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ORIGINAL ARTICLE

Hand, foot and mouth disease in children: Aclinico

epidemiological study
K Bhumesh Kumar, A Geeta Kiran, B Udaya Kumar
Department of Dermatology, Venereology and Leprosy, Gandhi Medical College, Hyderabad, Telangana, India
ABSTRACT
Background: Epidemics of hand, foot, and mouth disease(HFMD) are increasing every year globally. The disease now
presents an increasing threat to public health worldwide. HFMD is a highly contagious viral infection characterized by a
typical maculopapular or vesicular eruptions on the hands and feet and in the oral cavity. It affects predominantly children
and/or immunocompromised adults and follows a benign selflimiting course. However, HFMD cases with severe or lethal
complications such as encephalitis, meningitis, pulmonary edema, and myocarditis have been reported mostly in children,
and also in immunocompromised adults. The common pathogens are coxsackievirus A16, enterovirus 71, and recently
coxsackieviruses A6 and A10 have been included. Differences in the course of HFMD have been observed depending on
the virus type, age, and immune status.
Aim: This study is to review the clinico epidemiological data for HFMD for early diagnosis and treatment, to prevent the
complications and to implement the precautionary measures during outbreaks.
Materials and Methods: Aprospective observational study is conducted from August 2013 to January 2014. Consecutive
cases clinically diagnosed as HFMD, in the pediatric age group were taken up.
Results: We report the clinico epidemiological study of 50cases of HFMD, their benign course and recovery among
immunocompetent children.
Conclusion: Early accurate diagnosis and treatment of HFMD along with monitoring is crucial to prevent severe
complications. Hence, a high index of suspicion is required to diagnose HFMD.
Key words: Coxsackievirus, hand, foot and mouth disease, immunocompetent children

INTRODUCTION

and, foot, and mouth disease(HFMD), a viral

infection which predominantly affects the
children is characterized by a brief prodrome and
erythematous papulovesicles mostly localized to palms
and soles with or without oral ulcerations. Involvement
of buttocks, knees, elbows, and perioral skin is found
less commonly.[1,2] HFMD is usually been associated
with coxsackie A16, not uncommonly by coxsackie
A5, A10, and by human enterovirus 71.[3] The most
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DOI:
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cases occur during summer and early autumn.[1,2] In

most instances, this is a mild selflimiting illness. The
skin lesions heal spontaneously without scarring. The
analysis of the recent epidemics has shown a spectrum
ADDRESS FOR CORRESPONDENCE
Dr.K Bhumesh Kumar,
Department of Dermatology, Venereology and Leprosy, Gandhi Medical
College, Hyderabad500003, Telangana, India.
E-mail: drbhumesh124@gmail.com
This is an open access article distributed under the terms of the Creative
Commons AttributionNonCommercialShareAlike 3.0 License, which allows
others to remix, tweak, and build upon the work noncommercially, as long as
the author is credited and the new creations are licensed under the identical
terms.
For reprints contact: reprints@medknow.com

How to cite this article: Kumar K B, Kiran A G, Kumar B U. Hand, foot

and mouth disease in children: A clinico epidemiological study. Indian J
Paediatr Dermatol 2016;17:7-12.

2016 Indian Journal of Paediatric Dermatology | Published by Wolters Kluwer - Medknow

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Kumar, etal.: HFMD in children

of central nervous system complications.[4] Mortality

is due to cardiorespiratory failure in severely affected
children.[5]

MATERIALS AND METHODS

A prospective observational study is conducted from
August 2013 to January 2014 in Hyderabad city.
Consecutive cases clinically diagnosed as HFMD,
in pediatric age group, attending DVL outpatient
department(OPD) were taken up.
Inclusion Criteria
All clinically diagnosed cases of HFMD children were
taken up for the study.
Exclusion Criteria
All above 18years of age were excluded from the
study.
Objectives
This study is to review the clinico epidemiological
data for HFMD for early diagnosis, to prevent the
complications and to implement the precautionary
measures during outbreaks.

