Hand Foot and Mouth Disease Prevention Tips, Remedies

By Dr Raghuram Y.S. MD (Ay). 
A few days back a 13 year old patient with mouth sores came to me. Later he developed similar sores, some of which looked like blisters on his hand and sole of his foot. Gradually the sores multiplied. He found it difficult to walk and eat food. He said that he has heard even some of his friends having same complaints and some have even taken leave from the school.

He asked me ‘Doctor, is this Hand Foot and Mouth Disease?’ He was absolutely right.
There was nothing strange that he knew it, he had read about it in his text book.
It is also important that all of us know about this disease which is quiet common now days

What is ‘Hand Food and Mouth Disease’?

As the name indicates HFMD is a common viral illness that causes sores on the-

• Hand (Palmar aspect of the hand)
• Foot (Sole of the foot)
• Mouth (Lips, tongue, gums and throat)
• The sores can also appear on the buttocks, genitalia, knee and elbows
• The sores may be less or many in number
• The sores are often painful
• Usually the illness doesn’t last for more than a week. Sometimes, it may extend to several days.

Occurrence

In whom does HFMD occur?

• More common in infants and children younger than 5 years of age and also in the school going children.
• Adults  are not spared from getting this disease (they can get it from their kids)

When does HFMD occur?
HFMD can occur at anytime of the year but it is quiet common during summer and fall.

Not to be confused with Mad cow disease:
There is another condition called Foot and Mouth Disease (Hoof and Mouth Disease) or Mad Cow Disease. This occurs in animals whereas Hand foot and mouth disorder occurs in humans.

Prevention tips

Prevention tips for hand foot and mouth disease:

• There is no vaccine that can protect us from the viruses that cause HFMD
  Secretion from nose and mouth cause spread of virus. So avoid kissing or sharing the food with the patient.
• Infected stools / fecal matter can spread the virus. Wash your hands with soap and water after changing the diaper of the infected child.
• Maintaining good hygiene (Ex. Hand washing), this can minimize chances of spreading or getting infections. You need to wash your hands frequently. If you touch a blister or change the diaper of the affected child, make sure to wash your hands thoroughly. Hands should always be washed after using the toilet, with soap and water or use hand wipes or gels treated with germ-killing alcohol.
• Staying at home while you are sick, you need to talk to your healthcare provider or doctor if you are not sure when you can return to your work or school, Teachers in school and day care can also be intimated. The patient should not go to school or office till the fever completely subsides and oral rashes completely heal.
• Tell the teachers of the school or day care to which your child goes that your kid is having HFMD and seek a break. Ask them when your child can return to the school or tell them that you are going to take a Doctor’s opinion before sending the kid to the school.
• Tell all your family members about the disease. Insist them to wash their hands frequently.
• Keep observing your child especially when they have this disease. Don’t allow your child to share their toys while he or she is infected. They can spread the disease to other too. Also don’t allow the kids to give kisses when they are infected. Related
• Disinfecting common areas: Frequently cleaning and disinfecting the touched surfaces and soiled items including toys is mandatory. The high traffic areas and surfaces should be first cleaned with soap and water followed by cleansing with chlorine bleach and water.
• Childcare centers should follow a strict protocol of cleaning and disinfecting all common areas, including shared items like toys. Baby’s pacifiers should be cleaned often.
• Avoiding close contact such as kissing, hugging or sharing eating utensils or cups with people suffering from HFMD
• Good hygiene classes: Train children regarding how to practice good hygiene and how to keep themselves clean.
• Isolate contagious people: People who have active illness should limit their exposure to others or should be told to do so. You should keep children with HFMD out of child care or school until fever is gone and mouth sores have healed.

Remedial measures

• Give plenty of cool fluids. This makes swallowing easy. Since the child has sore throat and blisters in the mouth and throat, the child cannot take hot and solid food. Cold foods come in hand as they soothe the sores.
• Milk based fluids, apple juice, pomegranate juice, sherbet, juice etc
• Foods and drinks which are acidic or spicy in taste and nature shall be avoided. Ex. orange juice, these can further make the sores more painful.
• Citrus fruits and fruit drinks, salty and spicy foods should be avoided
• Allow soft food which doesn’t require much chewing
• Allow rinsing of mouth with warm water / warm salt water after taking food
• Lukewarm baths can also reduce body temperature
• Use mouthwashes or sprays that numb mouth pain (anaesthetic gels or creams)

Note:

• HFMD is not transmitted to or from the pets or other animals
• The disease often breaks out within a community when many cases become evident during a particular period of time.
• Painful mouth sores makes it difficult to swallow. When fluids are not taken in sufficient quantity by people suffering from HFMD having painful mouth sores it can lead to dehydration (loss of body fluids). If the child or adult having HFMD cannot take fluids, they need to get it infused through intravenous route.

