxsackievirus and enterovirus can also be responsible.[4][5]


A diagnosis usually can be made by the presenting signs and symptoms alone.[13] If the diagnosis is unclear, a throat swab or stool specimen may be taken to identify the virus by culture.[13] The common incubation period (the time between infection and onset of symptoms) ranges from three to six days.[6]


Medications are usually not needed as hand, foot and mouth disease is a viral disease that typically gets better on its own. Currently, there is no specific curative treatment for hand, foot and mouth disease.[13] Disease management typically focuses on achieving symptomatic relief. Pain from the sores may be eased with the use of analgesic medications. Infection in older children, adolescents, and adults is typically mild and lasts approximately 1 week, but may occasionally run a longer course. Fever reducers and lukewarm baths can help decrease body temperature.

A minority of individuals with hand, foot and mouth disease may require hospital admission due to uncommon neurologic complications such as inflammation of the brain, inflammation of the meninges, or acute flaccid paralysis.[5] Non-neurologic complications such as inflammation of the heart, fluid in the lungs, or bleeding into the lungs may also occur.[5]


Complications from the viral infections that cause HFMD are rare, but require immediate medical treatment if present. HFMD infections caused by Enterovirus 71 tend to be more severe and are more likely to have neurologic or cardiac complications including death than infections caused by Coxsackievirus A16.[13] Viral or aseptic meningitis can occur with HFMD in rare cases and is characterized by fever, headache, stiff neck, or back pain.[5][13] The condition is usually mild and clears without treatment; however, hospitalization for a short time may be needed. Other serious complications of HFMD include encephalitis (swelling of the brain), or flaccid paralysis in rare circumstances.[11][13]

Fingernail and toenail loss have been reported in children 4–8 weeks after having HFMD.[6] The relationship between HFMD and the reported nail loss is unclear; however, it is temporary and nail growth resumes without treatment.[6][15]


No vaccine is currently available to protect individuals from infection by the viruses that cause HFMD,[16] but such vaccines are being developed.[13][17] HFMD is highly contagious and is transmitted by nasopharyngeal secretions such as saliva or nasal mucus, by direct contact, or by fecal-oral transmission. Preventive measures include avoiding direct contact with infected individuals (including keeping infected children home from school), proper cleaning of shared utensils, disinfecting contaminated surfaces, and proper hand hygiene. These measures have been shown to be effective in decreasing the transmission of the viruses responsible for HFMD.[13][16]


Hand, foot and mouth disease most commonly occurs in children under the age of 10[6][13] and tends to occur in outbreaks during the spring, summer, and fall seasons.[4] HFMD is most commonly caused by infection with Coxsackievirus A16.[4]

Major outbreaks[edit]

  • In 1998, there was an outbreak in Taiwan, affecting mainly children.[18] There were 405 severe complications, and 78 children died.[19] The total number of cases in that epidemic is estimated to have been 1.5 million.[4]
  • In 2008 an outbreak in China, beginning in March in Fuyang, Anhui, led to 25,000 infections, and 42 deaths, by May 13.[4] Similar outbreaks were reported in Singapore (more than 2,600 cases as of April 20, 2008),[20] Vietnam (2,300 cases, 11 deaths),[21] Mongolia (1,600 cases),[22] and Brunei (1053 cases from June–August 2008)[23]
  • In 2009 17 children died in an outbreak during March and April 2009 in China's eastern Shandong Province, and 18 children died in the neighboring Henan Province.[24] Out of 115,000 reported cases in China from January to April, 773 were severe and 50 were fatal.[25]
  • In 2010 in China, an outbreak occurred in southern China's Guangxi Autonomous Region as well as Guangdong, Henan, Hebei and Shandong provinces. Until March 70,756 children were infected and 40 died from the disease. By June, the peak season for the disease, 537 had died.[26]
  • The World Health Organization reporting between January to October 2011 (1,340,259) states the number of cases in China had dropped by approx 300,000 from 2010 (1,654,866) cases, with new cases peaking in June. There were 437 deaths, down from 2010 (537 deaths).[27]
  • In December 2011, the California Department of Public Health identified a strong form of the virus, coxsackievirus A6 (CVA6), where nail loss in children is common.[28]
  • In 2012 in Alabama, United States there was an outbreak of an unusual type of the disease. It occurred in a season when it is not usually seen and affected teenagers and older adults. There were some hospitalizations due to the disease but no reported deaths.[29]
  • In 2012 in Cambodia, 52 of 59 reviewed cases of children reportedly[30] dead (as of July 9, 2012) due to a mysterious disease were diagnosed to be caused by a virulent form of HFMD.[31] Although a significant degree of uncertainty exists with reference to the diagnosis, WHO report states, "Based on the latest laboratory results, a significant proportion of the samples tested positive for enterovirus 71 (EV-71), which causes hand foot and mouth disease (HFMD). The EV-71 virus has been known to generally cause severe complications amongst some patients."[32]
  • HFMD infected 1,520,274 people with 431 deaths reported up to end of July in 2012 in China.[33]
  • The governorate of Daraa in Syria reported over 200 cases of HFMD there in early 2015.[34] These were due to the central Syrian government denying the region water chlorination as a punishment in wartime.


