Hand, Foot, and Mouth Disease: Symptoms, Treatment & When to Seek Care

What Is Hand, Foot, and Mouth Disease?

Hand, Foot, and Mouth Disease (HFMD) is a common viral infection caused primarily by coxsackievirus A16 and enterovirus 71. It mainly affects children under 5 years old and causes fever, painful mouth sores (blisters), and a distinctive rash with blisters on the hands, feet, and sometimes buttocks. The disease is highly contagious but usually mild, resolving within 7-10 days.

Hand, Foot, and Mouth Disease is one of the most common childhood illnesses encountered in daycare centers, preschools, and kindergartens around the world. Despite its alarming name and the discomfort it can cause, HFMD is generally a mild illness that runs its course without causing long-term problems. The condition gets its name from the characteristic locations where symptoms appear: painful sores inside the mouth, and a blister-like rash on the palms of the hands and soles of the feet.

The disease is caused by a group of viruses called enteroviruses. The most common culprit is coxsackievirus A16, which typically causes milder illness. Another strain, enterovirus 71 (EV-A71), can occasionally cause more severe complications, particularly neurological problems, though this remains rare in most countries. Other coxsackieviruses, including A6, A10, and B viruses, can also cause HFMD with varying presentations.

Understanding the difference between various viral strains is important because it explains why children can get HFMD multiple times throughout their childhood. Immunity develops only against the specific virus that caused the infection, not against other strains that can also produce HFMD. This means a child who recovered from a coxsackievirus A16 infection could still catch HFMD caused by enterovirus 71 or coxsackievirus A6.

Who Is Most at Risk for HFMD?

While anyone can contract Hand, Foot, and Mouth Disease, certain groups face higher risk of infection and potential complications. Children under the age of 5 are most susceptible because their immune systems are still developing and they haven't yet built up immunity to the various viruses that cause HFMD. Infants and toddlers in daycare or group settings have the highest rates of infection due to close contact with other children and the tendency of young children to put objects in their mouths.

Older children and adults can also become infected, particularly those who have close contact with infected young children, such as parents, caregivers, and teachers. Adults typically experience milder symptoms or may have no symptoms at all (asymptomatic infection), but they can still spread the virus to others. Pregnant women should be especially cautious around infected individuals, as although complications are rare, the virus can potentially affect the developing baby in rare circumstances.

What Are the Symptoms of Hand, Foot, and Mouth Disease?

The hallmark symptoms of HFMD include fever (usually 101-103°F/38-39°C), painful red spots and blisters inside the mouth (especially on the tongue, gums, and inner cheeks), and a rash with small blisters on the palms, soles, and sometimes buttocks. Children often experience sore throat, loss of appetite, irritability, and drooling due to mouth pain. Symptoms typically appear 3-6 days after exposure to the virus.

Hand, Foot, and Mouth Disease follows a fairly predictable pattern of symptom development, though the severity and specific manifestations can vary from child to child. Some children experience all the classic symptoms, while others may only have mouth sores or only a skin rash. Understanding this progression helps parents recognize the illness early and provide appropriate care.

The illness typically begins with a prodromal phase lasting 1-2 days, during which children may feel generally unwell. They often develop a low-grade fever, reduced appetite, and may complain of a sore throat or feeling tired. Young children who cannot verbalize their discomfort may simply become fussy, clingy, or irritable. This early phase is sometimes mistaken for a common cold or the beginning of another childhood illness.

Within a day or two of the initial symptoms, the characteristic mouth sores develop. These begin as small red spots that quickly evolve into painful ulcers or blisters. The sores typically appear on the tongue, gums, inner cheeks, and the back of the throat. They can range in size from a few millimeters to almost a centimeter and are often surrounded by a red halo. These mouth lesions cause significant discomfort and are the primary reason children with HFMD refuse to eat or drink - the pain intensifies when food or liquid touches the sores.

