Open Access Highly Accessed Research article

An outbreak of coxsackievirus A6 hand, foot, and mouth disease associated with onychomadesis in Taiwan, 2010

Sung-Hsi Wei2, Yuan-Pin Huang1, Ming-Chih Liu1, Tsung-Pei Tsou1, Hui-Chen Lin1, Tsuey-Li Lin1, Chen-Yen Tsai3, Yen-Nan Chao1, Luan-Yin Chang5* and Chun-Ming Hsu4

Author Affiliations

1 Taiwan Centers for Disease Control, Taipei, Taiwan

2 Institute of Public Health, National Yang-Ming University, Taipei, Taiwan

3 Department of Pediatrics, China Medical University Beigang Hospital, Yunlin, Taiwan

4 Department of Pediatrics, Kuang Tien General Hospital, Taichung, Taiwan

5 Division of Infectious Diseases, Department of Pediatrics, National Taiwan University Hospital, College of Medicine, National Taiwan University, No. 7, Chung-Shan South Road, Taipei 100, Taiwan

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BMC Infectious Diseases 2011, 11:346  doi:10.1186/1471-2334-11-346

Published: 14 December 2011



In 2010, an outbreak of coxsackievirus A6 (CA6) hand, foot and mouth disease (HFMD) occurred in Taiwan and some patients presented with onychomadesis and desquamation following HFMD. Therefore, we performed an epidemiological and molecular investigation to elucidate the characteristics of this outbreak.


Patients who had HFMD with positive enterovirus isolation results were enrolled. We performed a telephone interview with enrolled patients or their caregivers to collect information concerning symptoms, treatments, the presence of desquamation, and the presence of nail abnormalities. The serotypes of the enterovirus isolates were determined using indirect immunofluorescence assays. The VP1 gene was sequenced and the phylogenetic tree for the current CA6 strains in 2010, 52 previous CA6 strains isolated in Taiwan from 1998 through 2009, along with 8 reference sequences from other countries was constructed using the neighbor-joining command in MEGA software.


Of the 130 patients with laboratory-confirmed CA6 infection, some patients with CA6 infection also had eruptions around the perioral area (28, 22%), the trunk and/or the neck (39, 30%) and generalized skin eruptions (6, 5%) in addition to the typical presentation of skin eruptions on the hands, feet, and mouths. Sixty-six (51%) CA6 patients experienced desquamation of palms and soles after the infection episode and 48 (37%) CA6 patients developed onychomadesis, which only occurred in 7 (5%) of 145 cases with non-CA6 enterovirus infection (p < 0.001). The sequences of viral protein 1 of CA6 in 2010 differ from those found in Taiwan before 2010, but are similar to those found in patients in Finland in 2008.


HFMD patients with CA6 infection experienced symptoms targeting a broader spectrum of skin sites and more profound tissue destruction, i.e., desquamation and nail abnormalities.

Coxsackievirus A6; Hand; foot; and mouth disease; Onychomadesis