tongue in children[Chart 5]. Oral erosions were either

single or multiple in number.
Exanthemas
52%(26) cases presented with cutaneous
manifestations [Figures35] as a presenting complaint
with itching and pain over the skin lesions in 6 and
2cases, respectively. Remaining 70%(18) cases
were asymptomatic [Chart6]. Exanthemas were
usually present in clusters of 310 maculopapules on
erythematous skin involving the extremities either
40

30

20

10

20%(10)
0

50

A total of 50cases were observed during an outbreak

of HFMD. The youngest child among the cases
studied was 7monthold and the oldest being
16years [Chart1]. The infection predominantly
affected the children younger than 5years(80%).
Male to female ratio was 1:1. History of contact
with similar cases was found in 84%(42) of
cases [Chart2]. All 50cases presented with both
enanthemas and exanthemas either serially or
simultaneously, of which 44%(22) cases were
associated with prodromal symptoms such as fever,
irritability, etc. [Charts 3 and 4]. All the cases were
mild in the form. There were no symptoms and signs
of the primary immunodeficiency disorders such as
recurrent or atypical microbial infections, and they
were not on immunosuppressive medication.

40

Below 5 years

Above 5 years

Chart 1: Predominantly affected age group is below 5years(youngest age

was 7monthold, and the oldest age was 16yearold)

RESULTS

Enathemas
Oral involvement [Figures1 and 2] was found among
48%(24) of 50cases as a presenting complaint, of
which 70%(17) cases gave history of either drooling
of saliva or refusal of feeds probably due to painful
erosions in infants. In seven cases(30%), painful oral
erosions were seen on the soft palate, buccal mucosa,
lateral side of the tongue, or on the dorsum of the

80%(40)

30
20

84%(42)

10
0

16%(8)
History of contact

No history of contact

Chart 2: History of contact with similar cases is seen in 42(84%). No

history of contact in 8(16%)
30
25
20
15
10

46%(28)
44%(22)

5
0

Prodromal symptoms

No prodromal symptoms

Chart 3:22cases(44%) were associated with prodromal symptoms like

fever and irritability. No prodromal symptoms in 28(46%)

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Kumar, etal.: HFMD in children

48%(24)
52%(26)

Enanthem as presenting
complaint
Exanthem as presenting
complaint

Chart 4: All 50cases presented with both enathemas and exanthemas

of 23days duration. Presenting complaint as enanthem is 48% and as
exanthema is 52%

Figure 2: Erosion on tongue

Figure 1: Erosion on soft palate

Figure 3: Football shaped vesicle on erythmatous base on palm and sole

Figure 4: On buttocks
Figure 5: Extensive involvement on trunk

on the hand or palm then spreading to other parts

of the body such as buttocks, legs, arms, and trunk.
The dorsal aspect of the hands and sides of the fingers
wereinvolved more often than the palmar aspect and
feet.

The diagnosis of HFMD was made based on

detailed clinical history and examination. Routine
investigations of complete blood profile, erythrocyte
sedimentation rate, Creactive protein, complete

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Kumar, etal.: HFMD in children

20

15

70%(17)

30%(7)
10

70%(18)

Symptoms
5

sign
0

10

20

30

Chart 5: Enanthemas: History of excessive crying, drooling of saliva

and refusal of feeds is seen in infants in 17cases(70%) whereas painful
erosions on the soft palate, buccal mucosa, lateral, dorsal and ventral side
of the tongue is seen in children in 7cases(30%)

urine examination and chest Xray were normal.

Tzanck smears were negative ruling out other viral
infections such as herpes simplex virus, varicella, and
measles.
All the children were treated with supportive
and symptomatic therapy such as cold sponging,
antipyretics, plenty of oral fluids along with
reassurance and counseling their parents. The lesions
subsided in 710days without any significant
complications such as dehydration, encephalitis,
meningitis, myocarditis, and pulmonary edema. All
cases were treated on OPD basis, and none of the
patients required hospitalization.

