Scarlet Fever: Symptoms, Treatment & When to See a Doctor

What Is Scarlet Fever and What Causes It?

Scarlet fever is a bacterial infection caused by group A Streptococcus (Streptococcus pyogenes), the same bacteria that causes strep throat. It occurs when the bacteria release toxins that cause the characteristic red rash. Scarlet fever most commonly affects children between 5 and 15 years old and is highly contagious through respiratory droplets.

Scarlet fever, also known as scarlatina, was once a feared childhood illness that caused significant mortality. Today, with effective antibiotic treatment, it is typically a mild illness that resolves completely within one to two weeks. However, it remains important to seek medical attention promptly, as untreated scarlet fever can lead to serious complications affecting the heart, kidneys, and other organs.

The infection spreads primarily through respiratory droplets when an infected person coughs or sneezes. It can also spread through direct contact with an infected person's saliva or nasal secretions, or by touching surfaces contaminated with these secretions. The incubation period - the time between exposure and symptom onset - is typically 2 to 5 days.

While scarlet fever can occur at any age, it is most common in school-age children. This is partly because children in this age group have close contact with each other in school and childcare settings, and partly because many adults have developed immunity through previous exposure to the bacteria. Infants and toddlers under age 3 are rarely affected because they still have some protective antibodies from their mothers and have less frequent close contact with other children.

Why does scarlet fever cause a rash?

The rash that characterizes scarlet fever is caused by erythrogenic toxins produced by the streptococcal bacteria. Not all strains of group A Streptococcus produce these toxins, which is why some people with strep throat do not develop scarlet fever. The toxins cause the small blood vessels in the skin to dilate and leak, producing the characteristic red, sandpaper-like rash.

A person can have scarlet fever more than once because there are multiple types of erythrogenic toxins. Having scarlet fever from one toxin type does not provide immunity against other toxin types. However, repeated infections are less common because partial immunity does develop over time.

What Are the Symptoms of Scarlet Fever?

The main symptoms of scarlet fever include high fever (38.3C/101F or higher), severe sore throat, difficulty swallowing, and a distinctive red rash that feels like sandpaper. Other characteristic signs include a "strawberry tongue," flushed cheeks with a pale area around the mouth, and red lines in skin creases (Pastia's lines). Symptoms typically appear 2-5 days after exposure.

Scarlet fever typically begins suddenly with general symptoms of illness before the characteristic rash appears. Understanding the progression of symptoms helps parents recognize the condition early and seek appropriate medical care. The illness typically follows a predictable pattern over the course of about one week.

In the first 1-2 days, children usually develop a high fever, often reaching 38.9C (102F) or higher. The fever is typically accompanied by headache, body aches, nausea, and sometimes vomiting. Many children also experience chills and loss of appetite during this initial phase. The throat becomes severely sore and swollen, making swallowing painful and difficult.

The tonsils and back of the throat appear red and swollen, often with white or yellowish patches of pus. The lymph nodes in the neck become swollen and tender to touch. These symptoms closely resemble strep throat, and indeed, scarlet fever is essentially strep throat accompanied by the characteristic rash caused by bacterial toxins.

The characteristic scarlet fever rash

The rash typically appears within 1-2 days after the onset of fever and sore throat. It usually begins on the neck, chest, and armpits before spreading to the rest of the body. The rash has a distinctive sandpaper-like texture that is often more noticeable by touch than by sight. When pressed, the rash temporarily turns white (blanches) before returning to its red color.

One of the most distinctive features is the appearance of the face: the cheeks become flushed and red, while the area around the mouth remains notably pale. This creates what is called "circumoral pallor" - a pale triangle around the mouth that contrasts sharply with the flushed cheeks. Another characteristic finding is "Pastia's lines" - bright red lines in skin creases, particularly in the armpits, elbows, and groin, where the rash is most intense.

The strawberry tongue

The tongue undergoes characteristic changes during scarlet fever. Initially, it develops a white coating with red, swollen taste buds poking through - this is called "white strawberry tongue." After a few days, the white coating peels off, leaving the tongue bright red and bumpy, resembling a strawberry - hence the term "red strawberry tongue." This tongue appearance is highly suggestive of scarlet fever.

When Should You See a Doctor?

See a doctor promptly if your child has a sore throat with fever and develops a rash, especially one that feels like sandpaper. Seek immediate medical attention if your child has difficulty breathing or swallowing, cannot drink fluids, has a fever above 40C (104F), shows signs of dehydration, or if symptoms worsen after starting antibiotics.

It is important to have your child evaluated by a healthcare provider if you suspect scarlet fever. While the condition is typically not severe with proper treatment, early diagnosis and antibiotic treatment are essential to prevent potential complications and reduce the spread of infection to others.

