Heads… Shoulders… Knees… and hand, foot, and mouth?

Introduction

Paediatric presentations with rash and fever are common among acute healthcare providers, with ambulance services no exception. Paramedics are certainly no strangers to the distress experienced by a febrile child with painful-looking lesions.

Whilst the quality of care delivered by paramedics to children continues to improve, there remain variable levels of confidence and exposure to this patient group. This blog discusses a common illness experienced by infants and cursed by parents – hand, foot, and mouth disease (HFMD).

HFMD is one of the most common viral exanthems seen in young children; however, what is perhaps less well known is its variability in presentation and severity, largely due to the increasingly recognised variant of the disease – Eczema Coxsackium (EC).

This more atypical pattern is often more unpleasant for the patient, and can often be misinterpreted, leading to the risk of unnecessary conveyance and presentation to hospital, as well as increased parental anxiety.

Whilst both ‘classic’ HFMD and EC are self-limiting, paramedics can play a significant role in the safe and early recognition, reassurance, and identification of the small proportion of cases that require prompt escalation of care.

What is ‘Classic Hand, Foot and Mouth Disease’?

HFMD is a viral illness, most commonly caused by Coxsackie A16 or Enterovirus 71. It spreads readily via respiratory droplets, direct contact, and the faecal-oral route, which explains the frequent hotspots of transmission observed in shared childcare settings such as nurseries and early years settings in schools.

What are the symptoms?

In classic HFMD, pain from oral ulceration is often the most distressing symptom, and the principal cause of reduced oral intake and loss of appetite.

The illness usually resolves within 7-10 days with supportive care. It is not unusual for parents to report a peak in symptom management early in the disease process, lasting approximately 24-48 hours before symptoms begin to improve.

Complications are very rare in otherwise well, immunocompetent children.

What is ‘Atypical HFMD’?

Eczema Coxsackium is often more dramatic and may involve hundreds of lesions. It often looks disproportionate to the child’s clinical well-being and other findings. The child is often uncomfortable but otherwise systemically well, with the exception of a fever and mild tachycardia. This is an important differentiator for more serious differentials .

For pre-hospital clinicians, in the absence of a clinically unwell child and other red flags, the visual and visceral impact of a pronounced rash should not be mistaken for severity.

Differentiation: always the pre-hospital challenge

Classic HFMD is typically straightforward to diagnose and distinguish from other conditions. However, distinguishing Eczema Coxsackium from more emergent dermatological conditions can be particularly challenging.

Need to rule out!	Hallmark features	Pre-hospital clues	Example
Eczema Herpeticum	Punched-out vesicles, rapid systemic decline	Child often unwell; presence or risk of periorbital involvement	Eczema Herpeticum
Cellulitis	Warmth, unilateral swelling, tenderness, evolving erythema	More painful than appearance might suggest; possible portal?	Cellulitis
Allergic Reaction	Urticaria (hives), swelling, wider systemic symptoms	Exposure history, itch is much more prominent	Urticaria
Stevens-Johnson Syndrome	Mucosal sloughing, medication trigger	Painful erosions, early peeling of skin	Stevens-Johnson Syndrome
Meningococcal Rash	Non-blanching, petechial into purpuric rash	Systemically unwell, broader symptoms of meningism, something not right	Meningococcaemia

A perhaps simple, relatively reliable question to guide and sense-check clinical thinking:

Does the rash hurt more than it appears it should?

Pain out of proportion is a warning sign.

Similarly, the absence of systemic illness, a short-lived fever, a good appetite, normal behaviour, and interactive play is reassuring.

So what do we need to do for HFMD – both ‘classic’ and ‘atypical’?

There is no antiviral treatment for either HFMD or Eczema Coxsackium. Management priorities focus on comfort, hydration, and parental understanding, reassurance and strategies to support their unwell child.

Do we need some steroids?

Parents, particularly those of children with diagnosed eczema, may ask whether to use corticosteroids on the rash. It’s important to remember that topical steroids are not routinely recommended for acutely blistered lesions unless directed by a healthcare professional with advanced training in dermatology.

Will I get this?!

As many parents and caregivers of little ones will tell you, HFMD spreads efficiently and can persist on surfaces for a number of days. Parents and clinicians should be aware of droplet transmission, contact with leaking vesicle fluid, and faecal shedding for several weeks.

Simple precautions such as gloves, good cleaning regimes and gentle handwashing of both the patient and caregivers can help prevent HFMD from becoming a wider family problem.

Symptoms in adults can often be more pronounced and, whilst not dangerous, can certainly be more troublesome than in children. Adults may experience fewer lesions but often more pain, particularly in the hands and feet, which can make work (and parenting) extremely uncomfortable.

Reassurance – often the most important intervention

Reassurance, empathy and compassion for both the patient, but importantly the caregivers may be the most important element of care delivered in patients with presentations such as HFMD and Eczema Coxsackium.

Avoid describing hand, foot, and mouth disease as a ‘minor illness’ – the word minor is unlikely to align with a caregiver’s perception of their child’s distress, rash and the potential sleep deprivation they are currently grappling with.

Try using these phrases instead:

When should this be escalated?

Safety-netting advice

Every discharged child in the community should receive explicit, rigorous and actionable advice to seek help or attend ED in the following circumstances:

• If urine output becomes <50% of normal and/or nil output for over 8 hours
• If oral intake becomes impossible, despite analgesia discussed +/- Difflam throat spray
• In the event of significant breathing difficulty, unusual or concerning drowsiness, new concerning symptoms, or non-blanching rash
• If symptoms worsen, rather than improve, after day 5

Avoid generic statements such as ‘seek help if you’re worried’. It’s important to anchor instructions with timeframes and measurable findings for the caregivers.

