can hand foot and mouth disease present without mouth sores

Hand, foot, and mouth disease (HFMD) typically presents with painful oral lesions (mouth sores), usually scattered ulcerative lesions or vesicles within the oral cavity, appearing within 1–2 days of symptom onset and commonly found on the hard palate, tongue, buccal mucosa, lips, and pharynx NICE CKS. These mouth sores often precede or coincide with the appearance of characteristic rash lesions on the hands and feet NICE CKS.

However, atypical and variant presentations of HFMD do exist where oral lesions may be absent or not clinically apparent. For example, cases described as eczema coxsackium, mainly caused by Coxsackievirus A6, show widespread skin involvement including areas such as perioral, chest, back, extremities, and gluteogenital regions but lack oral mucosal vesicles or ulcers Ceballos et al. 2025.

Similarly, adults with HFMD may present atypically with perioral vesicles or papulopustular eruptions without the classical intraoral ulcers, as documented in specific case reports that describe oral symptoms as more variable or even absent Martins et al. 2025.

Therefore, while mouth sores are a hallmark and common feature of HFMD, especially in children, HFMD can occasionally present without mouth ulcers in both children (particularly with variant forms associated with underlying skin conditions like atopic dermatitis) and adults with atypical or more widespread presentations NICE CKS,Martins et al. 2025,Ceballos et al. 2025.

In clinical practice, this means that the diagnosis of HFMD should not be absolutely excluded if characteristic skin lesions on the hands, feet, or other body parts are present but mouth sores are absent. Additional diagnostic methods such as PCR for enteroviruses can help confirm atypical cases Ceballos et al. 2025.