Hand, foot and mouth disease:
blisters in nursery children, course & what really helps

1. What is hand, foot and mouth disease?

Hand, foot and mouth disease (HFMD) is a contagious viral infection that mainly affects children under ten. Typical signs are painful blisters and small ulcers in the mouth and a rash on the palms of the hands and soles of the feet — hence the name. It is caused by enteroviruses, a large group of viruses that spread mainly via hands, saliva and stool.^¹

The good news: in otherwise healthy children, the illness is almost always mild and clears up on its own within about a week. A great many infections even go completely unnoticed — more than 80 per cent, according to the Robert Koch Institute (RKI), Germany's national public health institute.^¹ That is also why the disease spreads so easily in nurseries: many children pass the virus on without being ill themselves.

Because of the blisters, HFMD is often confused with other childhood illnesses. Unlike chickenpox, the rash appears mainly on the hands, feet and in the mouth, and it usually hardly itches. The painful spots in the mouth resemble mouth ulcers or gum inflammation caused by herpes viruses — more on telling them apart in section 5.

2. Typical and atypical course

What the illness looks like depends mainly on the virus type and on age.^¹,²

3. Symptoms and complications

The illness usually begins with non-specific symptoms; the typical rash only follows after one to two days:^¹,³

• Starts with fever, loss of appetite and a sore throat — the child seems grizzly and does not want to eat.
• Sore mouth — red spots that turn into blisters and small, painful ulcers on the tongue, gums and inside of the cheeks. Many children drool a lot and refuse food and drink.
• Rash on the hands and feet — flat red spots or small, oval blisters with a red rim, mainly on the palms, soles and between the fingers; often on the bottom too. The classic rash hardly itches.
• Course — most children are well again after five to seven days; the blisters dry up without scarring.^¹

Possible complications

• Dehydration — the most common serious consequence, because young children do not drink enough due to the pain in their mouth.^²
• Fingernails or toenails coming off — a few weeks after the infection, especially after atypical forms. It looks alarming but is harmless; the nails grow back.^¹
• Nervous system — very rarely meningitis, encephalitis or paralysis. Severe courses have mainly been described in outbreaks of enterovirus A71 in Asia; in Germany they are a rarity.^¹

4. Cause, transmission and incubation period

• Cause: group A enteroviruses, most commonly coxsackieviruses A6 and A16, as well as A10 and enterovirus A71. Because there are many different types, you can get the illness more than once.^¹
• Transmission: mainly via the hands — through contact with saliva, nasal secretions, blister fluid or stool, and via contaminated toys, door handles and changing mats. In the first few days, transmission through droplets is also possible.^¹
• Incubation period: usually three to ten days between infection and the first symptoms.^¹
• Contagious phase: highest in the first week of illness, as long as the blisters have not dried up. However, the virus can be shed in the stool for several weeks — which is why hand hygiene after nappy changes and after using the toilet remains important even after recovery.^¹
• Weakened immunity due to medicines: people receiving strongly immunosuppressive treatment, such as chemotherapy, can generally have more severe or prolonged viral infections. With enteroviruses this is rare, but it is a reason to let the practice know about contact.

5. Diagnosis and telling it apart

Hand, foot and mouth disease is usually a diagnosis made at a glance: the combination of a sore mouth and a rash on the palms and soles is so typical that laboratory tests are generally not needed.^¹

• Call ahead: mention the suspicion to the paediatric practice so that your child does not have to sit in a full waiting room for long.
• Looking in the mouth and at the skin: location and type of blisters, condition of the mucous membranes, signs of a bacterial infection.
• Fluid balance: how much has the child drunk, and how many wet nappies have there been? This decides whether care at home is enough.
• Virus testing only in exceptional cases: in severe or unclear cases, in newborns or during outbreaks, the virus can be detected by PCR, ideally from stool or blister fluid. Antibody blood tests are not considered useful.^¹
• Telling it apart: similar-looking conditions include chickenpox (blisters all over the body, very itchy), gum inflammation caused by herpes viruses (badly swollen, bleeding gums), scarlet fever (fine rash, strawberry tongue), measles or a rash caused by medicines.
• Medication list: which medicines has the child already had — and how much? A new rash after an antibiotic is a separate matter for the practice.

A general overview of rashes and their causes can be found in the article Skin rash.

