GPAtlas🧭 When to suspect
Suspect hand, foot and mouth disease (HFMD) in a child with the classic triad of a short febrile prodrome, painful mouth ulcers, and a non-itchy vesicular rash on the palms and soles (and frequently the buttocks). It is a common, self-limiting viral illness, seen mainly in children under 10 and especially those under 5, and is caused by enteroviruses – most often coxsackievirus A16, with coxsackievirus A6 producing more widespread, atypical disease and enterovirus A71 (EV-A71) linked to the rare neurological form (mainly seen in the Asia-Pacific region).
The typical course is a 1–2 day prodrome of mild fever, sore throat, reduced appetite and malaise, followed by an oral enanthem (vesicles and shallow ulcers on the tongue, buccal mucosa and palate) and a skin exanthem on the hands, feet and nappy area. It spreads by the faecal–oral and respiratory droplet routes and by contact with vesicle fluid; the virus is shed in stool for weeks after recovery. Incubation is usually 3–5 days.
The job in primary care is straightforward: it is a clinical diagnosis needing no swabs, the illness settles in 7–10 days, and the two priorities are keeping the child hydrated and recognising the rare unwell child – dehydration, neurological complications, or the unwell neonate.
| Key differential | Distinguishing features |
|---|---|
| Herpangina (coxsackievirus) | Vesicles and ulcers confined to the posterior oropharynx (soft palate, tonsillar pillars); no hand or foot rash. |
| Herpetic gingivostomatitis (herpes simplex virus, HSV) | Painful, bleeding gingivitis and anterior mouth ulcers, often a systemically unwell toddler having a first HSV episode; no acral rash. |
| Chickenpox (varicella zoster virus, VZV) | Itchy, trunk-predominant (centripetal) rash in crops at different stages with crusting; lacks the palm/sole pattern. |
| Aphthous ulcers | Recurrent oral ulcers with no rash and no viral prodrome. |
|
🧠 Clinical pearl Atypical, widespread HFMD – with lesions spreading beyond the palms and soles, sometimes onto eczematous skin (“eczema coxsackium”) – usually reflects coxsackievirus A6 and can be mistaken for chickenpox or eczema herpeticum. Several weeks later the same children may develop painless nail shedding (onychomadesis) and peeling of the palms and soles. Both are benign and self-resolving, so parents can be firmly reassured. |
Source: NICE · UKHSA · DermNet
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