Hand Foot And Mouth Disease: Symptoms, Types, Causes and Treatment

Hand, Foot, and Mouth Disease (HFMD) is a common yet often misunderstood viral illness that affects millions of children and, increasingly, adults worldwide. Known for its telltale rash and mouth ulcers, HFMD is usually mild but can sometimes lead to severe complications. In this article, we unravel the symptoms, types, causes, and treatments of HFMD, drawing on the latest research and clinical guidelines to provide a comprehensive, evidence-based overview.

Symptoms of Hand Foot And Mouth Disease

Hand, Foot, and Mouth Disease presents with a unique constellation of symptoms that set it apart from other common childhood illnesses. Recognizing these early can help prevent complications and limit the spread of the disease.

Early Signs	Skin Manifestations	Oral Issues	Source
Fever, sore throat, reduced appetite	Red spots, blisters on hands, feet, buttocks; rash may spread to elbows, knees, genitals	Painful mouth ulcers, blisters on tongue, gums, palate	1, 3, 5, 8

Table 1: Key Symptoms

Typical Symptom Progression

HFMD often begins subtly. Early symptoms include fever, a sore throat, and reduced appetite, which may be mistaken for a common cold or flu. Within a day or two, small red spots appear inside the mouth—especially on the tongue and gums. These spots rapidly evolve into painful blisters and ulcers, making eating and drinking uncomfortable for children (1, 3).

A day or two after the mouth lesions, a characteristic rash develops on the palms of the hands and soles of the feet. Unlike chickenpox, the rash of HFMD is usually not itchy, though itching can occur in some individuals. The rash may also spread to the buttocks, genital area, elbows, or knees (1, 5, 8).

Expanded Symptom Spectrum

While most cases of HFMD are mild, certain strains—particularly Coxsackievirus A6 (CA6) and Enterovirus 71 (EV71)—can cause atypical or severe presentations:

• Widespread Skin Involvement: Some patients develop more extensive rashes, including periorificial (around the mouth, nose, or anus) lesions and involvement of areas with existing eczema (“eczema coxsackium”) (3, 8).
• Systemic Symptoms: Higher fever, vomiting, fatigue, and myoclonic jerks may occur, especially in severe cases (2, 8).
• Neurological Complications: Rarely, symptoms escalate to include headache, neck stiffness, irritability, and signs of meningitis or encephalitis (4, 13, 15).

When to Seek Medical Attention

Most children recover from HFMD within 7–10 days without complications. However, parents and caregivers should seek prompt medical attention if a child experiences:

• Persistent high fever
• Signs of dehydration (dry mouth, reduced urination, lethargy)
• Severe headache, neck stiffness, confusion, or seizures
• Rapid breathing or difficulty breathing (13, 15)

HFMD’s symptoms are usually self-limiting, but awareness of severe warning signs is essential for timely intervention.

Types of Hand Foot And Mouth Disease

HFMD is not a single-variant infection. Instead, it comprises several types, defined by the causative virus and resulting clinical features. Understanding these distinctions helps in anticipating complications and guiding public health responses.

Type/Strain	Typical Age Group	Unique Features	Source
EV71	<5 years	Severe neurological risks; fatalities	2, 4, 15
CV-A16	<5 years	Classic mild symptoms	4, 6, 11
CV-A6	All ages	Widespread, severe rash; adults affected	3, 7, 8, 10, 11
CV-A10	Children	Less common; mild to moderate	2, 4, 11

Table 2: HFMD Types and Features

Classic HFMD Types

The two most historically significant viruses responsible for HFMD are:

• Coxsackievirus A16 (CV-A16): Causes the classic, generally mild form of HFMD. Children under five are mainly affected, and complications are rare (4, 6).
• Enterovirus 71 (EV71): Notorious for causing severe disease, particularly in young children. In addition to the typical rash and mouth ulcers, EV71 can invade the nervous system, leading to encephalitis, meningitis, acute flaccid paralysis, and even death in rare cases (2, 4, 15).

Emerging Viral Types

• Coxsackievirus A6 (CV-A6): Since 2008, CA6 has emerged as a major cause of HFMD outbreaks worldwide. It causes disease in both children and adults, often with more severe and widespread skin involvement. Lesions may appear in atypical locations, and adults can present with severe or “atypical” HFMD (3, 7, 8, 10, 11).
• Coxsackievirus A10 (CV-A10): Less common, CA10 can cause outbreaks and is associated with mild to moderate symptoms. Vesicles on the hands, feet, and elbows are less frequent compared to other types (2, 4, 11).

Variability in Clinical Presentation

The clinical expression of HFMD varies based on the viral strain:

• CA6: More likely to cause extensive and severe skin eruptions, sometimes mimicking other skin diseases. Adults may be affected, especially in household outbreaks (3, 7, 8).
• EV71: More likely to lead to serious neurological complications, such as aseptic meningitis or encephalitis, and is associated with higher fatality rates (2, 4, 13, 15).
• CV-A16 and CV-A10: Usually result in milder, classic presentations (2, 4, 6).

Geographic and Demographic Distribution

While HFMD primarily affects young children worldwide, CA6’s emergence has led to a broader age range being affected—including older children and adults—reflecting the dynamic nature of the disease’s epidemiology (7, 8, 10).

Causes of Hand Foot And Mouth Disease

HFMD is caused by a group of highly contagious viruses belonging to the Enterovirus genus. Understanding the transmission and risk factors is crucial for prevention and control.

