Treatment Guideline Chart
Hand, foot and mouth disease (HFMD) is characterized by fever, vesicular stomatitis, and papular/vesicular lesions located peripherally (ie palms of hands, knees, soles of feet, buttocks or genitalia).
Oral vesicular lesions are 1-3 mm, mostly found on the buccal mucosa, tongue and soft palate.
Each oral lesion is surrounded by erythema and is tender to touch.
Patient may complain of sore throat or sore mouth, fever and may be difficult to feed.
Most common cause of HFMD is coxsackievirus A16 (A16).

Hand,%20foot%20-and-%20mouth%20disease Diagnosis


  • Has caused disease outbreaks in Taiwan, Singapore & Malaysia
  • Infection usually causes fever w/ temperature >39°C & for >3 days
  • Causes a more severe infection
  • May be accompanied by complications:
    • Meningitis
    • Encephalitis
    • Neurogenic pulmonary edema
    • Myocarditis
    • Acute flaccid paralysis


Stage I

  • Manifestations:
    • Oral ulcers
    • Vesicles on palms, soles, knees &/or buttocks
    • Herpangina w/ oral ulcers over anterior tonsils, soft palate, buccal mucosa, or uvula
  • Systemic symptoms are generally brief & the patient recovers within 7 days
  • Infection is self-limited & patients spontaneously recover

Stage II (CNS Involvement)

  • Manifestations:
    • May be confirmed w/ cerebrospinal fluid (CSF) analysis & isolation in cell culture or polymerase chain reaction (PCR)
    • Disturbances in motor function may persist for weeks but will slowly resolve
    • Viral meningitis does not lead to long-term neurologic or cognitive sequelae; however, viral encephalitis may lead to neurologic sequelae & deaths are rare but may occur
    • Acute motor neuron disease may occur
      • Transient muscle weakness is more common than flaccid paralysis
      • Temporary paresis
      • Cranial nerve involvement may result in complete unilateral occulomotor palsy

Stage IIIa [Autonomic Nervous System (ANS) Dysregulation]

  • Manifestations:
    • Cold sweating, mottled skin, tachycardia, tachypnea, & hypertension
    • Patients should be treated w/ intravenous (IV) immunoglobulin

Stage IIIb (Cardiopulmonary Failure)

  • Manifestations:
    • Pulmonary edema
    • Decreased ejection fraction (EF) of left ventricle
    • Noninvasive hemodynamic monitoring provides information while under intensive care

Stage IV

  • Convalescence/recovery phase from cardiopulmonary failure

Laboratory Tests

  • Swab specimens
    • Throat & vesicle swabs are the most recommended samples for virus detection &/or isolation
    • Stool samples/rectal swab may also be used
  • Cerebrospinal fluid (CSF) examination
    • Used for patients w/ hand, foot & mouth disease (HFMD) w/ suspected central nervous system (CNS) involvement
    • May be used for EV71 & CA16 virus detection; also used for detection &/or isolation of enteroviruses
      • Has <5% virus detection rate
  • Blood examinations:
    • Complete blood count (CBC), blood glucose
    • Blood culture - used to rule out septicemic shock in HFMD w/ cardiopulmonary failure
  • Indirect immunofluorescence assay (IFA)
    • A rapid but expensive test used for EV71 identification
  • Echocardiography
    • May be considered for patients w/ HFMD w/ suspected CNS & autonomic nervous system involvement (ANS) involvement
  • Magnetic Resonance Imaging (MRI)
    • Used for patients w/ HMFD w/ suspected CNS involvement


  • Patient is clinically very ill or toxic-looking
  • Temperature >38oC for >48 hours
  • High suspicion of cardiac or neurologic complications
    • Guardian is unable to cope & care for the patient
    • Intravenous (IV) rehydration is warranted
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