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 M. Fox
Sean M. Fox
Articles: 583


  1. Here in Australia (and even more so in SE Asia) there have been nasty outbreaks of HFMD caused by Enterovirus 71 where the severity has been not so much dermal but the ensuing meningo-encephalitis which has proven fatal in some cases.

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