Ayurvedic home remedies

Home remedies for worms and persistent infections:

• Juice of onion would expel the worms from stomach and intestines. It can be given mixed with honey in a dose of 1-2 spoons in children. Crush the onion. Extract juice. Take 2 teaspoons of onion juice. Mix it with a teaspoon of honey. Give this twice a day, after food.
• Neem and asafoetida remedy:
  Take 3-5 neem leaves.
  Crush it, make it into a paste.
  Take  one pinch (100 mg) of asafoetida. Fry it in half a teaspoon of ghee.
  Mix this fried asafoetida with neem paste.
  Administer this mix along with a teaspoon of honey, once or twice a day, based on doctor’s advice.
• Palasha beeja churna – Seed powder of Butea monosperma  mixed with equal quantity of Vidanga Churna (Embelia ribes) and given in a dose of ¼ spoons mixed in buttermilk. It should be followed by a purgative like medicated castor oil.
• Powder of Vidanga – Embelia ribes – ¼ spoons mixed in honey, curds, buttermilk or lemon juice – early in the morning. If a purgative is given and the bowel is cleansed before and after the administration, it will work in a wonderful way.
• Equal parts of the juices of Holy Basil (Tulsi) and mint (Pudina) – in a dose of 1 spoonful taken in the morning and evening
• Take the root bark of neem plant (Azadirachta indica), grind / rub it in water and apply the paste all around the abdomen. The microorganisms in the stomach and intestines get expelled through stools.

For oral rashes –
Herbal Gargles & Mouthwashes, Rinsing (Kavala / Gandoosha) with:
Decoctions of one of the below said –

• Amalaki – Amla – (Emblica officinalis)
• Vidanga (Embelia ribes)
• Peruka, Svaduphala – Guava (Psidium guajava)
• Leaves of Mehandi / Madayantika – Lawsonia inermis (Mehndi plant)

Decoctions of the bark of one of the below mentioned:

• Palasha – Butea monosperma
• Vata – Ficus benghalensis (Banyan tree)
• Babbula – Acasia nilotica / Vachellia nilotica
• Jambu – Syzygium cumini

Home remedies for Mouth sores:

• Salt water gargle
• Gargle with Water and lemon juice
• Application of root bark of Amalaki (Emblica officinalis) with honey
• Latex from the stem of Papaya tree is applied
• Inner bark of neem tree is kept in mouth and slowly sucked
• Chewing Babul leaves

Other options:

• Shuddha Tankana Bhasma (Borax) is mixed with honey and applied on the sores
• The mixture of powders of seed of mango, Loha Bhasma (ash of iron), Svarnagairika (Red ochre) and Rasanjana (Extract of Daruharidra – Berberis aristata) mixed in honey is applied over the painful sores
• Gargle with Jatyadi ghritam, Milk processed or boiled with Yashtimadhu churna (Glycyrrhiza Glabra)
• Application of Arimedadi Tailam / Irimedadi tailam over the sores.

Modern Aspects of Hand Foot And Mouth Disorder:

Causes

What causes HFMD?
HFMD is a disease of viral origin
It is caused by viruses that belong to the enterovirus genus (group) which also includes viruses like polioviruses, coxackieviruses, echoviruses and enteroviruses.

Coxsackievirus A16 is the most common cause of HFMD in the US (the same virus can also cause many other diseases) and belongs to a group of viruses called non-polio enteroviruses. It is a highly contagious intestinal virus.

Enterovirus 71 has also been associated with the disease. Less often this virus has been associated with severe disease such as encephalitis.

Epidemiology

• Hand Foot and Mouth Syndrome  most commonly occurs in children under the age of 10
• It tends to occur in outbreaks during spring, summer and fall seasons
• It is most commonly caused by the infection with Coxsackievirus A16

Transmission

How is HFMD transmitted?
Oral ingestion is the main source of coxsackievirus infection and HFMD
The viruses causing HFMD are found in an infected person’s:

• Secretions of the Nose and Throat (saliva, sputum, nasal mucosa)
• Fluid discharges from the blister
• Stools (faeces)

Thus the viruses from the infected person may spread to another person through:

• Close personal contact, Example – Kissing the person having HFMD
• Air (through coughing and sneezing)
• Contact with faeces / infected stool (Ex. when you change the diaper or when young children get their hand soiled by stools and then touch the objects. When the other children put those objects in their mouth they get this disease.)
• Contact with contaminated objects and surfaces, Example – Touching a door knob that has viruses on it and then touching your eyes, mouth or nose
• Swallowing recreational water (example – water in swimming pool etc), the possibility is less, getting infected in this way is more likely to happen if the water becomes contaminated with faeces from a person who has HFMD and also if the water is not properly treated with chlorine

Generally the person with HFMD is most contagious during the first week of illness.
The viruses remain in the respiratory tract and intestinal tract for several weeks to months after the symptoms are resolved.
People can also be contagious for days or weeks after the symptoms have reduced or gone away
Some people especially adults may not develop any symptoms but they can still spread the virus to others.

