Red Spots On Your Child's Body: How To Tell The Difference Between Chickenpox Or Hand Foot Mouth Disease

The number of cases of hand, foot, and mouth disease (HFMD) in the country is increasing at an alarming rate. A total of 82,846 cases were reported as of 4 June 2022, an increase of 32 times compared to 2,485 cases in the same period in 2021, following the relaxation of distancing, masking, and the opening of day care centres and schools¹.

According to the Director General of Health, Tan Sri Dr Noor Hisham Abdullah, most cases of HFMD occur among children aged six (6) years and below¹.

Although HFMD can be classified as a common endemic disease in children, many parents are still confused and unable to differentiate HFMD from other childhood diseases. Perhaps because the symptoms of HFMD are almost similar to those of other diseases, especially chickenpox^2,3.

Let’s understand the differences between these two diseases so that parents are more aware and can respond effectively if their child is infected.

What is Chickenpox?

Varicella is an infectious disease caused by the Varicella-Zoster virus. This disease, better known as ‘chickenpox’, usually occurs in children under the age of 10 years old³.

After the first infection, most people will have lifelong immunity, though the virus may re-emerge later on in life as shingles for some⁴.

According to Dr. JoAnn, a paediatrician from FirstStep Child Specialist Clinic, chickenpox is so contagious that 90% of those who come into contact with an infected person can get the disease, especially if they are not immune. “This explains why chickenpox outbreaks often occur in schools or daycares. With the contagious nature of chickenpox, parents should visit their children’s doctors to understand more about the preventive measures that they can take, including suitable vaccinations.,” she adds.* 

The chickenpox virus is spread through respiratory fluids or direct contact with blistered skin fluids. The most common symptom of chickenpox is a rash on the body. One to two days before the rash on the body appears, your child will begin to feel weak, headaches, have a poor appetite, and fever⁵.

The rash will appear around the face, chest, and back of the body at the beginning of the infection and then spread to all parts of the body. The rash will turn into blisters filled with fluid that are very itchy. The blisters eventually dry out and become scabs⁶.

It is important for parents to note that children who have been vaccinated against chickenpox may be prevented from getting the disease or will experience milder symptoms and fewer rash if they do get infected and the recovery process will occur more quickly^5,6.

To get a more in-depth understanding on chickenpox, we asked Dr. JoAnn to share some important information as well as her personal experience in treating patients, particularly children with chickenpox. 

1. Who is most at risk of getting infected by the Varicella-Zoster virus?

Dr. JoAnn: The majority of chickenpox cases occur in young children. However, older children and adults can also get it if they are not immune.* 

2. Is chickenpox usually mild or serious?

Dr. JoAnn: For most healthy people, chickenpox is usually mild, and they recover fully without any specific treatment. However, complications from chickenpox can occur in certain high-risk individuals such as infants, adolescents, adults, pregnant mothers and those with a weakened immune system, for example, those undergoing chemotherapy.* 

3. What are the possible complications associated with chickenpox?

Dr. JoAnn: Some possible complications associated with chickenpox infection include bacterial infection of the skin, infection of the lungs (pneumonia), infection or swelling of the brain (encephalitis, cerebellar ataxia), bleeding problems (hemorrhagic complications), and bloodstream infections (sepsis).* 

“Although these complications are deemed rare, I have personally seen and treated children with these complications. It is heartbreaking to see any child or parents go through this. With the availability of vaccines for chickenpox, parents should speak with their children’s doctors to understand more.,” Dr. JoAnne shares.*

What is HFMD?

Hand, foot and mouth disease (HFMD) is an infection caused by viruses from the Enterovirus group especially Coxsackievirus A16, Coxsackievirus A6, Enterovirus 71 (EV71) and several other viruses⁷.

The virus is spread by direct contact with saliva, blister fluid and faeces from infected individuals. Children usually get infected from other children in a ‘faecal-oral’ pattern i.e. the infection is acquired from exposure to faeces or secretions from the nose or mouth⁸.

The symptoms of the disease are usually mild with symptoms of fever followed by a watery rash or blisters on the hands, feet, mouth and tongue². Children infected with HFMD usually have a markedly reduced appetite for food and drinks due to the pain experienced especially on the throat and tongue².

Although the disease infects all ages, HFMD most commonly occurs in children especially those aged ten (10) years and below. But that doesn’t mean that adults and older children can’t also be infected with HFMD⁹.

Cases of HFMD caused by EV71 virus infection is also associated with the increased risk of getting complications such as encephalitis and inflammation of the heart (myocarditis)¹⁰.

The Difference Between Chickenpox and HFMD

The two diseases share similar general symptoms and signs such as lethargy, fever and rash, but there are several features that distinguish them^2,3:

• Virus Type

Chickenpox is caused by the Varicella-Zoster virus⁵ and HFMD is caused by the Enterovirus type virus, specifically the Coxsackie virus⁷.

• Nature of Rash

The chickenpox rash will spread to all parts of the body⁶ while the HFMD rash is concentrated in the mouth, diaper slits, palms and soles of the feet⁸.

• Characteristics of Rash

The rash caused by chickenpox starts with small red spots that then become blisters with pus and will rupture, dry out and eventually become scab before healing⁵. Whereas the rash caused by HFMD usually appears first in the mouth like an ulcer and followed by flat red spots which in turn become small blisters11. Chickenpox rash is very itchy and HFMD rash can be very painful^5,11.

• Duration

Chickenpox usually lasts about 4 – 7 days⁶. HFMD will heal 7 to 10 days after symptoms begin¹².

• Infectiousness

Chickenpox infection is usually once in a lifetime except for when Varicella-zoster virus which lies dormant in the nerve tissues and may reactivate as Shingles³. HFMD infection can occur in a person repeatedly because there are different variants of the Enterovirus¹⁰.