The Characteristic Skin Rash

Shortly after the mouth sores appear (usually within 1-2 days), the distinctive skin rash develops. The rash consists of flat or slightly raised red spots that may develop into small blisters. Unlike chickenpox blisters, HFMD blisters are typically smaller, more numerous in specific locations, and don't usually itch significantly.

The rash most commonly appears on the following areas:

• Palms of the hands: Often the most noticeable location, with multiple small blisters
• Soles of the feet: Can make walking uncomfortable for older children
• Buttocks and genital area: Common in young children, especially those in diapers
• Knees and elbows: Less common but can occur, especially with coxsackievirus A6
• Face and trunk: Occasionally affected, more common with certain viral strains

The blisters may contain clear fluid and can sometimes appear grayish. While they may look concerning, they rarely become infected and typically heal without scarring. The rash usually resolves within 7-10 days, with the blisters drying up and forming crusts before completely disappearing.

Symptoms in Infants vs. Older Children

Infants and toddlers often cannot communicate their discomfort verbally, making it important for parents to recognize behavioral signs of HFMD. Young children with the disease may exhibit excessive drooling (because swallowing hurts), refuse to breastfeed or take a bottle, become unusually irritable or inconsolable, have disturbed sleep, and pull at their mouths or ears. The mouth sores in infants can be particularly distressing as they interfere with feeding at an age when hydration is critically important.

Older children, typically those over 3 years of age, can usually describe their symptoms and may complain specifically about mouth pain, sore throat, or discomfort when walking if they have blisters on their feet. They may also mention that their hands feel strange or tender. Older children generally cope better with the illness because they can understand that it will get better and can communicate their needs more effectively.

How Contagious Is Hand, Foot, and Mouth Disease?

HFMD is highly contagious and spreads through direct contact with an infected person's saliva, nasal secretions, blister fluid, or feces. The disease is most contagious during the first week of illness, but the virus can remain in stool for weeks after symptoms resolve. Common transmission routes include close personal contact, coughing and sneezing, touching contaminated surfaces, and changing diapers of infected children.

Understanding how Hand, Foot, and Mouth Disease spreads is crucial for preventing transmission to other family members and classmates. The virus spreads very efficiently, which is why outbreaks in daycare centers and schools can affect many children quickly. The incubation period - the time between exposure to the virus and the appearance of symptoms - is typically 3 to 6 days.

The virus is present in several body fluids of infected individuals, each providing a potential route of transmission. Respiratory droplets released when an infected person coughs, sneezes, or even talks can contain the virus. These droplets can land directly on others nearby or settle on surfaces where the virus can survive for varying periods. Saliva is particularly infectious, which is why sharing utensils, cups, or food with an infected child is a common transmission route.

The fluid inside the blisters contains high concentrations of the virus. When blisters break, the released fluid can contaminate surfaces and spread infection through touch. This is why the rash phase of the illness, despite often occurring after the fever has subsided, remains a highly contagious period. Parents and caregivers should avoid touching blisters directly and wash their hands thoroughly after any contact with an infected child.

Perhaps the most persistent source of transmission is fecal matter. The virus continues to be shed in stool for several weeks after symptoms have completely resolved - sometimes up to 4-6 weeks. This extended shedding period is particularly important in childcare settings where diaper changes are frequent. Even children who appear completely healthy can continue spreading the virus through the fecal-oral route, making diligent hand hygiene essential long after the illness seems to have passed.

When Can My Child Return to School or Daycare?

There is no universal rule about when children with HFMD can return to group settings, and recommendations vary by country and institution. However, most health authorities suggest children can return when they feel well enough to participate in activities, the fever has been gone for at least 24 hours (without fever-reducing medication), mouth sores have healed enough to eat and drink comfortably, and all open blisters have dried and crusted over.

Some childcare facilities may have stricter policies requiring children to stay home for a specific number of days after diagnosis. It's important to communicate with your child's school or daycare about their specific requirements. Even after returning, continued emphasis on hand hygiene helps reduce the risk of spreading any remaining virus.

How Is Hand, Foot, and Mouth Disease Treated?