Can a child (or adult) having HFMD spread the disease to others?

• Yes, children are most likely to spread HFMD during the first week of the illness when the disease is active. But the virus can stay in the stools for several months and may spread to others

When can we see the symptoms of HFMD?

• After getting exposed to the virus it usually takes 3-6 days (incubation period) for a child or adult to get the symptoms of HFMD
• Thus when the symptoms of HFMD are seen we can learn that it had already been 3-6 days since the person has been exposed to the enterovirus.

Symptoms

What are the symptoms of Hand Foot and Mouth Disease?
To start with the child may present with one or all of –

• Tiredness, Malaise (a feeling of being unwell)
• Sore throat
• Fever of around 101⁰ F (38⁰ C) to 103⁰ F (39⁰ C)
• Cold like symptoms and cough (in some cases)
• Reduced appetite

After 1 or 2 days 

• Sores or blisters in or on the mouth (herpangina), hands and feet. The sores in the mouth often starts as small red spot that later turns into a blister and go on to become ulcers. Sores also occur on the gums, tongue and inner cheek
• After a couple of days (1-2 days usually) a skin rash with red spots and sometimes blisters develop on the palms of the hand and soles of the feet. Sores and blisters are also found on the lower calf area
• Sores and blisters can also occur on buttocks, groin, knee and elbows (and genitals also)
• Sometimes we can see a skin rash appearing before the appearance of sores or blisters
• The blisters may be a few in number or many
• Sometimes the blisters break open and form a crust
• The rash is rarely itchy in children but can be extremely itchy in adults
• The sores and blisters are painful many times. It makes difficult for the child to swallow food and to walk. The sores may extend to deep inside the throat
• Painful mouth sores makes it difficult for swallowing enough water and liquids. This leaves some children (and adults also) dehydrated
• The blisters and sores usually go away within a week or so (7-10 days)
• Painful facial ulcers, blisters or lesions may also develop in or around the mouth or nose
• In some exclusive cases there may be no symptoms also. In others the symptoms may be very mild in nature. But they can still pass the virus to others.
• Irritability is quiet common in infants and toddlers

When should you see a doctor?

Contact your doctor if:

• Mouth sores or a sore throat becomes worse and severely painful so as to keep your child away from drinking fluids
• The signs and symptoms progress from bad to worse
• Medicine does not lower a high fever
• Signs of dehydration such as dry skin and mucus membrane, weight loss, irritability, decreased alertness, decreased or dark urine occurs

Diagnosis

How is HFMD diagnosed?

• Usually the symptoms give a clear tell-tale picture of HFMD.
• A physician can tell that the child has HFMD by the symptoms described by you or your child and also by having a look at the sores and blisters on the mentioned areas of the body.
• Tests and investigations are usually not needed.
• However if the symptoms are severe or when the diagnosis is unclear, samples from throat or faeces may be sent to the laboratory to test for the virus

Complications

• Dehydration – Painful oral and throat sores make it difficult to take adequate fluids leading to dehydration
• Neurological complications (uncommon)

Viral or aseptic meningitis – Presents with fever, headache, stiff neck, back pain and requires hospitalization (occurs rarely)

Encephalitis (inflammation of the brain) or polio-like paralysis (rarer)

Acute flaccid paralysis (rare)

Non-neurological complications such as:
Inflammation of the heart
Fluid in the lungs
Bleeding into the lungs

Loss of finger and toe nails occurs mostly in children within a few weeks after having HFMD. Nail loss is said to be temporary, nails grew back even without medical treatment.

Differential Diagnosis

Herpangina:

• Causative agent: Coxsackie-virus A1-A10, A-16, 122, Echovirus 3, 6, 9, 16, 17, 25, 30
• Severity of illness – Usually moderate, can be severe at times
• Lesions: Papules, Vesicles – ulcerations on an erythematous base, usually 2-4mm in dimension
• Location of lesions – Posterior oral cavity, Tonsils, soft palate, uvula
• Other features – Temperature generally high
• Diagnosis – Usually clinical

Herpetic gingivo-stomatitis:

• Causative agent: Herpes simplex virus – 1
• Severity of illness – Moderate to severe
• Lesions: Vesicles, ulcerations
• Location of lesions – Anterior oral cavity, Lips, Gingiva, buccal mucosa
• Other features – Temperature generally high, Lymphadenopathy
• Diagnosis – Usually clinical, A Tzanck smear of vesicle fluid will show multi-nucleated giant cells, A direct fluorescent antigen test for herpes simplex virus