• Treatment

Varicella vaccine can help prevent chickenpox and doctors may prescribe antivirals in some cases¹³. HFMD has no specific treatment other than treating the symptoms¹².

• Secondary Complications

Usually, chickenpox is mild but complications such as pneumonia, inflammation of the brain can occur⁵.  Bacterial infections can also occur in chickenpox rash due to scratching due to itching³. In addition, the chickenpox virus that is known to lie dormant in the nerve cells and become active again, causing shingles which are very painful skin blisters⁵.

Chickenpox can cause abnormalities in the foetus if contracted early in pregnancy and makes the baby very sick if contracted towards the end of pregnancy⁵. HFMD is also usually harmless, mainly pain from ulcers in the throat and mouth which causes children to lose their appetite and can lead to dehydration¹².

Prevention

Both Chickenpox and HFMD are caused by highly contagious viruses^5,7. The viruses can pass from person to person on unwashed hands and contaminated surfaces. It can also spread through droplets of fluid sprayed into the air when an infected person sneezes or coughs. Contact with rash or blister fluid can also spread the virus easily^5,6.

So why does chickenpox spread so easily among young children? 

“Chickenpox spreads so easily among young children due to a few factors. Young children are often curious and tend to touch everything, sometimes putting objects or their hands into their mouths. They also tend to drool, which helps in the virus spread. Furthermore, it isn’t easy to maintain social distancing among young children,” Dr. JoAnn explains.*

Therefore, some of the prevention measures to help protect children from being infected with Chickenpox and HFMD is to keep the environment clean, always wash hands with soap, manage disposable diapers properly and most importantly parents are advised not to send their children to daycare, babysitter or kindergarten to prevent infection and outbreaks if your children show symptoms or if there are other children who show symptoms¹⁴.

“Vaccinating against chickenpox is one of the preventive measures for this highly contagious disease. Most people vaccinated against chickenpox have a lower risk of infection or develop milder symptoms if they are infected,” adds Dr. JoAnn as a reminder to all parents out there.*

So parents, now that you know the difference between the symptoms of Chickenpox and HFMD, you can identify it better. Or if you want to learn how to better protect your children against preventable diseases, speak to your family doctor or paediatrician at the next visit. 

*This information is provided as a professional service by MSD. The views expressed in the publication reflects the experience and opinions of the authors.

MY-VVX-00134 Oct/2022

REFERENCES:

1. From the Desk of the Director-General of Health Malaysia. Kenyataan Akhbar KPK 7 Jun 2022 – Situasi Semasa Kejadian Penyakit Tangan, Kaki dan Mulut (HFMD) di Malaysia (ME 22 2022). Available From: https://kpkesihatan.com/2022/06/07/kenyataan-akhbar-kpk-7-jun-2022-situasi-semasa-kejadian-penyakit-tangan-kaki-dan-mulut-hfmd-di-malaysia-me-22-2022/. Last Accessed 26 August 2022. 
2. Centers for Disease Control and Prevention. Hand, Foot, and Mouth Disease (HFMD). Available From: https://www.cdc.gov/hand-foot-mouth/about/signs-symptoms.html. Last Accessed 26 August 2022.
3. National Health Services Inform. Chickenpox. Available From: https://www.nhsinform.scot/illnesses-and-conditions/infections-and-poisoning/chickenpox. Last Accessed 26 August 2022. 
4. Centers for Disease Control and Prevention. Shingles (Herpes Zoster).  Available From: https://www.cdc.gov/shingles/about/transmission.html. Last Accessed 26 August 2022. 
5. Mayo Clinic. Chickenpox. Available From: https://www.mayoclinic.org/diseases-conditions/chickenpox/symptoms-causes/syc-20351282. Last Accessed 26 August 2022.  
6. Centers for Disease Control and Prevention. Chickenpox (Varicella). Available From: https://www.cdc.gov/chickenpox/about/symptoms.html. Last Accessed 26 August 2022. 
7. Centers for Disease Control and Prevention. Hand, Foot, and Mouth Disease (HFMD). Available From: https://www.cdc.gov/hand-foot-mouth/about/transmission.html. Last Accessed 26 August 2022. 
8. Stanford Medicine Children’s Health. Hand-Foot-and-Mouth Disease in Children. Available From: https://www.stanfordchildrens.org/en/topic/default?id=hand-foot-and-mouth-disease-in-children-90-P01857. Last Accessed 26 August 2022. 
9. Better Health Channel. Hand, foot and mouth disease. Available From: https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/hand-foot-and-mouth-disease. Last Accessed 26 August 2022. 
10. Yi E, Shin Y, Kim J, Kim T & Chang S. Enterovirus 71 infection and vaccines. Clinical and Experimental Vaccine Research. 2017;6(1). 
11. National Health Services Inform. Hand, foot and mouth disease. Available From: https://www.nhsinform.scot/illnesses-and-conditions/infections-and-poisoning/hand-foot-and-mouth-disease.  Last Accessed 27 September 2022. 
12. Centers for Disease Control and Prevention. Hand, Foot, and Mouth Disease (HFMD). Available From: https://www.cdc.gov/hand-foot-mouth/about/treatment.html. Last Accessed 26 August 2022. 
13. Centers for Disease Control and Prevention. Chickenpox (Varicella). Available From: https://www.cdc.gov/chickenpox/about/prevention-treatment.html. Last Accessed 26 August 2022. 
14. Centers for Disease Control and Prevention. Hand, Foot, and Mouth Disease (HFMD). Available From: https://www.cdc.gov/hand-foot-mouth/about/prevention.html. Last Accessed 26 August 2022.