Scarlet Fever Symptoms, Diagnosis, and Treatment

What You Need to Know About Scarlet Fever in Children

Scarlet fever
What is scarlet fever?. Joanne Green / Getty Images

Although it sounds like a scary diagnosis, it is important to remember that, at least in the 21st century, scarlet fever is basically strep throat with a rash. What do you need to know about the symptoms, diagnosis, and treatment of this disease which is currently increasing?

The History of Scarlet Fever - Why is the Disease Less Frightening Than in the Past?

Why do people get concerned when they hear the words scarlet fever?

There are a few reasons.

Often times people are concerned because they confuse scarlet fever with rheumatic fever. Rheumatic fever which can lead to rheumatic heart disease is a serious complicated of untreated strep throat which can lead to heart valve problems and more.

Another reason that scarlet fever may bring fear, is that the infection was, at one time, more dangerous than it is today. There were deadly scarlet fever epidemics in the 19th and early 20th century, which are remembered by their starring role in many children's stories, including the Velveteen Rabbit, Little Women, and Little House on the Prairie.

Fortunately, scarlet fever is not as serious as it once was, both because we now have antibiotics to treat it and perhaps because the strain of bacteria that causes scarlet fever has become weaker. Today, scarlet fever is essentially little more than a strep throat with a rash.

Fairly uncommon since the 1960s, there has been a resurgence in cases of scarlet fever in recent years, especially in the U.K.

Learn more about the history of scarlet fever.

Scarlet Fever Symptoms

The symptoms of scarlet fever, also called "scarletina," typically include other classic strep throat symptoms, including a fever, sore throat, red tonsils with pus on them, and swollen glands.

Some children have all of these symptoms, and some only have a few.

In addition, after about 24 hours (12 to 48) children with scarlet fever will develop a red, sunburn-like, sandpapery rash all over their body. The rash usually starts on their neck and face and then spreads over their trunk, arms, and legs.

Other characteristics of scarlet fever include that:

  • The rash  (a "scarletinoform rash") is usually darker in a child's flexor skin creases (Pastia lines), such as the creases of their elbows, groin, and neck
  • The area around a child's mouth is usually spared from the rash (this is referred to as circumoral pallor,) but their cheeks may be flushed (this may be referred to as having a "slapped cheek appearance")
  • The rash blanches with pressure, so for example, it disappears for a few seconds if you press down on it (rashes that don't blanch are often due to tiny bleeding spots—petechiae—and can be a sign of serious illness)
  • Children often develop a red tongue with a white coating which has been coined "strawberry tongue"
  • As it goes away, the skin on a child's trunk and then hands and feet may peel for several weeks

It is possible to have scarlet fever without strep throat, as other strep infections, including skin and wound infections (for example, impetigo,) can also cause scarlet fever, as long as they are being caused by the same group A strep bacteria that causes strep throat.

If a child doesn't have any symptoms of strep throat, but it does seem like they have scarlet fever, then signs or symptoms of another source for a strep infection should be looked for. It's not uncommon for a strep screen to be positive in this case, even though the throat doesn't have the appearance of strep throat.

Diagnosis of Scarlet Fever

The diagnosis of scarlet fever is usually made based on the appearance of the rash and associated symptoms of a strep infection. The presence of a strep infection can be confirmed by a rapid strep test and/or strep culture.

Cause of Scarlet Fever

As noted above, scarlet fever is related to infection with the group A strep bacteria which causes strep throat and impetigo.

Yet not all strains of strep lead to scarlet fever.

Some strains of group A strep release a toxin (an exotoxin) in the body. It is the toxin and not the bacteria itself which leads to the classic symptoms of scarlet fever.

Scarlet Fever Treatments

The treatments for scarlet fever are the same as the treatments for strep throat and include antibiotics such as penicillin, amoxicillin, or cephalosporins (antibiotics which begin with cef-, ceph-, or kef-.) Antibiotics such as macrolides (for example, erythomycin) are less effective. It's important to complete a full course of therapy (all doses) in order to protect against rheumatic fever.

