What Is the History of Scarlet Fever?

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Scarlet fever was once the terror of children's books and parents in the Victorian era. It's been creeping back. England has seen the highest rate in almost 50 years. Thousands of kids each winter are now coming home sick with what was thought to be a disease of the past. By March 2016, there were almost 600 cases in kids in England and Wales reported a week. The Scarlet Fever winter season continues until mid April.

The disease was once very common - and dangerous - before we had antibiotics for children. The disease had become rare, but some places have seen a rise in infections. In the United Kingdom, more cases were seen in 2015 - 17,000 - than in past year, when 8000 cases were seen in 2013-2014 winter season; this was double what was seen in years before.

The bacteria that causes strep throat causes scarlet fever. This bacteria is group A Streptococcus, also known as group A strep or GAS. In fact, scarlet fever affects people who develop strep throat, or more rarely strep skin infections. The difference is: in scarlet fever, the bacteria release a toxin that produces a rash and red tongue - and sometimes other symptoms.

Otherwise, strep throat and scarlet fever are caught and develop in the same way: the infection spreads from person to person via droplets from when person coughs or sneezes. The incubation period — the time between exposure and illness — is about 2-4 days.

Both infections are treated with the same antibiotics to reduce symptoms, risk of serious side effects, and risk of spread to others.

The disease spreads more in crowded conditions. Hand washing and covering coughs and sneezes can help prevent spread. A child is still infectious until after 2 days of antibiotics.

The Standard Case: The Velveteen Rabbit

This disease was once very common in childhood and found throughout children's books. The boy in the book The Velveteen Rabbit had a common case of the disease. He was about to lose his stuffed rabbit because objects that have been touched (or coughed on) might have been contaminated and spread the bacteria to the next person touching them.

The boy's Scarlet Fever would have included the standard symptoms: a red sandpaper rash and a strawberry red tongue. The rash begins 12-72 hours after the fever and will have tiny 1-2mm bumps which feel rough. Pressing on the rash will make it fade, turning lighter or white. The rash begins as "small flat blotches" on the head, neck, or chest and spreads, before becoming rough and more notable on skin folds (Pastia's lines) like in armpits, elbows etc. The rash does not affect near the mouth, leaving a circle of normal skin around the mouth. After at least 3 days, probably a week, the rash will begin to peel, from the face, as well as hands (palms and fingers). The peeling may continue for weeks. There may also be a red sore throat, red and swollen tonsils, and swollen lymph nodes in the neck. The tongue might at first be white and almost furry with red bumps and later just bright red.

Most infections occur before age 10, with infections commonly around age 4. Rarely do infections happen before age 2. Adults often have immunity. Outbreaks often happen in schools.

Specific antibiotics should be given to reduce the severity and infectiousness. A doctor can test for scarlet fever, such as through a throat swab, to confirm diagnosis and give antibiotics.

Complicated Course: Little Women

Most cases are relatively mild. Before antibiotics, more cases were more serious. In the book Little Women, one of the sisters had Scarlet Fever causing her to bed bound and ill, later dying. She likely had rheumatic fever with rheumatic heart disease, one of the feared sequelae, now rarely seen because of antibiotics.

Only about 0.3% of those infected develop Rheumatic Fever which can cause heart valve damage or Rheumatic Heart Disease (especially at the mitral valve). It is a disease where antibodies react just to bacteria but also to our own bodies - which can cause painful joints, heart inflammation, rash, skin nodules, and months later, uncontrolled rapid arm or face movements. 

The disease can be associated with kidney disease (post streptococcal glomerulonephritis). Additionally, children can have ear or skin infections, pneumonia (lung infection), throat abscesses, and joint pains after Scarlet Fever. It is worse if it occurs with Chickenpox.

Please seek medical attention if a child becomes worse despite antibiotics. There may be additional infections or medical concerns that may develop.

Misdiagnosis: Little House on the Prairie

In Little House on the Prairie, the older sister, Mary, is blind. In the book, it is said to be from Scarlet Fever. This is thought to be a misdiagnosis, as blindness is not associated. There are diseases that need different treatments which are often confused with Scarlet Fever. Although many cases of Scarlet fever will be obvious, it's easy to make misdiagnoses.

One disease is Kawasaki Disease a disease where the immune system causes inflammation of small and medium vessels - causing a fever for at least 4 days, strawberry red tongue, lymph node swelling, redness and swelling of hands with later peeling, a rash, and red eyes. It does not at first glance seem that different from Scarlet Fever but the treatment and outcomes are.

Other diseases that cause rash or skin peeling may also be confused - from measles to staph scalded skin, Roseola (Sixth Disease), Parvovirus B19 (Fifth Disease), impetigo (skin infection) and many others.

Changing Rates of Infection

Scarlet Fever has become less prevalent worldwide as improved living conditions, crowding, hand washing, aging populations, and antibiotics have reduced the disease. However, there have been outbreaks in China, as well as Hong Kong and Taiwan, and additionally in England since 2010. Media coverage may also increase the number of identified infections.


A growing problem has been outbreaks associated with drug resistance. Scarlet Fever outbreak in Hong Kong, Taiwan, and mainland China, especially Shanghai was associated with antibiotic resistance (clindamycin and macrolides). This was not the case in England.

What Is Group A Strep?

Group A Strep is a common bacteria that causes strep throat, skin infections, and Scarlet Fever. It can also be associated with other serious diseases. 

Invasive Group A Strep disease is rare, but includes bacteremia (bacteria in the blood), pneumonia (lung infection), streptococcal toxic shock syndrome (causing shock), and necrotizing fasciitis (devastating and often lethal skin infection, "flesh-eating" bacteria).​

It is thought these infections, but not Scarlet Fever, lead to 1/2 a million deaths a year. This makes Group A Strep one of the 5 most lethal germs worldwide.