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Figure 1. Vesicles are present on the thumb and fifth toe.
Figure 2. Multiple erythematous papules and a few scattered vesicles are present over the perineum.
Figure 3. Superficially eroded papules are present on the lips.
An outbreak of the vesicular exanthem known as hand-foot-and-mouth disease was first described in 1958.1 The anatomically descriptive name was applied following an epidemic in Birmingham, England, in 1959.2 Although the infectious exanthem was originally ascribed to Coxsackievirus type A16, the clinical picture has also been described with Coxsackievirus types A5, A9, A10, B1, B3, and enterovirus 71.3
The clinical features of hand-foot-and-mouth disease occur in almost 100% of the affected preschool-aged children, but only 11% of infected adults have the cutaneous findings.4 The disease tends to be more severe in children younger than 5 years. The skin lesions are frequently preceded by a prodrome of fever (temperature, 38.3° to 40°C), anorexia, malaise, and a sore mouth. The exanthem usually appears 1 to 2 days after the onset of fever but may vary depending on the serotype of the Coxsackievirus involved. The exanthem follows the exanthem by one to several days.
The exanthem typically begins as small red macules on the soft and hard palate, buccal mucosa, gingivae, and tongue. The macules rapidly progress to vesicles that can range in size from 1 to 3 mm up to 2 cm. The vesicles rapidly ulcerate. Oral lesions may persist for 1 to 6 days. Young children with extensive involvement around the mouth may become dehydrated from poor fluid intake.
The exanthem is primarily found on the extremities, particularly on the dorsal and palmar and plantar surfaces of the hands and feet. The buttocks are the most commonly involved site beside the hand and foot lesions. The lesions are less commonly found on the arms, legs, and face. The exanthem initially contains macular and papular characteristics but quickly progresses to superficial 3- to 7-mm gray vesicles on an erythematous base. The vesicles are often elliptical or arcuate. The lesions persist for 2 to 7 days. They may rupture, leaving a superficial scab.
Involvement of the buttocks and perineum with the exanthem is common (31% of the reported cases of hand-foot-and-mouth disease).1,2,5-9 The lesions on the buttocks are of the same size and typical of the early forms of the exanthem, but they are not frequently vesicular in nature. Lesions involving the perineum seem to be more common in children who wear diapers, suggesting that friction or minor trauma may play a role in the development of lesions. Occasionally, children present with a diaper rash, the oral and extremity lesions being evident only on careful examination.
The differential diagnosis of hand-foot-and-mouth disease includes other viral exanthems, including herpes simplex virus and varicella infections. The hands and feet of infants and children suspected of having herpes gingivostomatitis, herpangina, or aphthous stomatitis should be examined carefully for the vesicles consistent with hand-foot-and-mouth disease. Insect bites and allergic contact dermatitis may also cause similar appearing lesions.
Accepted for publication August 15, 1997.
Reprints: Kevin A. Slavin, MD, University of California, San Francisco, Division of Pediatric Infectious Diseases, San Francisco General Hospital, 1001 Potrero Ave, 6E6, San Francisco, CA 94110.
Picture of the Month. Arch Pediatr Adolesc Med. 1998;152(5):506. doi:
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