Contact your doctor or visit a clinic if your child develops a sore throat accompanied by fever, especially if there are any signs of rash. Even if the symptoms seem mild initially, getting a proper diagnosis allows for timely treatment. Many healthcare providers can diagnose scarlet fever based on the characteristic clinical findings, though a rapid strep test or throat culture may be performed to confirm the diagnosis.

Most children with scarlet fever can be treated at home with oral antibiotics and supportive care. However, some situations require more urgent medical attention to ensure your child receives appropriate care quickly.

Diagnosis of scarlet fever

Healthcare providers typically diagnose scarlet fever based on the characteristic combination of symptoms: fever, sore throat, the sandpaper-like rash, and the distinctive tongue changes. A physical examination will also look for swollen lymph nodes, Pastia's lines in skin creases, and the pale area around the mouth.

To confirm the presence of streptococcal bacteria, your doctor may perform a rapid strep test, which provides results within minutes. If the rapid test is negative but scarlet fever is still suspected, a throat culture may be taken. This more accurate test takes 24-48 hours for results but can detect infections that the rapid test might miss.

How Is Scarlet Fever Treated?

Scarlet fever is treated with antibiotics, typically penicillin V or amoxicillin for 10 days. It is crucial to complete the entire course of antibiotics even if your child feels better, as stopping early can lead to serious complications like rheumatic fever. Children are no longer contagious after 24-48 hours of antibiotic treatment.

Antibiotic treatment is the cornerstone of scarlet fever management. The bacteria that cause scarlet fever - group A Streptococcus - remain highly sensitive to penicillin, which has been the first-line treatment for decades. Prompt antibiotic treatment shortens the duration of symptoms, reduces the risk of spreading the infection, and most importantly, prevents serious complications.

The most commonly prescribed antibiotics are penicillin V (taken by mouth) or amoxicillin. Both are given for a full 10-day course. Amoxicillin is sometimes preferred for young children because it comes in a pleasant-tasting liquid form. For children allergic to penicillin, alternatives include azithromycin, cephalexin (for those with mild penicillin allergy), or clindamycin.

Most children begin to feel significantly better within 24-48 hours of starting antibiotics, with fever decreasing and throat pain improving. However, completing the full 10-day course is absolutely essential, even when your child feels completely well. Stopping antibiotics early allows some bacteria to survive, which can lead to recurrence of infection and increases the risk of serious complications.

Home care and symptom relief

While antibiotics treat the underlying bacterial infection, additional measures can help keep your child comfortable during recovery. These supportive care measures address symptoms like fever, throat pain, and maintaining hydration.

For fever and pain relief, acetaminophen (paracetamol) or ibuprofen can be given according to age-appropriate dosing guidelines. These medications help reduce fever and relieve the discomfort of sore throat. Never give aspirin to children under 16 years old due to the risk of Reye's syndrome, a rare but serious condition.

Keeping your child well-hydrated is essential, especially when fever is present. Offer plenty of cool fluids frequently throughout the day. Cold drinks, ice pops, and smooth soups can be particularly soothing for a sore throat. Avoid acidic drinks like orange juice or lemonade, which can irritate the throat.

Soft, easy-to-swallow foods are best when throat pain is severe. Good options include yogurt, pudding, mashed potatoes, soup, smoothies, and soft-cooked eggs. Avoid spicy, crunchy, or acidic foods that may cause additional throat irritation.

Rest is important during the acute phase of illness. Keep your child comfortable at home with age-appropriate activities like reading, puzzles, or watching shows. Use a cool-mist humidifier in the bedroom to help ease breathing and throat discomfort. Ensure your child is dressed comfortably - not too warmly despite having a fever.

What Are the Potential Complications?

If left untreated, scarlet fever can lead to serious complications including rheumatic fever (which can damage the heart), post-streptococcal glomerulonephritis (kidney inflammation), peritonsillar abscess, ear infections, and sinusitis. These complications are rare when antibiotics are given promptly and the full course is completed.

Before the availability of antibiotics, scarlet fever was a dreaded childhood illness that caused significant suffering and even death. Today, serious complications are uncommon because effective antibiotic treatment eliminates the bacteria before they can cause lasting damage. However, understanding the potential complications emphasizes why prompt treatment and completing the full antibiotic course are so important.

Rheumatic fever is the most serious potential complication, though it is now rare in countries with access to healthcare and antibiotics. This inflammatory condition can develop 2-4 weeks after an untreated or inadequately treated streptococcal infection. Rheumatic fever affects multiple organs, most importantly the heart, where it can cause permanent valve damage. Other symptoms include joint pain and swelling, involuntary movements, skin rash, and nodules under the skin.