DISCUSSION
HFMD is also known as vesicular stomatitis with
exanthema caused by coxsackievirus which is highly
contagious.[6] During epidemics, the virus spread by
horizontal transmission with an incubation period
of 36days. Initially, viral implantation occurs in
the buccal and ileal mucosa followed by spread to
the lymph nodes within 24h. Oral lesions begin as
erythematous macules that evolve into 23mm
vesicles on an erythematous base. The vesicles may
involve the palate, buccal mucosa, gingival, lips and
tongue. The vesicles are rarely observed because they
rapidly become eroded. They are painful with drooling
of saliva and may interfere with the mastication
and feeding as it observed in our study, especially
in infants. In 44% of cases, tongue involvement is
reported.[7] Viremia rapidly ensues, with spread to
the oral mucosa and skin. All lesions will be cleared
over a period of 12weeks because after 710days,
neutralizing antibody levels increase and the virus is
eliminated.[8]
10

30%(8)

Symptomatic

Asymptomatic

Chart 6: Exanthemas: Asymptomatic in 18(70%) cases and symptomatic

in 8cases(30%)

The same was noted in our study in the form of clinical

clearance of lesions in 1 to 2 weeks.
Normally there is no enteric virus flora in a human
being. In an individual, only one type of enterovirus
multiplies within the intestine at any given point of
time. Polio vaccination has been eliminated polioviruses
from the gut, thereby increasing the chances of other
enteroviruses like coxsackievirus and echo viral
infections. It is possible that the emergence of HFMD
in India may be related to the mass polio vaccination.[9]
The largest outbreak of HFMD occurred in an eastern
part of India in 2007, where about 38cases of HFMD
in and around Kolkata was reported.[10]
Complications
such
as
dehydration,
meningoenchephalitis, myocarditis, pulmonary edema
and death occasionally occur in children with HFMD.[11]
Complications mainly depend on the strain of the
organism, age and immune status of the child. Out of
all complications, dehydration was the most common.
It may be due to hyperpyrexia and refusal of feeding
due to painful erosions, it may be easily prevented by
plenty of oral fluids, cold sponging, and antipyretics.
In our study of HFMD, we could not find any major
complications since this outbreak may be caused by
coxsackievirus A16. It is a benign and most common
strain whereas enterovirus 71 is a rare strain commonly
associated with severe complications. Hence, early
diagnosis and treatment along with monitoring for
severe complication is mandatory because clinically we
may not know the strain of the virus.
Oral lesions of HFMD can be easily misdiagnosed as
aphthous ulcers, varicella or herpangina. However,
aphthous ulcers are multiple, more painful and
recurrent not associated with prodromal symptoms.

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Kumar, etal.: HFMD in children

Varicella rarely presents with oral lesions and the

skin lesions are more concentrated on the trunk,
rarely affecting the palms and soles. Herpangina is
a viral infection of the children caused by a TypeA
coxsackievirus which presents with similar types of
oral ulcers extensively involving the tonsils, pharyngeal
mucosa, soft palate and the posterior part of buccal
mucosa.[12] Most of the parents come to us with the
suspicion of either measles or varicella infection.
Treatment
Medications are usually not needed as HFMD is a viral
disease that typically gets better on its own. Currently,
there is no specific treatment for HFMD.[13] Disease
management typically focuses on achieving symptomatic
relief. Pain from the sores may be eased with the use
of analgesic medications like the topical application of
anesthetics and viscous lidocaine or dyphenhydramine.
Infection in older children, adolescents, and adults is
typically mild and lasts approximately 1week, but may
occasionally run a longer course. Prodromal symptoms
like fever can be treated with plenty of oral fluids, cold
sponging, and antipyretics. Aminority of individuals
with HFMD may require hospital admission due to
uncommon neurologic complications such as encephalitis,
meningitis, or acute flaccid paralysis.[14] Nonneurologic
complications such as myocarditis, pleural effusion, or
bleeding into the lungs may also occur.[14]
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.[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
or flaccid paralysis in rare circumstances.[13]
Fingernail and toenail loss have been reported in
children 48weeks after having HFMD.[15] The
relationship between HFMD and the reported nail
loss is unclear; however, it is temporary, and nail
growth resumes without treatment.[15]
Prevention
Currently, there is no specific vaccine or antiviral
therapy against HFMD but such vaccines are being
developed.[13] HFMD is highly contagious and is
transmitted by nasopharyngeal secretions such as

saliva or nasal mucus, by direct contact, or by fecaloral

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]

