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In this summary

Background

  • Scarlet fever is a common childhood infection caused by Streptococcus pyogenes (also known as group A Streptococcus [GAS]). These bacteria may be found on the skin, throat and other sites where they can live without causing problems. Under some circumstances GAS can cause non-invasive infections such as pharyngitis, impetigo and scarlet fever. On rare occasions they can cause severe disease, including streptococcal toxic shock syndrome, necrotising fasciitis, and septicaemia
  • Statutory notifications of scarlet fever, based on clinical symptoms consistent with this diagnosis, are submitted to local health protection teams (HPTs)

Diagnosis

Symptoms

  • Symptoms are non-specific in early illness and include:
    • sore throat
    • headache
    • fever
    • nausea
    • vomiting
  • After 12 to 48 hours the characteristic red, generalised pinhead rash develops, typically first appearing on the chest and stomach, rapidly spreading to other parts of the body, giving the skin a sandpaper-like texture. On more darkly-pigmented skin, the scarlet rash may be harder to spot, although the ’sandpaper’ feel should be present. Patients typically have flushed cheeks and pallor around the mouth. This may be accompanied by a ‘strawberry tongue’. During convalescence peeling of the skin may occur at the tips of fingers and toes and less often over wide areas of the trunk and limbs

Complications

  • Although scarlet fever is usually a mild illness, some patients may require hospital admission to manage symptoms or complications. These include:
    • ear infection
    • throat abscess (quinsy)
    • pneumonia
    • sinusitis
    • meningitis
  • While such complications arise in the early stages, sequelae including acute glomerulonephritis and acute rheumatic fever can arise at a later stage. A proportionate increase in scarlet fever hospital admissions has been identified during the recent upsurge period with 1 in 30 cases being seen in secondary care for management of scarlet fever or allied complications. Prompt treatment with appropriate antibiotics significantly reduces the risk of complications. Clinicians should advise patients, or their parents/guardians, to keep an eye out for any symptoms which might suggest these complications and to seek medical help immediately if concerned
  • Clinicians should consider the following actions:
    • prescribe an appropriate treatment course of antibiotics without waiting for the culture result if scarlet fever is clinically suspected (see table below)
    • advise exclusion from nursery/school/work for at least 24 hours after the commencement of appropriate antibiotic treatment
    • consider taking a throat swab to assist with differential diagnosis or if the patient is:
    • thought to be part of an outbreak
    • allergic to penicillin, to determine antimicrobial susceptibility. GAS can be resistant to non-penicillin options such as macrolides and clindamycin. This will facilitate a prompt treatment change if required
    • in regular contact with vulnerable individuals such as the immunocompromised, the comorbid, or those with skin disease, who are at risk of complications of S. pyogenes including streptococcal toxic shock syndrome (e.g. healthcare workers). This will facilitate prompt public health action and help with differentiating the diagnosis from mimicking illnesses such as rubella and measles
    • notify  your Health Protection Team, including information on the school/nursery attended if relevant
  • Further information on clinical management of scarlet fever can be found in the NICE CKS for Scarlet Fever

Table 1. Antibiotic treatment for scarlet fever

ChoiceDrugAgeDose (by mouth)Frequency and duration

1

Penicillin V*

<1 month

12.5 mg/kg (max 62.5 mg)

Every 6 hours for 10 days

1 month to <1 year

62.5 mg

1 to <6 years

125 mg

6 to <12 years

250 mg

12 to 18 years

250–500 mg

Adults

500 mg

2

Azithromycin

6 months < 12 years

12 mg/kg (max 500 mg)

Once a day for 5 days

12 years and over

500 mg

*For children who are unable to swallow tablets, or where compliance to penicillin V is a concern, amoxicillin 50 mg/kg once daily (max=1000 mg) or 25 mg/kg (max=500 mg) twice daily may be used as an alternative

if allergic to penicillin

unlicensed indication

  • Clinicians should be mindful of a potential increase in invasive GAS (iGAS) infection which can follow trends in scarlet fever. It is important to maintain a high index of suspicion, especially in relevant patients (such as those with chickenpox, and women in the puerperal period). Early recognition and prompt initiation of specific and supportive therapy for patients with iGAS infection can be lifesaving

Full guideline available from…

assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/656687/Guidelines_for_the_public_health_management_of_scarlet_fever_outbreaks__.pdf

Public Health England. Guidelines for the public health management of scarlet fever outbreaks in schools, nurseries and other childcare settings.  Updated October 2017

First included: January 2019