Aphthous Stomatitis:

• Causative agent: Unknown
• Severity of illness – Mild to severe
• Lesions: Ulcerations; larger than in viral enanthems
• Location of lesions – Lips, tongue, buccal mucosa, generally not diffuse
• Other features – A febrile, May be recurrent
• Diagnosis – usually clinical

Stevens-Johnson Syndrome

• Causative agent: Immunological
• Severity of illness – Moderate to severe
• Lesions: Coalescent vesicles, which later ulcerate
• Location of lesions – Lips, gingival, buccal mucosa, tongue, pharynx
• Other features – Target like cutaneous lesions, Diffuse mucous membrane involvement , febrile erosive stomatitis, severe conjunctivitis, disseminated cutaneous eruption.

Chicken pox

• Causative agent: Varicella virus
• Severity of illness – Moderate to severe
• Lesions: Round vesicle on an erythematous base that evolves into a pustule
• Location of lesions – Highly pruritic (itchy) rashes limited to the trunk and extremities
• Diagnosis – Direct fluorescent antigen test for varicella zoster virus (VZV)

Erythema multiforme (EM):

• Causative agent: Type IV Hypersensitivity Reaction
• Severity of illness – Usually severe
• Lesions: Papules evolving into pathognomonic target lesion or iris lesion, flat irregular purpuric macules with occasional blistering
• Location of lesions – Acral distribution (palms, soles, fingers, nail beds), Skin, oral mucosa

Allopathic treatment for HFMD
HFMD usually does not require a treatment. It can be taken care at home itself.
Acetaminophen or Ibuprofen will take care of the fever and pain. Aspirin shall be avoided.

Ayurvedic concept and treatment

Since the diseases like HFMD are modern day diseases which have come into light in recent times, we cannot make an exact comparison of this condition to any disease or symptom complex that has been explained in Ayurvedic texts. But we cannot deny that diseases with a similar clinical picture existed even in ancient times. The presentation of the disease and the approach in handling it might have changed with time but the disease manifestation might have existed and the nomenclature would have been different.

Among Ashtanga Ayurveda (8 limbs / branches of Ayurveda) Graha Chikitsa is one branch. Many diseases, the causes of which had remained unknown and which were difficult to be diagnosed were classified under this category. Graha is a name given to the planets or unseen organisms. It was believed that some unknown and unseen (invisible) entities would produce a few diseases and they were called Graha’s.

Graha’s are said to be of ominous nature and produced dreadful diseases beyond understanding. When compared with the modern day diseases the Graha’s can be compared to the micro-organisms  like viruses, bacteria etc. because they too remain unseen but cause various diseases. But the only difference with the scientific advancement with evolution is that these Graha’s are being made visible and specific treatments and medicines have been found out to tackle them effectively.

Graha’s were said to bother the children more than the adults (though adults too were not exempted). In another section called Bala Chikitsa (Ayurvedic paediatrics) which deals with the diseases occurring in the children and their treatment, Bala Graha’s or the Graha’s afflicting the children have been dealt in detail.

One among these Bala Graha’s is a disease or syndrome called Shakuni Graha. The signs and symptoms of Shakuni Graha closely resemble the clinical picture of HFMD.

Shakuni Graha Sanskrit verse

स्रस्तांगो भयचकितो विहंग गंधिः।
संस्रा विव्रण परिपीडितः समन्तात् स्फोटैश्च प्रचित तनुः सदाह पाकैर्विज्ञेयो भवति शिशुः क्षतः शकुन्या॥ {सु.उ.२७/१०}
स्रस्तांगत्वमतीसारो जिह्वा तालु गले व्रणाः।
स्फोटाः सदाहरुक्पाकाः सन्धिषु स्युः पुनः पुनः॥
निश्यह्नि प्रविलीयन्ते पाको वक्त्रे गुदेऽपि वा।
भूयं शकुने गन्धत्वं क्वरश्च शकुनि ग्रहे॥ {अ.सं.उ.३/१५}
srastāṃgo bhayacakito vihaṃga gaṃdhiḥ|
saṃsrā vivraṇa paripīḍitaḥ samantāt sphoṭaiśca pracita tanuḥ sadāha pākairvijñeyo bhavati śiśuḥ kṣataḥ śakunyā|| {su.u.27/10}
srastāṃgatvamatīsāro jihvā tālu gale vraṇāḥ|
sphoṭāḥ sadāharukpākāḥ sandhiṣu syuḥ punaḥ punaḥ||
niśyahni pravilīyante pāko vaktre gude’pi vā|
bhūyaṃ śakune gandhatvaṃ kvaraśca śakuni grahe|| {a.saṃ.u.3/15}

Though the symptom complex of Shakuni Graha explained by Sushruta doesn’t match exactly with HFMD, the symptoms explained by Vagbhata in Ashtanga Sangraha have a close resemblance.