HFMD cases were first described in New Zealand in 1957.[13]


Novel antiviral agents to prevent and treat infection with the viruses responsible for HFMD are currently under development. Preliminary studies have shown inhibitors of the EV-71 viral capsid to have potent antiviral activity.[8]


  1. ^ Frydenberg, A; Starr, M (August 2003). "Hand, foot and mouth disease.". Australian family physician 32 (8): 594–5. PMID 12973865. 
  2. ^ Ooi, MH; Wong, SC; Lewthwaite, P; Cardosa, MJ; Solomon, T (2010). "Clinical features, diagnosis, and management of enterovirus 71". Lancet Neurology 9 (11): 1097–1105. doi:10.1016/S1474-4422(10)70209-X. PMID 20965438. 
  3. ^ a b c d Kaminska, K; Martinetti, G; Lucchini, R; Kaya, G; Mainetti, C (2013). "Coxsackievirus A6 and Hand, Foot, and Mouth Disease: Three Case Reports of Familial Child-to-Immunocompetent Adult Transmission and a Literature Review". Case Reports in Dermatology 5 (2): 203–209. doi:10.1159/000354533. PMID 24019771. 
  4. ^ a b c d e f g h i j Repass GL, Palmer WC, Stancampiano FF (September 2014). "Hand, foot, and mouth disease: Identifying and managing an acute viral syndrome". Cleve Clin J Med 81 (9): 537–43. doi:10.3949/ccjm.81a.13132. PMID 25183845. 
  5. ^ a b c d e Li, Y; Zhu, R; Qian, Y; Deng, J (2012). "The characteristics of blood glucose and WBC counts in peripheral blood of cases of hand foot and mouth disease in China: a systematic review". PLOS ONE 7 (1): e29003. doi:10.1371/journal.pone.0029003. PMID 22235257. 
  6. ^ a b c d e f Hoy, NY; Leung, AK; Metelitsa, AI; Adams, S (2012). "New concepts in median nail dystrophy, onychomycosis, and hand, foot and mouth disease nail pathology". ISRN Dermatology 2012 (680163): 680163. doi:10.5402/2012/680163. PMID 22462009. 
  7. ^ al.], ed. Dan L. Longo ... [et (2012). Harrison's principles of internal medicine. (18th ed.). New York: McGraw-Hill. ISBN 978-0-07174889-6. 
  8. ^ a b Pourianfar HR, Grollo L (February 2014). "Development of antiviral agents toward enterovirus 71 infection". J Microbiol Immunol Infect. S1684-1182 (13): 00236–3. doi:10.1016/j.jmii.2013.11.011. PMID 24560700. 
  9. ^ "Foot and Mouth Disease update: further temporary control zone established in Surrey". Defra. 2007-08-14. Archived from the original on 2007-09-27. Retrieved 2007-08-14. 
  10. ^ Jeffery, Simon (2001-11-23). "Foot and Mouth Disease". The Guardian (London). Retrieved 2007-08-14. 
  11. ^ a b Huang, CC; Liu, CC; Chang, YC; Chen, CY; Wang, ST; Yeh, TF (23 September 1999). "Neurologic complications in children with enterovirus 71 infection.". The New England Journal of Medicine 341 (13): 936–42. doi:10.1056/nejm199909233411302. PMID 10498488. 
  12. ^ "HAND". babymd.net. Baby MD. Retrieved April 7, 2012. 
  13. ^ a b c d e f g h i j k l Sarma, N (March–April 2013). "Hand, foot and mouth disease: current scenario and Indian perspective". Indian Journal of Dermatology, Venereology, and Leprology 79 (2): 165–175. doi:10.4103/0378-6323.107631. PMID 23442455. 