There is no specific antiviral treatment for HFMD - the infection must run its course. Treatment focuses on managing symptoms and preventing complications, especially dehydration. This includes giving acetaminophen or ibuprofen for fever and pain, offering cold fluids and soft foods, using topical oral anesthetics if recommended by a doctor, and ensuring adequate rest. Most children recover fully within 7-10 days.

Because Hand, Foot, and Mouth Disease is caused by a virus, antibiotics are ineffective and not prescribed. Antiviral medications that work against enteroviruses do not exist in routine clinical practice. Therefore, treatment is supportive, meaning the focus is on relieving symptoms and preventing complications while the body's immune system fights off the infection. This approach, while sometimes frustrating for parents who want to "fix" their child's illness, is completely appropriate for this typically mild disease.

The most important aspect of home care is managing pain and maintaining hydration. The painful mouth sores can make children reluctant to eat or drink, creating a real risk of dehydration, particularly in young children and infants. Dehydration is actually the most common complication of HFMD and the main reason children sometimes need medical attention.

Pain and Fever Management

Over-the-counter pain relievers can significantly improve comfort and make eating and drinking easier. Acetaminophen (paracetamol) can be given to children of all ages following age-appropriate dosing guidelines. Ibuprofen can be used for children over 6 months of age and may provide additional anti-inflammatory benefit. It's important to never give aspirin to children, as it has been associated with Reye's syndrome, a rare but serious condition.

For mouth pain specifically, some doctors recommend topical oral anesthetics applied directly to the sores. Products containing benzocaine should be used with caution and only as directed, as excessive use can cause problems. A simple home remedy that many parents find helpful is a mixture of equal parts liquid antacid (like Maalox) and liquid antihistamine (like Benadryl), which can be applied to sores with a cotton swab before meals. However, always consult your pediatrician before using any medication combinations.

Keeping Your Child Hydrated

Preventing dehydration requires creative approaches when mouth sores make drinking painful. Cold beverages are generally better tolerated than warm or hot drinks because they have a mild numbing effect. Ice pops, smoothies, cold milk, and ice water are often more acceptable to children with HFMD than regular drinks. Avoid acidic beverages like orange juice, lemonade, or carbonated drinks, as these can sting the mouth sores and increase pain.

For young infants, continue breastfeeding or formula feeding as normally as possible. The baby may take smaller amounts more frequently if mouth pain makes prolonged feeding difficult. If the baby refuses to feed or shows signs of dehydration, contact your healthcare provider promptly. Signs of dehydration in infants include fewer than 6 wet diapers in 24 hours, no tears when crying, a sunken soft spot on the head, unusual sleepiness, and dry mouth and lips.

Food Choices During HFMD

When children are ready to eat, soft, bland foods that don't require much chewing and won't irritate mouth sores are best. Good options include yogurt, pudding, applesauce, mashed bananas, ice cream, smoothies, soup (lukewarm, not hot), mashed potatoes, and scrambled eggs. Avoid crunchy, spicy, salty, or acidic foods that can aggravate mouth sores.

When Should You Seek Medical Care for HFMD?

Most cases of HFMD can be managed at home, but you should seek medical care if your child has a fever lasting more than 3 days, shows signs of dehydration, is unable to drink fluids, appears very ill or unusually drowsy, develops a stiff neck or severe headache, or if symptoms worsen instead of improving after 7 days. Infants under 3 months with fever always require immediate medical evaluation.

While Hand, Foot, and Mouth Disease is typically a mild, self-limiting illness, parents should know when medical evaluation is necessary. Most children recover uneventfully at home with supportive care, but certain warning signs indicate the need for professional medical assessment.

The most common reason children with HFMD need medical attention is dehydration. If your child cannot or will not drink enough fluids due to mouth pain, and shows signs of dehydration as described above, they may need intravenous fluids administered in a clinic or hospital setting. Don't wait until dehydration becomes severe - early intervention is much easier to manage.