Symptoms

The child afflicted by Shakuni Graha presents with the following symptoms:

• Looseness of the body parts (Malaise or tiredness)
• Diarrhoea (loose motions)
• Painful sores in the mouth (oral mucosa and gums), tongue, palate and throat which sometimes suppurate (pus discharge)
• Sores / blisters all over the body, these blisters suppurate (forms pus) and cause burning sensation (all over the body includes hand and foot)
• The sores / blisters are formed repeatedly over the joints and regress by themselves (HFMD too is seen to manifest in the elbow and knee joints, some sores form and some disappear and are often found in clusters)
• The blisters are seen predominantly in the night but they are not seen during the day time (intensity and appearance of sores is more at night)
• Mouth sores
• Anal (buttock) sores
• Fear / irritability
• Fever
• Smell of a fish / water bird from the body and stools (contamination of stools)

We can compare HFMD with Shakuni Graha because the clinical picture of both the diseases has a similarity

Treatment

Treatment of Shakuni Graha:
शकुन्यां मधुक ह्रीबेरोशीर शारिवापध्मकोत्पलमंजिष्ठालोध्रप्रियंगुगैरिकैः प्रदेहः।{अ.सं.उ.६/३०}
शुक्ति शंख शम्बूक भस्म मंजिष्ठाभया मधुकैस्तैलं पक्वं व्रणरोपणम्॥{अ.सं.उ.३/६४}
अर्जुनफललोध्रमधुकोदुम्बरवचाचूर्णः क्षौद्रयुक्तो मुखपकेमुखाद् घर्षः। विशारवोक्तं सर्पिः पानम्।
स्कन्दोक्त धूपः॥{अ.सं.उ.३/३२}
शकुन्यार्मपरीतस्य कार्यो वै येन जानता।
वेतसाम्रकपित्थानां क्वाथेन परिषेचनम्॥
कषायमधुरस्तैलं कार्यमभ्यञ्जने शिशोः।
मधुकोशीर ह्रीबेर शारिवोत्पलपध्मकैः॥
रोध्रप्रियंगु मंजिष्ठागैरिकैःप्रदिहेच्छिशुम्।
व्रणेषूक्तानि चूर्णानि पथ्यानि विविधानि च॥
स्कन्दग्रहे धूपितानि तानिहापि प्रयोजयेत्।|
शतावरी मृगैर्वारुनागदन्ती निदग्धिकाः॥
लक्ष्मणां सहदेवां च बृहतीं चापि धारयेत्।{सु.उ.३०/३-६}
वचा काकदानी सर्पकञ्चुक सर्षपैरुष्ट्राजाव्यश्व गो रोमाभिश्च सघृतैर्धूपः।{अ.सं.उ.६/४}
सर्षपाः सर्पनिर्मोको वचा काकादनी घृतम्।
उष्ट्राजाविगवां चैव रोमाण्युद्धूपनं शिशोः॥{सु.उ.२८/३-७}
क्षीरीवृक्षाणां क्वाथेन जीवनीयगणं गर्भं दत्त्वा सक्षीरं सिद्धं सर्पिः पानम्।{अ.सं.उ.६/१५}
क्षीरवृक्षकषाये च काकोल्यादौ गणे तथा।
विपक्तव्यं घृतं वापि पानीयं पयसान्वितम्।{सु.उ.२९}
śakunyāṃ madhuka hrīberośīra śārivāpadhmakotpalamaṃjiṣṭhālodhrapriyaṃgugairikaiḥ pradehaḥ|{a.saṃ.u.6/30}
śukti śaṃkha śambūka bhasma maṃjiṣṭhābhayā madhukaistailaṃ pakvaṃ vraṇaropaṇam||{a.saṃ.u.3/64}
arjunaphalalodhramadhukodumbaravacācūrṇaḥ kṣaudrayukto mukhapakemukhād gharṣaḥ| viśāravoktaṃ sarpiḥ pānam|
skandokta dhūpaḥ||{a.saṃ.u.3/32}
śakunyārmaparītasya kāryo vai yena jānatā|
vetasāmrakapitthānāṃ kvāthena pariṣecanam||
kaṣāyamadhurastailaṃ kāryamabhyañjane śiśoḥ|
madhukośīra hrībera śārivotpalapadhmakaiḥ||
rodhrapriyaṃgu maṃjiṣṭhāgairikaiḥpradihecchiśum|
vraṇeṣūktāni cūrṇāni pathyāni vividhāni ca||
skandagrahe dhūpitāni tānihāpi prayojayet||
śatāvarī mṛgairvārunāgadantī nidagdhikāḥ||
lakṣmaṇāṃ sahadevāṃ ca bṛhatīṃ cāpi dhārayet|{su.u.30/3-6}
vacā kākadānī sarpakañcuka sarṣapairuṣṭrājāvyaśva go romābhiśca saghṛtairdhūpaḥ|{a.saṃ.u.6/4}
sarṣapāḥ sarpanirmoko vacā kākādanī ghṛtam|
uṣṭrājāvigavāṃ caiva romāṇyuddhūpanaṃ śiśoḥ||{su.u.28/3-7}
kṣīrīvṛkṣāṇāṃ kvāthena jīvanīyagaṇaṃ garbhaṃ dattvā sakṣīraṃ siddhaṃ sarpiḥ pānam|{a.saṃ.u.6/15}
kṣīravṛkṣakaṣāye ca kākolyādau gaṇe tathā|
vipaktavyaṃ ghṛtaṃ vāpi pānīyaṃ payasānvitam|{su.u.29}