Post-streptococcal glomerulonephritis is another serious complication that involves inflammation of the kidneys' filtering units. It typically occurs 1-3 weeks after the streptococcal infection and presents with blood in the urine, decreased urine output, swelling (particularly around the eyes and in the legs), and high blood pressure. While most children recover completely, some may experience lasting kidney problems.

Other potential complications include peritonsillar abscess (a collection of pus near the tonsils), ear infections (otitis media), sinus infections, pneumonia, and rarely, invasive streptococcal infections affecting the bloodstream, muscles, or other tissues.

How Can You Prevent Scarlet Fever?

Prevent scarlet fever spread through frequent handwashing, not sharing food or drinks, covering coughs and sneezes, and keeping sick children home from school until they have taken antibiotics for at least 24 hours and no longer have a fever. There is no vaccine for scarlet fever, so hygiene measures are the primary means of prevention.

Since there is currently no vaccine against scarlet fever, prevention focuses on reducing transmission of the streptococcal bacteria through good hygiene practices. These measures are particularly important during outbreaks and when someone in the household has been diagnosed with the infection.

Handwashing is the single most effective measure for preventing the spread of scarlet fever. Teach children to wash their hands thoroughly with soap and water for at least 20 seconds, especially before eating, after using the bathroom, after blowing their nose or coughing, and after touching shared surfaces. When soap and water are not available, alcohol-based hand sanitizers can be used.

Respiratory hygiene also plays a crucial role. Teach children to cover their mouth and nose with a tissue when coughing or sneezing, and to throw the tissue away immediately. If no tissue is available, coughing or sneezing into the elbow rather than the hands helps prevent contaminating surfaces and other people.

Avoid sharing food, drinks, eating utensils, or personal items like toothbrushes with someone who has scarlet fever or any strep throat infection. The bacteria can easily spread through saliva and nasal secretions, so even taking a sip from another person's cup can transmit the infection.

When can my child return to school?

Children with scarlet fever should stay home from school, daycare, or other group activities until they have taken antibiotics for at least 24 hours and no longer have a fever. After this point, they are generally no longer contagious and can safely return to their normal activities, even if the rash is still visible.

If your child has been exposed to scarlet fever but has not developed symptoms, there is no need to keep them home as a precaution. However, monitor them for signs of illness, particularly fever and sore throat, for 1-2 weeks after exposure. Contact your doctor if symptoms develop.

Protecting other family members

When one child in the household has scarlet fever, taking precautions can help prevent other family members from becoming infected. Have the sick child use separate towels, drinking glasses, and eating utensils. Clean frequently touched surfaces like doorknobs, light switches, and bathroom fixtures regularly.

Family members who develop sore throat or fever should be evaluated by a healthcare provider, as they may also have a strep infection requiring treatment. Some doctors may recommend testing or preventive antibiotics for close family contacts, particularly if there are high-risk individuals in the household.

What to Expect During Recovery

Most children recover fully from scarlet fever within 1-2 weeks with proper antibiotic treatment. Fever typically resolves within 24-48 hours of starting antibiotics, the rash fades after about 7 days, and skin peeling on the hands and feet may continue for several weeks. Skin peeling is a normal part of recovery and is not contagious.

With appropriate antibiotic treatment, the recovery from scarlet fever follows a predictable pattern. Understanding this timeline helps parents know what to expect and when to be concerned if recovery does not proceed as expected.

The fever is usually the first symptom to improve, typically within 24-48 hours of starting antibiotics. Your child may still not feel completely well at this point, but the improvement in fever is a good sign that the antibiotics are working. If fever persists or worsens after 48 hours of treatment, contact your healthcare provider.

The sore throat gradually improves over the first few days of treatment, though some discomfort may persist for up to a week. Continue offering soft foods and plenty of fluids during this time. The swollen lymph nodes in the neck may take a bit longer to return to normal size.

The rash typically reaches its peak intensity around days 4-5 of illness, then begins to fade. By about day 7, the rash has usually resolved, though the skin may have a somewhat rough texture. This is when the distinctive skin peeling phase begins.

Skin peeling after scarlet fever

As the rash resolves, the skin often begins to peel, particularly on the fingertips, toes, and in the groin area. This peeling can continue for several weeks after the illness has resolved and may look quite dramatic. Parents are sometimes alarmed by this peeling, but it is a completely normal part of recovery and does not indicate ongoing infection or the need for additional treatment.

The peeling skin is not contagious, and children can participate in normal activities during this phase. Keeping the skin moisturized with gentle, fragrance-free lotions can help manage any discomfort. Avoid picking or forcibly removing peeling skin, as this can cause irritation.

Full recovery, including resolution of skin peeling, typically occurs within 2-4 weeks from the start of illness. After recovery, your child has some immunity to the particular toxin type that caused their scarlet fever, though they could potentially develop the condition again if exposed to a different toxin type.