Prolonged or high fever warrants medical evaluation. While fever is expected in the first few days of HFMD, it should typically resolve within 2-3 days. If fever persists beyond 3 days, returns after initially resolving, or reaches very high levels (above 104°F/40°C), contact your healthcare provider. Persistent fever may indicate a secondary bacterial infection or, rarely, a more serious complication.

Certain neurological symptoms require urgent medical attention. These are rare but more commonly associated with enterovirus 71 infections. Seek emergency care if your child develops a stiff neck, severe headache that doesn't respond to pain medication, unusual drowsiness or difficulty waking, confusion or altered consciousness, seizures, or weakness in arms or legs.

Red Flags Requiring Immediate Medical Attention

• Difficulty breathing: Any respiratory distress needs emergency evaluation
• Unable to swallow: Severe throat swelling preventing swallowing is an emergency
• Unresponsive or very difficult to wake: Could indicate serious complication
• Persistent vomiting: Prevents hydration and may indicate other problems
• Bluish color to lips or skin: Sign of inadequate oxygen - call emergency services
• Signs of meningitis: Stiff neck, light sensitivity, bulging fontanelle in babies

How Can You Prevent Hand, Foot, and Mouth Disease?

There is no vaccine for HFMD, so prevention relies on good hygiene practices. The most effective measures include frequent handwashing with soap and water (especially after diaper changes and bathroom use), disinfecting frequently touched surfaces and toys, avoiding close contact with infected individuals, not sharing utensils or cups, and teaching children to cover their mouths when coughing or sneezing.

Preventing Hand, Foot, and Mouth Disease can be challenging, particularly in environments where young children congregate. The virus spreads easily, and children are often contagious before they show obvious symptoms. However, consistent application of basic hygiene measures can significantly reduce transmission risk.

Hand hygiene is the single most important preventive measure. The enteroviruses that cause HFMD are effectively removed by proper handwashing with soap and water for at least 20 seconds. Teach children to wash hands thoroughly after using the bathroom, before eating, after blowing their nose, and after playing with shared toys. Hand sanitizers with at least 60% alcohol can be used when soap and water aren't available, though they are less effective against enteroviruses than proper handwashing.

For caregivers and parents, handwashing is especially critical after changing diapers or helping a child use the toilet, since the virus persists in stool long after other symptoms resolve. Even if the child seems completely recovered, continue meticulous hand hygiene during diaper changes for several weeks after the illness.

Environmental Cleaning and Disinfection

Regular cleaning and disinfection of surfaces can help prevent spread, particularly during active outbreaks. Enteroviruses can survive on surfaces for varying periods, making environmental contamination a real transmission route. Focus cleaning efforts on frequently touched surfaces such as doorknobs, light switches, and faucets, toys and play equipment, diaper changing surfaces, bathroom fixtures, and shared items like remote controls or tablets.

Use EPA-registered disinfectants labeled as effective against enteroviruses, or a solution of 1 tablespoon of bleach per quart of water. Allow surfaces to remain wet with the disinfectant for the recommended contact time before wiping dry. Toys that young children put in their mouths should be washed with soap and water and then disinfected, especially during outbreaks.

Preventing Spread Within the Family

When one family member develops HFMD, preventing spread to others can be difficult but is worth attempting. Assign the sick child their own cup, utensils, and towels that are not shared. Avoid kissing or close face-to-face contact with the infected child during the most contagious period. Clean and disinfect shared spaces more frequently. Consider having one caregiver primarily responsible for the sick child's care to limit exposure to others.

What Are the Potential Complications of HFMD?

Most children recover from HFMD without complications. The most common complication is dehydration from refusing to drink due to mouth pain. Rare but more serious complications include viral meningitis, encephalitis (brain inflammation), and polio-like paralysis - these are more often associated with enterovirus 71 infections. Some children experience temporary nail changes or nail shedding weeks after the initial infection.

While Hand, Foot, and Mouth Disease is almost always a mild illness that resolves without lasting effects, parents should be aware of potential complications. Understanding these helps in recognizing when a child's illness might be taking a more serious turn.