6. Treatment: drinking, eating, easing pain

There is no medicine against the enteroviruses themselves and no vaccine in Germany. Treatment aims to ease pain and fever and, above all, to prevent dehydration. The immune system does the rest, usually within a week. Which medicines suit the individual case is decided by the treating practice.^¹,²

7. Fever and pain medicine: what to watch out for

Paracetamol: dose correctly, never give it twice

Paracetamol is well tolerated by children as long as the dose is right. It becomes dangerous when doses add up: when both parents give syrup independently of each other, when suppositories and syrup are combined, or when a combination product also contains paracetamol. The maximum daily amount and the minimum interval between two doses are stated in the package leaflet and depend on body weight.^⁴ If you switch to suppositories for a child who will not drink, you will find tips in the guide Using suppositories and patches.

Ibuprofen: effective, but not with dehydration

Ibuprofen often eases inflammatory pain in the mouth somewhat better than paracetamol. However, the Summary of Product Characteristics points out that there is a risk of kidney damage in dehydrated children.^⁴ So if your child is hardly drinking, is vomiting or has diarrhoea, talk to the practice before the next dose. Ibuprofen is also better tolerated when the child has something in their stomach.

No aspirin for children and teenagers

Acetylsalicylic acid (aspirin) should only be given to children and teenagers with feverish viral infections on medical advice, because in rare cases it can trigger life-threatening Reye's syndrome with damage to the liver and brain.^⁴ Acetylsalicylic acid is also contained in some combination products for colds — so it is worth checking the active ingredient. An overview of common painkillers is given in Painkillers compared.

8. Adults, pregnant women and newborns

Adults

Most adults have already come into contact with various enteroviruses and do not fall ill, or only mildly. Parents of young children still catch it regularly, especially with the atypical variants. Fever, a painful mouth and blisters on the hands and feet can then be quite debilitating for a few days. The treatment is the same as for children: drink, rest and take pain relief if needed.^¹,³

Pregnancy

An infection during pregnancy is usually mild or goes unnoticed. According to current knowledge, there is no evidence of an increased risk of birth defects. What matters is the period shortly before the birth: if the mother has symptoms then, she can pass the virus on to the newborn.^¹ So let your gynaecology practice or maternity clinic know if you fall ill around your due date or have close contact with a sick child. Which pain and fever medicines are suitable during pregnancy is explained in the guide Medications during pregnancy.

Newborns

In newborns, an enterovirus infection is usually mild as well. In very rare cases, however, it leads to a severe infection affecting the whole body, with involvement of the liver or heart; the risk is highest in the first two weeks of life.^¹ Fever, poor feeding or unusual drowsiness in such a young baby should therefore always be checked by a doctor immediately.

9. After the illness: nails, skin, catching it again

Some families get a surprise a few weeks after the illness: fingernails or toenails come away from the nail bed or fall off completely. This happens mainly after atypical courses and is painless and harmless. The new nail grows in from behind — on the fingers this takes a few months, on the toes longer.^¹,³ Until then, it helps to keep the nails short and not to tear off loose pieces. If nails change without a preceding infection, something else is behind it — see brittle nails.

The skin on the hands and feet may also peel after a few days. A rich moisturiser is usually all that is needed.

And: anyone who has had hand, foot and mouth disease is only protected against that one virus type. Falling ill again with a different type is possible and not at all unusual, especially in the nursery years.^¹

10. Everyday life: nursery, hygiene and siblings

• Nursery and school: there is no legal exclusion from nursery (Kita) or school for hand, foot and mouth disease. The Robert Koch Institute does not consider a general exclusion necessary; children can return once they are fever-free, feel well and the blisters have dried up — a doctor's certificate is generally not required. Some facilities and local public health offices (Gesundheitsamt) have their own rules; if in doubt, ask.^¹
• Inform the facility: so that other parents can watch out for symptoms and pregnant staff are aware. There is no nationwide notification requirement, although some federal states have additional rules.^¹
• Wash hands: thoroughly with soap, especially after nappy changes, after using the toilet and before eating. Enteroviruses are very hardy; many standard hand sanitisers are not sufficiently effective against them. If you disinfect, you need a product expressly labelled as “virucidal”.^¹
• Do not share: separate cups, spoons, towels and toothbrushes; regularly wash toys that end up in the mouth in hot water.
• Siblings: they often catch it before the illness has been recognised in the first child. Keeping them apart is hardly possible in everyday family life — but good hand hygiene reduces the risk.
• Fever medicine by weight: write down your child's current body weight where you keep the medicines. More tips in the guide Medications for children.
• Check your medicine cabinet: fever syrup or suppositories in the right strength, a thermometer, a dosing syringe — what is still missing is shown in the home pharmacy checklist.

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