CONCLUSION
Normally there is no enteric viral flora in human beings.
Usually, only one type of enterovirus multiplies in an
individual at any given point of time. Polio vaccination
has eliminated polio viruses from the gut thereby
increasing the chances of the coxsackievirus and
enteroviral infections. It is possible that the emergence
of HFMD in India may be related to the mass polio
vaccination. Coxsackievirus A16 is more common and
has a benign course, whereas enerovirus 71 is rare and
has a lethal outcome. Early accurate diagnosis and
treatment of HFMD along with monitoring is crucial
to prevent severe complications. Hence, a high index
of suspicion is required to diagnose HFMD.
Declaration of Patient Consent
The authors certify that they have obtained all
appropriate patient consent forms. In the form the
patient(s) has/have given his/her/their consent for his/
her/their images and other clinical information to be
reported in the journal. The patients understand that
their names and initials will not be published and
due efforts will be made to conceal their identity, but
anonymity cannot be guaranteed.
Financial Support and Sponsorship
Nil.
Conflicts of Interest
There are no conflicts of interest.

REFERENCES
1. MillerGD, TindallJP. Handfootandmouth disease. JAMA
1968;203:82730.
2. AngLW, KohBK, ChanKP, ChuaLT, JamesL, GohKT.
Epidemiology and control of hand, foot and mouth disease
in Singapore, 20012007. Ann Acad Med Singapore
2009;38:10612.
3. ChenKT, ChangHL, WangST, ChengYT, YangJY.
Epidemiologic features of handfootmouth disease and
herpangina caused by enterovirus 71 in Taiwan, 19982005.
Pediatrics 2007;120:e24452.
4. HoM, ChenER, HsuKH, TwuSJ, ChenKT, TsaiSF, etal.
An epidemic of enterovirus 71 infection in Taiwan. Taiwan

Indian Journal of Paediatric Dermatology | Vol 17 | Issue 1 |Jan-Mar 2016

11

[Downloaded free from http://www.ijpd.in on Sunday, February 07, 2016, IP: 104.35.136.178]
Kumar, etal.: HFMD in children
Enterovirus Epidemic Working Group. NEngl J Med
1999;341:92935.
5. HuangCC, LiuCC, ChangYC, ChenCY, WangST, YehTF.
Neurologic complications in children with enterovirus 71
infection. NEngl J Med 1999;341:93642.
6. BuchnerA, MlinekA. Handfootandmouth disease in
children in Israel. Harefuah 1973;84:3212.
7. ThomasI, JannigerCK. Hand, foot, and mouth disease. Cutis
1993;52:2656.
8. ChangLY, KingCC, HsuKH, NingHC, TsaoKC, LiCC, etal.
Risk factors of enterovirus 71 infection and associated hand,
foot, and mouth disease/herpangina in children during an
epidemic in Taiwan. Pediatrics 2002;109:e88.
9. MartinLA. Enteric viruses. In: PetersdorfRG, AdamsRD,
BraunwaldE, IsselbackerKJ, WilsonJD, editors. Harrison
Principles of Internal Medicine. 10thed. McGrawHill
International Book Company; 1983. p.112532.
10. SarmaN, SarkarA, MukherjeeA, GhoshA, DharS, MalakarR.

12

Epidemic of hand, foot and mouth disease in West Bengal,

India in August, 2007: A multicentric study. Indian J Dermatol
2009;54:2630.
11. ThomasJ. Hand foot and mouth diseaseAn overview. EJ
Indian Soc Teledermatol 2009;3:15.
12. SterlingJC. Viral infections. In: BurnsT, BreathnachS, CoxN,
GriffithsC, editors. Rooks Text Book of Dermatology. 7thed.,
Vol.25. Oxford: Blackwell Science; 2004. p.183.
13. SarmaN. Hand, foot, and mouth disease: Current scenario
and Indian perspective. Indian J Dermatol Venereol Leprol
2013;79:16575.
14. LiY, ZhuR, QianY, DengJ. 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 2012;7:e29003.
15. HoyNY, LeungAK, MetelitsaAI, AdamsS. New concepts in
median nail dystrophy, onychomycosis, and hand, foot, and mouth
disease nail pathology. ISRN Dermatol 2012;2012:680163.

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