  14. ^ "Hand, Foot and Mouth Disease: Signs & Symptoms". mayoclinic.com. The Mayo Clinic. Retrieved May 5, 2008. 
  15. ^ "Hand, Foot and Mouth Disease". Complications. Centers for Disease Control and Prevention. 2011. Retrieved 14 October 2013. 
  16. ^ a b "Hand, Foot and Mouth Disease". Prevention and Treatment. Centers for Disease Control and Prevention. 2013. Retrieved 18 October 2013. 
  17. ^ Hand, foot and mouth disease: First vaccine, BBC News, James Gallagher, 28 May 2013
  18. ^ Centers for Disease Control and Prevention (CDC) (1998). "Deaths among children during an outbreak of hand, foot, and mouth disease--Taiwan, Republic of China, April–July 1998". MMWR Morb. Mortal. Wkly. Rep. 47 (30): 629–32. PMID 9704628. 
  19. ^ Ho M, Chen ER, Hsu KH, et al. (1999). "An epidemic of enterovirus 71 infection in Taiwan. Taiwan Enterovirus Epidemic Working Group". N. Engl. J. Med. 341 (13): 929–35. doi:10.1056/NEJM199909233411301. PMID 10498487. 
  20. ^ Suhaimi, Nur Dianah (April 20, 2008). "HFMD: 1,000 cases a week is unusual, says doc". Singapore: The Sunday Times (Straits Times). pp. 1–2. 
  21. ^ Viet Nam News: HFMD cases prompt tighter health screening at airport(accessed May 15, 2008)
  22. ^ EV-71 Virus Continues Dramatic Rise (accessed May 23, 2008)
  23. ^ Bandar Seri Begawan (7 November 2008). "1,053 HFD cases recorded". The Birmingham News. Retrieved May 11, 2012. 
  24. ^ "Hand-foot-mouth disease death toll rises to 17 in East China's Shandong Province". China View. April 9, 2009. Retrieved September 29, 2009. 
  25. ^ "Health Ministry: Hand-foot-mouth disease claims 50 lives this year". China View. 10 April 2009. Retrieved 29 September 2009. 
  26. ^ http://news.xinhuanet.com/english2010/china/2010-06/24/c_13367598.htm
  27. ^ "China reports 537 deaths from hand-foot-mouth disease this year". People's Daily Online. 2010. Retrieved 16 October 2013. 
  28. ^ "Coxsackievirus A6 (CVA6)". California Department of Public Health. 2013. Retrieved 16 October 2013. 
  29. ^ Hannah Wolfson (February 13, 2012). "Outbreak of hand, foot and mouth disease severe in Alabama". The Birmingham News. Retrieved May 11, 2012. 
  30. ^ CBS News Staff (2012). "Joint Press Release Between The Ministry of Health Kingdom of Cambodia and the World Health Organization" (PDF). CBS News. Retrieved 16 October 2013. 
  31. ^ "Mysterious deadly illness in Cambodian children tied to hand, foot and mouth disease". Hand, Foot and Mouth Disease. World Health Organization. 2012. Retrieved 16 October 2013. 
  32. ^ "Global Alert and Response (GAR)". Undiagnosed illness in Cambodia-update. World Health Organization. 2012. Retrieved 16 October 2013. 
  33. ^ "Emerging disease surveillance and response". Hand, Foot and Mouth Disease. World Health Organization. 2013. Retrieved 16 October 2013. 
  34. ^ Sparrow, Annie (2015), "Syria: Death from Assad’s Chlorine", The New York Review of Books, (7 May issue).

External links[edit]

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