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
• 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. It is caused by enteroviruses:
• Most often coxsackievirus A16
• Coxsackievirus A6 producing more widespread, atypical disease
• Enterovirus A71 (EV-A71) linked to the rare neurological form (mainly seen in the Asia-Pacific region)
The typical course:
• 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
• 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
• 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. • Atypical HFMD 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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