Virus/Agent	Mode of Transmission	Risk Group	Source
Enterovirus 71 (EV71)	Fecal-oral, respiratory	Infants, young children	4, 9, 12, 15
Coxsackievirus A16	Fecal-oral, respiratory	Children <5 years	4, 6, 15
Coxsackievirus A6	Fecal-oral, respiratory	All ages	3, 8, 11
CA10, other Enteroviruses	Fecal-oral, respiratory	Children	2, 4, 11

Table 3: Causative Agents and Transmission

The Enterovirus Family

The main culprits behind HFMD are:

• Enterovirus 71 (EV71)
• Coxsackievirus A16 (CV-A16)
• Coxsackievirus A6 (CV-A6)
• Coxsackievirus A10 (CV-A10)
• Other enteroviruses: Less frequently, other serotypes like echoviruses may cause HFMD (4, 11, 12, 15).

How HFMD Spreads

HFMD is primarily transmitted through:

• Fecal-oral route: Contaminated hands, surfaces, diapers, and objects are common sources.
• Respiratory droplets: Coughing, sneezing, or close contact can spread the virus.
• Direct contact: With saliva, blister fluid, or stool of infected individuals (4, 9, 12).

The virus is highly contagious, especially during the first week of illness, but can still be shed in stool for weeks after recovery (6, 9, 12).

Risk Factors

• Age: Children under 5 years are most at risk due to immature immune systems and close contact in child care settings (4, 6, 9).
• Hygiene: Poor handwashing and sanitation practices facilitate spread (9).
• Crowded environments: Schools and daycare centers are common outbreak sites (9, 12).
• Climate and Season: In temperate regions, HFMD peaks in summer; in subtropical areas, spring and fall peaks are common (9).

Silent Infections and Immunity

A significant proportion of infections, especially with CV-A16 and EV71, may be asymptomatic (“silent”), yet these individuals can still spread the virus (6). After infection, people develop antibodies, but immunity may not be long-lasting or protective against all strains (6).

Treatment of Hand Foot And Mouth Disease

While HFMD is usually mild and self-limiting, effective management focuses on symptom relief, complication prevention, and—when necessary—hospital care for severe cases. Research into targeted treatments and vaccines is ongoing.

Approach	Details/Examples	Indication	Source
Supportive Care	Fluids, pain relief, fever reducers	All cases	5, 13, 15
Hospitalization	IV fluids, monitoring, complication management	Severe/neurological cases	13, 15
Antivirals (experimental)	Chloroquine, NLD-22 (in trials)	Research/clinical trials	14, 16, 17
Vaccines	Inactivated EV71 (limited coverage)	EV71 prevention (China only)	4, 15, 17

Table 4: Treatment and Prevention Strategies

Supportive and Symptomatic Care

For most patients, HFMD requires only symptomatic management:

• Fever/pain management: Acetaminophen or ibuprofen helps relieve discomfort.
• Hydration: Encourage fluids, especially if mouth ulcers make eating or drinking painful. Ice pops and cold drinks may soothe sore mouths.
• Rest: Keeping children home from school or daycare prevents spread and allows recovery (5, 13, 15).

Managing Severe Cases

Hospital care may be needed if:

• The child cannot drink enough due to mouth pain or vomiting.
• Severe neurological symptoms (e.g., seizures, confusion, severe headache) develop.
• There are signs of cardiopulmonary complications.

Close monitoring and supportive interventions, such as intravenous fluids and respiratory support, may be required in severe or rapidly progressing cases (13, 15).

Antiviral and Research Therapies

Currently, there are no approved specific antivirals for HFMD. However, research has shown promise in:

• Chloroquine: Demonstrated broad activity against HFMD-associated enteroviruses in laboratory and animal studies (14).
• Novel agents (e.g., NLD-22): Experimental compounds targeting EV71 are in development but not yet available for clinical use (16, 17).

Vaccines

• Inactivated EV71 vaccine: Available and approved in China, offering protection against EV71, but does not cover CV-A16, CA6, or other strains (4, 15, 17).
• Multivalent vaccines: Under research to broaden protection, but not yet commercially available (4, 11, 17).

Prevention

Until broadly effective vaccines and treatments are available, prevention relies on:

• Rigorous handwashing
• Disinfecting surfaces and toys
• Excluding sick children from group settings during the contagious period (4, 5, 9)

Conclusion

Hand, Foot, and Mouth Disease is a dynamic, evolving infectious disease with a wide spectrum of manifestations. While usually mild, its potential for severe complications and epidemic outbreaks warrants vigilance among parents, caregivers, and healthcare providers.

Key takeaways:

• Symptoms include fever, mouth ulcers, and rashes on the hands, feet, and sometimes buttocks or other areas. Severe or atypical symptoms may occur with certain viral strains (1, 3, 8).
• Types are mainly defined by the causative virus—EV71, CV-A16, CA6, and others—each with unique clinical and epidemiological profiles (2, 4, 11).
• Causes are enteroviruses transmitted via fecal-oral and respiratory routes, predominantly affecting young children but increasingly all age groups with newer strains (4, 6, 9, 12).
• Treatment is mainly supportive, with ongoing research into antivirals and vaccines. Most cases recover fully, but severe cases require prompt medical attention (5, 13, 14, 15, 17).

Staying informed about HFMD’s changing patterns and maintaining good hygiene practices remain the best defenses until comprehensive vaccines and treatments become widely available.