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An Outbreak of HFMD?

An Outbreak of HFMD?

When her 10-year-old daughter, Jordan, woke up one early July morning listless with a fever and a blistering rash all over her body, Jo Anne Wilhelm didn’t know what to make of it. The Bel Air, Md., mom knew Jordan was prone to rashes related to her skin disorder, Ichthyosis, but she had never seen anything like the profuse, symmetrical red bumps covering her arms, hands, feet and legs.

“We were alarmed because it was everywhere,” says Wilhelm. “She has had small rashes before but this was head to toe.”

Wilhelm immediately called Johns Hopkins Children’s Center pediatric dermatologist Bernard Cohen, who had treated Jordan’s Ichthyosis. After Wilhelm described the fever and rash, Cohen had a suspect right away. After all, he and his colleague, pediatric dermatologist Kate Puttgen, had already seen ten patients in the past week with identical presentations. Also, they had heard of a recent increase in similar cases from pediatric dermatologists in Southern California, and were well aware of a March 2012 report by the Centers for Disease Control and Prevention (CDC) of an outbreak of this disorder in Alabama, Connecticut, California and Nevada.

The culprit? Hand, foot and mouth disease, or HFMD, a common viral illness that typically affects infants and young children in the spring and summer months. Onset symptoms include fever and malaise, and a day or two later a non-itchy skin rash with flat or raised red spots on the hands and feet and/or mouth sores. HFMD is usually not serious and nearly all patients recover in 7 to 10 days without medical treatment. Wilhelm says after one week with no treatment her daughter’s rash is dry and not as red as it was initially.

“How do we treat them? With Tylenol and reassurance,” says Cohen.

But this particular strand of HFMD was concerning for Cohen and Puttgen because the underlying enterovirus was Coxsackievirus A6, which is common in Asia and Africa but not the United States and may present with more severe disease than HFMD associated with other viruses. Also, the more extensive Coxsackievirus A6 related rash may mimic lesions caused by herpes simplex virus, which can be more serious if untreated. To help quell any fears among parents and to help guide pediatricians, Cohen and Puttgen are trying to raise awareness about this particular outbreak of HFMD.

“The problem is it looks like disseminated herpes simplex, and parents may panic if they don’t know what it is,” Cohen says. “But unlike herpes simplex, this rash evolves very fast. It’s bad for a few days and then gets better very quickly without any treatment at all. Fortunately, none of the cases we’ve seen here have had huge complications.”

“We’ve talked to many of our pediatric dermatology colleagues around the country and the number of cases and the severity of the rash is clearly new and very different from the typical hand, foot and mouth disease we are used to seeing,” adds Puttgen. “The good news is that it looks bad but hasn’t actually caused severe symptoms for our patients.”

Because HFMD is a contagious viral illness, Cohen encourages parents to reduce the risk of infection by practicing good hygiene, including frequent hand washing. Pediatricians, Cohen adds, need not treat or refer patients to a pediatric dermatologist if they recognize the rash for what it is. He adds, however, that the A6 enterovirus appears to pose an increased risk of systemic findings compared with the garden variety enterorvirus.

“If the child is febrile but otherwise acting well, waiting and watching is appropriate,” Cohen says. “But if the child is having problems with oral intake or behaving ill, he or she needs to be seen by the pediatrician.”

For more information about hand, foot and mouth disease associated with Coxsackievirus A6, see the CDC’s March 2012 report.

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