Madhukadi lepa

Madhukadi Lepa (application/anointment):
Application with paste made up of the powders of the below said herbs –

• Yashtimadhu – (Liquorice / Licorice / Glycyrrhiza glabra)
• Hribera – Pavonia odorata / Coleus zeylanicus
• Usheera – Vetiveria zizanoides
• Sariva – Hemidesmus indicus
• Kamala – Nelumbo nicifera
• Manjishta – Rubia cordifolia
• Lodhra – Symplocos racemosa
• Priyangu – Callicarpa macrophylla
• Gairika – Red ochre (oxide of iron)

Madhukadi Lepa – 2 (Sushruta) {application / anointment}

• Yashtimadhu – Glycyrrhiza glabra
• Usheera – Vetiveria zizanoides
• Hribera – Pavonia odorata / Coleus zeylanicus
• Sariva – Hemidesmus indicus
• Neelotpala – Nymphaea stellata
• Padhmaka – Prunus cerasoides / Cerasus cerasoides
• Lodhra – Symplocos racemosa
• Priyangu – Callicarpa macrophylla
• Manjishta – Rubia cordifolia
• Gairika – Red oxide (oxide of iron)

Shuktyadi tailam

Shuktyadi Tailam (processed oil):

The oil processed with the paste of the below said drugs shall be used for application over blisters –

• Shukti Bhasma – Oyster shell ash / Ostrea gigas (Pinctada margaritifera)
• Shanka Bhasma – Conch shell ash
• Shambuka Bhasma – Snail shell ash
• Manjishta – Rubia cordifolia
• Haritaki – Terminalia chebula
• Yashtimadhu – Glycyrrhiza glabra

Arjunadi churna

Arjunadi Churna (herbal powder) – for oral sores (mouth ulcers):

• Arjuna – Terminalia arjuna (its fruit)
• Lodhra – Symplocos racemosa
• Yashtimadhu – Glycyrrhiza glabra
• Oudumbara / Udumbara – Ficus racemosa
• Vacha – Acorus calamus

The powder of the above said drugs is mixed with honey and applied over mouth sores

Vachadi Dhupa

Vachadi Dhoopa: (Herbal fumigation)
The below said drugs should be burnt and the fumes should be used for fumigation. This was probably with a view of disinfecting the area and living place of the infected person.

• Vacha – Acorus calamus
• Gunja – Abrus precatorius
• Sarpa kanchuka – Snake skin expels
• Sarshapa – Brassica campestris (mustard seeds)
• Kesha – Hairs of Camel, Goat, Sheep, Horse, Cow
• Ghrita – Ghee

Vetasadi Parisheka

Vetasadi Parisheka (processed water or decoction for bath / stream pouring):
The decoction of the below said is used for giving bath to the child affected with Shakuni Graha –

• Vetasa – Garcinia pedunculata
• Amra – Mango – Mangifera indica
• Kapitta – Limonia acidissima

Abhyanga

Abhyanga: (Herbal oil massage) –

• The oils prepared or processed using the decoctions of Kashaya rasa pradhana dravya’s (drugs predominant with astringent taste) ex. Pathadi kwatha (decoction prepared with Patha etc drugs) or with paste of Madhura rasa pradhana dravya’s (drugs predominant with sweet taste) ex. Kakolyadi gana sidda kashaya (decoction prepared using kakolyadi group of drugs) should be used to give a massage

Ghrita Pana

Ghrita panam – Intake of medicate ghee (as mentioned in Vishaka Graha):
The patient or child is administered with the below said medicated ghee:

• The ghee processed and prepared with the decoction prepared from Ksheeree Vriksha’s (latex yielding plants) and the paste of Jeevaneeya gana (Life-span enhancing and anti-ageing drugs) medicines
• Sushruta also has indicated the ghee prepared using Ksheeree Vriksha Kashaya (decoction of latex yielding plants) or Kakolyadi Gana Kwatha (Decoction of Kakolyadi group of medicines), water and milk.