In addition to antibiotics, making sure a child is well hydrated and treating their symptoms is important. Natural sore throat remedies such as honey may ease the discomfort. Pain relievers such as Tylenol (acetominophen) may also be helpful.

Epidemiology - What is the Incubation and Who Gets the Infection?

Scarlet fever often occurs at the same time of year when colds and flu are most common. Most cases occur in children of elementary school age, and it often spreads through a school. It is spread by droplets when a person coughs or sneezes, or by exposure to objects (fomites) in which these droplets are present (for example, sharing a cup.) Proper handwashing is important. In 2016, scarlet fever reached epidemic proportions in the U.K.

What Else Could it Be?

There are many other medical conditions which can have symptoms similar to scarlet fever, and therefore making the diagnosis with a strep screen or other testing important. Some of these include:

  • Kawasaki disease - Kawasaki disease is a condition much less common than scarlet fever which can cause some of the same symptoms such as a strawberry tongue, redness of the hands and feet which later peels, and a fever. Instead of an infection, Kawasaki's disease is thought to be an autoimmune condition in which autoantibodies (antibody's against self) attack blood vessels.
  • Rubella (German measles) - German measles is an infection which is rare in children now due to immunization. It can resemble scarlet fever with a rash which begins on the face. Usually only a nuisance in children, it can result in birth defects in babies born to women who contract the infection in the first half of pregnancy.
  • Rubeola (red measles) - Measles is uncommon now except in children who have not been immunized. It is a serious illness which begins with white spots in the mouth and a fever, followed by a rash. As one of the most easily spread diseases of childhood, measles is one reason why all children should be vaccinated, as widespread vaccination (the herd effect) plays a role in protecting even those who have not been vaccinated.
  • Parvovirus B19 (fifth disease) - Fifth disease is a common childhood infection which can resemble scarlet fever with a "slapped cheek" appearance and a rash. The infection resolves without treatment, but can cause miscarriages in pregnant women.
  • Roseola - Roseola is a common infection of early childhood. It usually begins with a high fever alone, which dissipates when the rash develops. The rash usually begins on the trunk and spreads up and down and to the extremities from there.
  • Staph scalded skin syndrome - Staph scalded skin syndrome, also known as fourth disease, is a serious infection which also begins with redness and a rash on the face. Unlike scarlet fever, it is often most prominent around the mouth. The rash of scalded skin syndrome often develops into blisters and then peels, looking like a severe burn, hence the name "scalded skin."

What You Need To Know

  • The rash of scarlet fever is caused by streptococcal pyrogenic exotoxins produced by certain strains of the group A strep bacteria that causes strep throat. Since not all strains of strep produce this exotoxin, you don't get scarlet fever every time you get strep throat.
  • The rash of scarlet fever usually lasts about three to four days.
  • Scarlet fever used to be a much more serious infection than it is today.
  • Children with scarlet fever are contagious until they have been on an antibiotic for at least 24 hours.
  • Group A strep is responsible for a number of other conditions, some of which are much more serious than scarlet fever. These include post-streptococcal glomerulnephritis, rheumatic fever, streptococcal toxic shock syndrome, and necrotizing enertolitis.

Bottom Line on Scarlet Fever

For those who enjoy classical literature, or were alive at the tail end of the scarlet fever epidemics of the last century, it can be terrifying to receive a diagnosis of scarlet fever. That said, at the current time scarlet fever is essentially nothing more than a strep throat accompanied by a rash.

It is easy to forget, however, how serious some of these infections were prior to the advent of antibiotics. It is important to seek medical treatment if you have symptoms suggestive of scarlet fever and to take all of your medication if you do have the disease. Serious complications, such as post-streptococcal glomerulonephritis and rheumatic may occur due to undertreated strep infections.


Evans, N. Scarlet Fever Warning as Number of Cases Jumps to Highest Level Since the 1960s. Nursing Children and Young People. 2016. 28(4):7.

Kliegman, Robert M., Bonita Stanton, St Geme III Joseph W., Nina Felice. Schor, Richard E. Behrman, and Waldo E. Nelson. Nelson Textbook of Pediatrics. 20th Edition. Philadelphia, PA: Elsevier, 2015. Print.

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