Conclusion

It’s important to remember that, regardless of absolute confidence in diagnosis, pre-hospital reassurance is not passive care; it is an active intervention that prevents unnecessary and sometimes traumatic hospital attendance and empowers parents and caregivers to manage their children’s care at home.

By confidently understanding these presentations, paramedics can reduce anxiety, improve patient care, and help ensure that children and their caregivers receive appropriate care at the right place and at the right time.

Addendum

An effort has been made to ensure that the images used in this article reflect the diverse community of London to which the author belongs.

For additional images of children with a variety of skin colours and tones, please consult resources such as DFTB Skin Deep (https://dftbskindeep.com/) and Mind the Gap (https://www.blackandbrownskin.co.uk/mindthegap).

References:

1. Fairgray V, Fitzpatrick D, Williams J, Bowles K.A. (2021). A national retrospective cohort study of the demographic and conveyance characteristics of paediatric patients presenting to the Scottish Ambulance Service, before and during the COVID-19 pandemic. Emergency Medicine Journal. 40 (1), p3-30.
2. Hetherington, J & Jones, I. (2021). What factors influence clinical decision-making for paramedics when attending to paediatric emergencies in the community within one ambulance service trust? British Paramedic Journal. 6 (1), p15-22.
3. Esposito, S & Principi, N. (2018). Hand, foot and mouth disease: current knowledge on clinical manifestations, epidemiology, aetiology and prevention. European Journal of Clinical Microbiology & Infectious Disease. 37 (1), p391-398.
4. Bryant P, Boyce S & King, E. (2016). Eczema Coxsackium. Archives of Disease in Childhood. 100 (4), p46-49.
5. Ventarola D, Bordone L & Silverberg, N. (2015). Update on hand-foot-and-mouth disease. Clinics in Dermatology. 33 (3), p340-346.
6. DFTB SkinDeep Image Bank (2024). Hand foot and mouth. Available at: https://dftbskindeep.com/all-diagnoses/handfoot-and-mouth/#!jig[1]/ML/999. Last accessed: 4^th December 2025.
7. Zhao, J, Hu, X. (2019). The complex transmission seasonality of hand, foot, and mouth disease and its driving factors. BMC Infectious Diseases. 19 (3), p521-523.
8. Saguil A, Kane S, Lauters R & Mercado, M. (2019). Hand-Foot-and-Mouth Disease: Rapid Evidence Review. American Family Physician. 100 (7), p408-414.
9. Cox, B & Levent, F. (2018). Hand, Foot, and Mouth Disease. JAMA. 320 (23), p2492.
10. Smith L, Ghali H, Creech J & Kiluk, V. (2025). Eczema Coxsackium: An Unusual Presentation in Atopic Dermatitis and Hand, Foot, and Mouth Disease. Pediatric Annals. 54 (12), p447-450.
11. Su, H.J. & Chen, C. (2021). Eczema Coxsackium. The Medical Journal of Australia. 215 (9).
12. Harris P, Wang A, Yin M, Lee C, Archuleta, S. (2014). Atypical hand, foot and mouth disease: eczema coxsackium can also occur in adults. The Lancet Infectious Diseases. 14 (11), p1043.
13. DFTB SkinDeep Image Bank. (2025). Eczema Coxsackium. Available at: https://dftbskindeep.com/all-diagnoses/eczema-coxsackium/#!jig[1]/ML/5902. Last accessed: 4^th December 2025.
14. DFTB SkinDeep Image Bank. (2025). Eczema Herpeticum. Available at: https://dftbskindeep.com/all-diagnoses/eczema-herpeticum/. Last accessed: 4^th December 2025.
15. DFTB SkinDeep Image Bank. (2025). Cellulitis. Available at: https://dftbskindeep.com/all-diagnoses/cellulitis/#!jig[1]/ML/4693. Last accessed: 4^th December 2025.
16. DFTB SkinDeep Image Bank. (2025). Allergic Reaction. Available at: https://dftbskindeep.com/all-diagnoses/anaphylaxis/. Last accessed: 4^th December 2025.
17. DFTB SkinDeep Image Bank. (2025). Meningococcal Septicaemia. Available at: https://dftbskindeep.com/all-diagnoses/meningococcal-septicaemia/#!jig[1]/ML/879. Last accessed: 4^th December 2025.
18. Taylor G, Oska-Gerak, C & Doggette R & Medler, J. (2020). Peeling away the challenge of Stevens-Johnson Syndrome. Emergency Physicians Monthly Magazine. Available at: https://epmonthly.com/article/peeling-away-the-challenge-of-stevens-johnson-syndrome/. Last accessed: 4^th December 2025.
19. Zhu P, Ji W, Li Z, Chen Y, Dai B, Han S, Chen S, Jin Y & Duan, G. (2023). Current status of hand-foot-and-mouth disease. Journal of Biomedical Science. 30 (15), p2023.
20. Leong,  S & Mahon, C. (2022). Hand, foot, and mouth disease. DermNet NZ. Available at: https://dermnetnz.org/topics/hand-foot-and-mouth-disease. Last accessed 1^st December 2025.
21. Tandon, S. (2021). Eczema Coxsackium. DermNet NZ. Available at: https://dermnetnz.org/topics/eczema-coxsackium. Last accessed 4^th December 2025.