How long should a patient with hand, foot, and mouth disease (HFMD) be kept out of school?

Duration of School Exclusion for Hand, Foot, and Mouth Disease

Children with hand, foot, and mouth disease (HFMD) should be excluded from school until all blisters have disappeared, which typically takes 3-5 days after the onset of symptoms.

Clinical Features and Transmission

Hand, foot, and mouth disease is a common viral illness primarily affecting young children under 5 years of age. It is characterized by:

• Fever (typically >102.2°F/39°C)
• Painful oral ulcers/vesicles
• Skin rash with vesicles on hands, feet, and sometimes buttocks
• Symptoms usually lasting less than 1 week

The disease is highly contagious and spreads through:

• Direct contact with nasal and throat secretions
• Contact with fluid from blisters
• Contact with feces of infected individuals
• Respiratory droplets

School Exclusion Guidelines

The appropriate duration for keeping children out of school is based on the period of highest infectivity:

• Children are particularly infectious until the blisters have disappeared 1
• Most contagious during the first week of illness
• The virus may remain present in feces for several weeks after symptoms resolve

Management Approach

1. Diagnosis: Based on characteristic clinical presentation of fever, oral lesions, and rash on hands and feet

2. Treatment:

   • Primarily supportive and symptomatic
   • Adequate hydration (cold fluids, popsicles)
   • Pain management for oral lesions
   • No specific antiviral therapy is currently available 2

3. Return to School Criteria:

   • Child should be fever-free for 24 hours without fever-reducing medication
   • All blisters should have disappeared
   • Child should feel well enough to participate in school activities

Special Considerations

• While exclusion from school until blisters disappear is recommended, some experts note that complete exclusion from childcare may not be practical as the virus can persist in feces for several weeks 1
• Hand hygiene is critical in preventing transmission, with studies showing that frequent handwashing is the most common protective measure taken by parents (82% in one study) 3

Prevention Strategies

• Frequent handwashing with soap and water, especially after diaper changes and before eating
• Avoiding close contact (kissing, hugging) with infected individuals
• Disinfection of contaminated surfaces and items
• Not sharing utensils or cups

HFMD is typically self-limiting with symptoms resolving within 7-10 days. While complications are rare, parents and school staff should monitor for any signs of serious illness such as persistent high fever, severe headache, or unusual lethargy, which may indicate rare neurological complications.