The above said medicated ghee helps in healing the lesions from within, have anti-viral property and provide long-standing immunity

Sandharana

Sandharana – Tying / Binding the drugs over the body parts –
The below said drugs (one or more) should be tied on the suitable body parts (arm, neck etc) of the child suffering from Shakuni Graha –

• Shatavari – Asparagus racemosus
• Mrugadani / Indravaruni – Citrullus colocynthis
• Ervaru – Snake cucumber / Cucumis melo / Cacumis utilissimus
• Nagadanti / Trivrit – Operculina turpethum
• Nidagdhika – Solanum xanthocarpum
• Lakshmana – Annona muricata / Annona macrocarpa
• Sahadeva – Sida rhombifolia / Vernonia cineria
• Brihati – Solanum indicum

Bali Mantra

Bali and Mantra (Sacrifice to Shakuni Graha, enchanting hymns to keep away the Shakuni Graha):

Considering the Shakuni Graha to be an ominous thing, Bali or sacrifice is given to please the Graha and divert it from the afflicted person. The bali is given in the following way:

The dish should be prepared by mixing Tila (Sesamum seeds), Tandula (Rice), Matsya (Fish), Manashila (Realgar) and Haratala (Orpiment), A bird should be moulded from the paste of sesamum seeds and their sacrifice should be given below the Karanja (Pongamia pinnata) tree.

The afflicted child should be given a bath in the garden of the house and the below said mantra / shloka (hymn) should be read in order to ward off the effects of Shakuni Graha –

अन्तरिक्षचरा देवी सर्वालङ्कारभूषिता।
अयोमुखी तीक्ष्णतुण्डा शकुनी ते प्रसीदतु॥
दुर्दर्शना महाकाया पिङ्गाक्षी भैरवस्वरा।
लम्बोदरी शङ्कुकर्णी शकुनी ते प्रसीदतु॥{अ.सं.उ.६/४४-४५}
antarikṣacarā devī sarvālaṅkārabhūṣitā|
ayomukhī tīkṣṇatuṇḍā śakunī te prasīdatu||
durdarśanā mahākāyā piṅgākṣī bhairavasvarā|
lambodarī śaṅkukarṇī śakunī te prasīdatu||{a.saṃ.u.6/44-45}

The above said treatment modalities point out at the scientific approach of ancient Ayurvedic doctors to tackle an unknown entity in an era which was supposed to be unscientific. The methods of fumigation for disinfection and purifying the susceptible environment, application of oils and paste to get rid of the blisters, application of pastes to soothe mouth ulcers, tying the herbs to the hand or neck (the drugs might have an anti-viral or repulsive property!), medicated water for bath etc point out towards a multi-dimensional approach. The said treatment approach is a holistic approach to combat with the unknown virus, to heal sores and blisters, to sanctify the environment, to avoid the disease from spreading to others, to cure the disease and also to provide immunity.

Thus Shakuni Graha and its treatments can be considered as the earliest references of HFMD (?) and its management taking into consideration the proximity of symptoms and treatment modalities

There are many other diseases explained in Ayurveda like Masurika, Romantika, Sheetala etc wherein the lesions / eruptions are limited only to the body (no oral sores) and other diseases like Mukharoga (Mukhapaka), Pittaja Jwara etc wherein we can find oral sores but the sores are absent on the body. Thus Shakuni Graha is the only comprehensive reference for HFMD in Ayurveda wherein the lesions are found in hands, foot and mouth.

The below said medications can be considered once the symptoms of HFMD comes down –

Other treatment modalities

Krimi Chikitsa (Anthelmintics/Antihelminthics/Vermifuges): The treatment and medicines said in Krimi Chikitsa (treatment of infections and worm infestations) should be given.

Useful medicines to combat krimi (microorganisms) are as said below:
(Click on the medicine names to know more about them)

• Vidangadi Churna – used in treatment of intestinal worms (helminthiasis), anorexia and abdominal pain.
• Palasha beeja churna (Butea monosperma / Flame of the Forest)
• Vidangarishtam – especially useful to relieve sores. It is generally used in treatment of abscess, fistula etc.
• Krimikuthara Ras – Used for the treatment of intestinal worm infections and viral infections.
• Krimighna Vati
• Krimighatini Vati
• Balarka Ras – used in treatment of fever with diarrhoea in children.
• Vidangadi lauha
• Chandrashuradi Kashayam

Kushta and Visphotaka Chikitsa (Treatment of Leprosy, skin diseases and eruptions):

Virechana: Once the patient has got rid of his active complaints and symptoms of HFMD, his immunity can be enhanced by giving a course of Virechana (therapeutic purgation) to cleanse the bowel of its contaminants and to remove residual infections. This should be done in adults. Alternatively Nitya Virechana (daily purgation) can be given with medicines like Avipatti churnam, Gandharvahastadi Kashayam, Sukumara Kashayam etc.