Dehydration is by far the most common complication and is usually preventable with good home care. Children who refuse all fluids due to mouth pain may need medical intervention for rehydration. This is especially concerning in infants and very young children, who have less fluid reserve and can become dehydrated more quickly.

Secondary bacterial infections can occasionally occur when skin blisters become contaminated with bacteria. Signs of bacterial infection include increasing redness, warmth, swelling, or pus around the blisters, as well as fever returning after initially resolving. These infections may require antibiotic treatment.

Rare Neurological Complications

In rare cases, particularly those caused by enterovirus 71, HFMD can lead to neurological complications. These are uncommon in most Western countries but have been more frequently reported in Asia-Pacific regions during certain outbreaks. Neurological complications include viral meningitis (inflammation of the membranes surrounding the brain and spinal cord), which causes headache, stiff neck, and light sensitivity; encephalitis (inflammation of the brain itself), which can cause altered consciousness, seizures, and neurological deficits; and acute flaccid paralysis, a polio-like weakness of the limbs that is extremely rare.

These serious complications develop during or shortly after the acute illness. Warning signs that might indicate neurological involvement include persistent or severe headache, stiff neck, unusual drowsiness or confusion, seizures, weakness in limbs, difficulty walking or balancing, and rapid deterioration despite home care.

Nail Changes After HFMD

An interesting and somewhat unsettling phenomenon that can occur weeks to months after HFMD is temporary nail shedding, known medically as onychomadesis. This occurs because the viral infection can temporarily affect the nail matrix (the tissue that produces the nail). Parents may notice horizontal ridges or grooves in nails, loosening of nails from the nail bed, or complete shedding of one or more nails.

While alarming to witness, this nail shedding is harmless and temporary. The nails regrow normally over several months. No treatment is necessary, though keeping the affected nails clean and protected can help prevent secondary issues. This complication is more commonly reported with coxsackievirus A6 infections.

Can Adults Get Hand, Foot, and Mouth Disease?

Yes, adults can contract HFMD, particularly those in close contact with infected children. Adults usually have milder symptoms than children or may be asymptomatic, though some adults experience significant illness with painful blisters and difficulty eating. Pregnant women should avoid exposure, though serious complications in pregnancy are rare. Adults remain contagious and should practice good hygiene to avoid spreading the virus.

While Hand, Foot, and Mouth Disease primarily affects young children, adults are not immune. Parents, caregivers, teachers, and healthcare workers who have close contact with infected children are at particular risk of contracting the disease. Adults who have never been exposed to the specific virus strain causing an outbreak are especially susceptible.

The clinical presentation in adults varies considerably. Many adults who become infected have no symptoms at all (asymptomatic infection) but can still spread the virus to others. This silent transmission makes outbreak control challenging, as adults may unknowingly expose other children or vulnerable individuals.

When adults do develop symptoms, they often experience milder illness than children, though this is not universal. Some adults develop full-blown HFMD with significant mouth ulcers and hand/foot rashes that cause considerable discomfort. The mouth sores in adults can be particularly bothersome, making eating and drinking painful for several days. Adults may also experience more prominent systemic symptoms such as fatigue, body aches, and a longer recovery period than typically seen in children.

HFMD During Pregnancy

Pregnant women are naturally concerned about any infectious disease exposure. While Hand, Foot, and Mouth Disease is generally considered low-risk during pregnancy, precautions are still advisable. If a pregnant woman contracts HFMD, she should inform her healthcare provider. In most cases, the illness passes without affecting the pregnancy or the developing baby.

Very rarely, enterovirus infections during pregnancy have been associated with adverse outcomes, though establishing a definite causal relationship is difficult. The greatest caution is warranted in the third trimester, close to delivery, as a newborn could potentially contract the virus during or shortly after birth when their immune system is least mature. Pregnant women should practice good hygiene and, when possible, avoid close contact with individuals known to have HFMD.