Severe Hand Foot Mouth Disease

Hand Foot Mouth DiseaseChildhood rashes are not my favorite topic or condition to contemplate. I use a rather simplistic approach (see Approach to Rashes) and a little bit of knowledge about typical childhood dermatologic eruptions (ex, Molluscum, Diaper Dermatitis, Perianal StrepScabiesErythema Multiforme). Sometimes, though, things can get a little weird (ex, pyoderma gangrenous). Additionally, the child’s own skin conditions can influence the appearance of typical conditions (like Atopic Dermatitis -> Eczema Herpeticum). Another condition to add to that unique list is Hand Foot Mouth Disease. Let’s look at Severe Hand Foot Mouth Disease:


Hand Foot Mouth Disease: Classic

  • Hand Foot Mouth Disease (HFMD) classically is associated w/:
    • Stomatitis of the oral mucosa – small vesicles and erosions in the mouth
    • Vesicles on the hands, feet, and occasionally the buttocks
    • Fever
    • Mild gastrointestinal symptoms
    • Known sick contracts
  • It is associated with enterovirus.


Hand Foot Mouth Disease: Severe

  • Severe forms of HFMD have been found to present in atypical fashions. [Mathes, 2013]
    • Associated with Coxsackievirus A6
    • Occur in outbreaks.
  • It can present in 4 other distinct manners: [Mathes, 2013]
    1. Widespread vesicles, bullae, and erosions that extend beyond palms and soles
      • Perioral, acral, and buttock areas are predominant
      • Younger children (<1 year) are more likely to have bullae.
    2. Eczema Coxasckium” – Eczema herpeticum-like eruption
      • Vesicles and erosions occurring in areas where eczema is present.
      • Eruptions are thought to be more prominent in areas of skin/mucosal “trauma”… so hands, feet, mouth… and that may explain why eczema leads to wider distribution. [Mathes, 2013]
    3. Gianotti-Crosti – like eruption
      • Acro-fascial papules, vesicles, and erosions
      • Spares the truck.
    4. Petechiae or purpura
      • Seen in older children (>5 years)
      • Often acral (involving the extremities)


Severe HFMD: The DDX

  • There are several mimics of severe HFMD.
  • Some notable ones include:
    • Bullous impetigo
    • Varicella
    • Immunologic disorders
    • Secondary bacterial infection of eczema
    • Urticaria multiforme
    • Vasculitis
    • Eczema herpeticum
    • Gianotti-Crosti syndrome [Chuh, 2016]
      • Monomorphic, papular eruptions in symmetric, acral distribution.
      • Also seen on face and buttock.
      • Associated with coxsackie virus (as well as, HBV, EBV, CMV, enterovirus, and HSV).
      • Also associated with atopic dermatitis!
  • If unsure, and testing is warranted, consider:
    • Enterovirus PCR testing of vesicle fluid (check with your lab for its specific requirements).
    • Viral culture for Coxsackievirus A6 is NOT recommended as it does not grow well in culture.
    • Also consider HSV culture or direct fluorescent antibody testing in patient with vesicular/bullous disease.


Moral of the Morsel

  • Not all severe appearing rashes are life-threatening. Be careful, but know the Ddx.
  • Once again, a virus can cause lots of concern. Don’t say “It’s just a virus.”
  • Keep unusual presentation of common conditions on your Ddx.



Chuh A1, Zawar V2, Lee A3, Sciallis G4. Is Gianotti-Crosti Syndrome Associated with Atopy? A Case-Control Study and a Postulation on the Intrinsic Host Factors in Gianotti-Crosti Syndrome. Pediatr Dermatol. 2016 Sep;33(5):488-92. PMID: 27339179. [PubMed] [Read by QxMD]

Mathes EF1, Oza V, Frieden IJ, Cordoro KM, Yagi S, Howard R, Kristal L, Ginocchio CC, Schaffer J, Maguiness S, Bayliss S, Lara-Corrales I, Garcia-Romero MT, Kelly D, Salas M, Oberste MS, Nix WA, Glaser C, Antaya R. “Eczema coxsackium” and unusual cutaneous findings in an enterovirus outbreak. Pediatrics. 2013 Jul;132(1):e149-57. PMID: 23776120. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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