Other herbal compounds useful to remove disease residues and provide long standing immunity:

Some important medicines which can be used to get rid of residual complaints including sores and blisters:

• Guggulutiktakam Kashayam / Ghritam
• Tiktakam Kashayam / Ghritam
• Dashamulakadutrayam Kashayam
• Amrutottaram Kashayam
• Nimbadi Kashayam
• Manjishtadi Kashayam
• Shonitamritam Kashayam
• Khadirarishtam
• Aragwadharishtam
• Kaishora Guggulu
• Panchatikta Ghrita Guggulu tablets
• Gandhaka Rasayanam – used in the treatment of skin diseases, itching, chronic fever, urinary tract disorders etc.
• Giloy Satwa
• Vyoshadi Vati / Vyoshadi vatakam
• Haridra Khandam
• Arogyavardhini Ras etc

Skin applications:

• Guluchyadi Tailam
• Jatyadi Tailam
• Shatadhouta ghritam
• Tuvaraka tailam
• Nirgundi tailam
• Mahamarichyadi tailam

Rasayana’s: Rejuvenator’s / Immune modulators

• Chyavanaprasham
• Agastyaharitaki Rasayanam
• Chitrakaharitaki Rasayanam
• Gandhaka Rasayanam
• Kalyana Gulam
• Madhusnuhi Rasayanam
• Manibhadra leham

Outbreaks of HFMD

• Individual cases and outbreaks of HFMD occur all through the world
• Cases occur more often in countries with temperate (varying) climates, more often in the spring to fall
• Since 1997, large outbreaks caused by enterovirus 71 have been reported mostly in the children belonging to east and Southeast Asia
• A small number of people develop severe complications which requires hospitalization or even causing death
• Research works are on to track down the reason for outbreaks and complications and also to develop treatments and vaccines to prevent HFMD in future

Major known outbreaks:

• 1998 – Taiwan – Children were mainly affected – 405 severe complications, 78 children died, Total number of cases in that epidemic is estimated to have been 1.5 million
• 2008 – China – 25,000 infections and 42 deaths
• Singapore – more than 2,600 cases
• Vietnam – 2,300 cases, 11 deaths
• Mongolia – 1,600 cases
• Brunei – 1053 cases
• 2009 – China – 115,000 cases reported, 773 severe cases and 50 fatal cases, 35 deaths
• 2010 – China – 70,756 infected children, 40 deaths (until March), 537 deaths (by June), approximately 1,654,866 cases in that year
• 2011 – China – 1,654,866 cases (WHO)
• December 2011 – California Department of Public Health identified a strong form of virus coxsackievirus A6(CVA6), where nail loss in children was common
• 2012 – Alabama, US – Occurred in a non-season, affected teenagers and older adults – No reported deaths
• Cambodia 52 deaths
• China – 1,520,274 infected, 431 deaths
• 2015 – Syria – 200 cases reported

Points of interest about HFMD

• HFMD cases were first described in Australia in 1956 and in New Zealand in 1957
• By early 1960’s HFMD emerged as a common childhood illness all around the world

Research

• Antiviral agents to prevent and treat infection with HFMD viruses are currently being studied and are under development
• Preliminary studies have shown inhibitors of the EV-71 viral capsid (protein shell of virus) to have potent antiviral activity
• HFMD is the most common infectious disease in China, its total incidence being around 500,000 – 1,000,000 cases per year

Read related: Hand, foot and mouth disease: spatiotemporal transmission and climate

• Experimental vaccines protect children from HFMD

• First vaccine for HFMD was reported by scientists in China

Now that you know everything about HFMD, I hope it would be easier for you to help your little ones, your family and friends when you find someone with the symptoms of the same. But when it comes to health issues self diagnosis and self medication is always dangerous. Remember that you have doctors to do that part!!

Consult Dr Raghuram by skype / email

References:

Hand, Foot, and Mouth Disease (HFMD)
Hand foot and mouth disease – Mayoclinic
Hand foot mouth disease: Medline Plus
Hand foot and mouth disease – Wikipedia
Hand, Foot, and Mouth Disease – Healthline
Hand-Foot-and-Mouth Disease (HFMD) Differential Diagnoses