When can a patient with herpangina (herpes-like rash) or hand, foot, and mouth disease (HFM) return to school?

Return to School Guidelines for Herpangina and Hand, Foot, and Mouth Disease

Patients with herpangina or hand, foot, and mouth disease (HFM) should remain out of school until fever resolves and lesions are healing, typically 3-5 days after symptom onset. While there are no specific guidelines exclusively addressing herpangina/HFM school exclusion, we can derive recommendations from infectious disease control principles for similar conditions.

Understanding the Conditions

Herpangina and hand, foot, and mouth disease are both enteroviral infections with similar characteristics:

• Caused primarily by coxsackieviruses and other enteroviruses
• Characterized by fever and painful oral lesions (herpangina) or oral lesions plus vesicular rash on hands, feet, and sometimes buttocks (HFM)
• Highest incidence in children under 10 years
• Typically self-limiting, resolving within 7-10 days 1

Return to School Criteria

The decision for return to school should be based on:

Primary Criteria:

1. Fever resolution: The child should be afebrile for at least 24 hours without antipyretic medications
2. Lesion status: Lesions should be healing and no longer actively weeping fluid
3. General condition: The child should feel well enough to participate in school activities

Timing Considerations:

• Most children can return to school 3-5 days after symptom onset
• This coincides with the period when they are typically no longer highly contagious

Transmission and Contagiousness

Understanding transmission helps explain the return-to-school timeline:

• Transmission occurs via fecal-oral, oral-oral, and respiratory droplet contact 1
• Peak contagiousness: During the first week of illness, particularly before rash appears
• Decreased contagiousness: Once lesions begin to heal and fever resolves
• Viral shedding can continue in stool for weeks, emphasizing the importance of good hand hygiene

Special Considerations

For Daycare Settings:

• Stricter exclusion may be warranted for very young children who cannot maintain good hygiene
• Attendance at child care centers has been associated with more severe HFMD cases 2

For Immunocompromised Individuals:

• Children with immune deficiencies may require longer exclusion periods
• These children should obtain clearance from their healthcare provider before returning

Prevention Measures Upon Return

To minimize spread after returning to school:

1. Handwashing: Emphasize frequent and thorough handwashing, which has been shown to significantly reduce HFMD transmission 3
2. Avoid sharing: No sharing of food, drinks, utensils, or personal items
3. Surface cleaning: Regular disinfection of commonly touched surfaces
4. Respiratory hygiene: Proper covering of coughs and sneezes

Comparison to Other Infectious Disease School Policies

While specific guidelines for herpangina/HFM are limited, we can draw parallels from other infectious conditions with similar transmission patterns:

• For conditions like streptococcal pharyngitis, return is permitted after 24 hours of appropriate treatment 4
• For viral rashes like varicella (chickenpox), return is permitted once lesions have crusted 4

Conclusion

The recommended approach balances infectious disease control with minimizing unnecessary school absence. While viral shedding may continue after symptoms resolve, the risk of transmission decreases significantly once fever resolves and lesions begin healing.

Parents should be advised that good hand hygiene remains essential even after return to school, as this is the most effective preventive measure against further spread of these enteroviral infections.