Links to other pages within Patient UK which are related to this topic:
Experience | Leaflets | Patient+ | Guidelines | Weblinks | News | Products | Other
Print options:   Other options:   Bookmark and Share

This is a PatientPlus article. PatientPlus articles are written for doctors and so the language can be technical. However, some people find that they add depth to the articles found in the other sections of this website which are written for non-medical people.

Scarlet Fever

Post your experience
See others (37 there)

Synonyms: scarlatina, scarlatinella

This disease is notifiable in the UK under the Public Health (Infectious Diseases) Regulations 1988.

Scarlet fever is an exotoxin-mediated disease arising from a specific bacterial infection by an erythrogenic toxin-producing strain of Streptococcus pyogenes (Group A beta-haemolytic streptococci or GpA BHS). In most cases scarlet fever evolves from a tonsillar or pharyngeal infection but the rash develops in less than 10% of so-called "strep throats". Scarlet fever can follow infection at other sites, including wounds, burns and postnatally (for example surgical scarlet fever and puerperal scarlet fever).

Pathophysiology1,2
  • GpA BHS are normally found in the nasopharynx but can cause disease, for example, pharyngitis, skin infections and pneumonia.
  • Scarlet fever is associated with pharyngitis and only rarely with infection at other sites. Up to about 10% of GpA BHS sore throats will go on to cause scarlet fever.
  • GpA BHS secrete a variety of haemolysing enzymes and toxins including the erythrogenic toxins causing the characteristic rash of scarlet fever.
  • Person to person spread is mainly by respiratory droplets. The incubation is typically 2 to 4 days but ranges from 12 hours to 7 days.
  • Patients are contagious both during the acute illness and the initial subclinical stage. Advice on exclusion from school is variable (see Prevention below).
Epidemiology1,2,3
  • In the 1800s there were serious epidemics of scarlet fever. The death rate from scarlet fever then was as high as 150/100,000. Complications, case mortality and incidence have fallen dramatically because of antibiotics, enhanced immunity and improved socio-economic conditions.4 There are still sporadic outbreaks.5
  • There has been a marked reduction in the incidence of scarlet fever over the last 10 years. Notifications have fallen from about 2,000 per quarter to 1,000 per quarter.6 There have been similar reductions in other countries.7
  • Infection usually affects children (peak between age 4 and 8 years). However it is unusual under age 2 years because of maternal antibodies to the exotoxin and lack of prior sensitisation.
  • The infection rate increases with overcrowding and close contact. School populations have a higher incidence.
  • Incidence decreases in adults as immunity develops.
  • Infection occurs throughout the year but pharyngitis occurs most often in school age children in spring and winter.
  • Geographically skin infections caused by streptococcal organisms are more common in warmer climates and in the warmer months.
Presentation
  • Incubation is 2 to 4 days (range 12 hours to 7 days). Onset of the illness is usually sudden with fever. The rash follows 12-48 hours after the fever.
  • Often prodrome of sore throat, fever, headache, vomiting, abdominal pain, myalgia. Tachycardia accompanies the fever.
  • Scarlatiniform rash appears on second day of illness. The rash has the following characteristics:
    • Appears typically on the neck first and also chest and scapular regions. It then affects trunk and legs later.
    • Rash has a coarse texture like sandpaper. It is punctate on a diffuse erythematous base (that is pin-point dark red spots on a general reddening of the skin).
    • Circumoral pallor is evident. The area round mouth is unusually pale against surrounding flushed face. This effect is more prominent than in other fevers.
    • Rash lasts for several days but after a few days of becoming generalised it may appear more prominent in skin creases with confluent petechiae or lines (capillary fragility). This sign, seen particularly in axillae and groin, is Pastia's sign and the lines known as "Pastia's lines".
    • The skin may start to peel (desquamation) even during the febrile stage. This peeling which often produces flakes of skin on the face, continues for several weeks. It also affects tips of the fingers, toes, axilla, groin and ears. It is a valuable sign if patient has not been seen during febrile phase.
  • The throat may have some of the typical features described:8
    • There may be small haemorrhagic spots on palate.
    • The tonsils are often red and oedematous.
    • The tonsils may be covered with pale exudate.
    • Accompanying tender cervical lymphadenopathy is typical.
  • The tongue has a characteristic appearance which develops during the illness:9
    • Initially, during the first 2 days of the illness, patients may have a 'white strawberry tongue'. The tongue is covered by prominent red papillae seen through a white 'fur'.
    • After about 2 days the 'fur' is lost (desquamation). The tongue appears to look more raw and red, but still has prominent papillae. This is called the 'raspberry tongue' or 'red strawberry tongue'.
Differential diagnosis2,10
Investigations
  • Throat swab and culture:
    • The most important proof of infection with 90% sensitivity for presence of GpA BHS. However less specific as there is 10-15% carrier rate in healthy subjects.
    • It is important to take throat swabs correctly avoiding lips, tongue and buccal mucosa.
    • Swab tonsils, posterior pharynx and any exudate under good illumination.
  • Antigen detection kits:
    • Various kits are available for near patient testing. Rapid antigen tests (RATs) and 'strep tests' use latex agglutination. Enzyme-linked immunosorbent assays (ELISA) are more expensive.
    • These are promoted to allow quick diagnosis and hence more appropriate administration of antibiotics. However the cost and variable sensitivity and specificity are amongst some of the reasons that use is limited.
  • Streptococcal antibody tests:
    • Proves recent infection but of no value in acute infection.
    • Has a value in patients with complications such as acute glomerulonephritis.
  • Full blood count:
    • A polymorphonuclear lymphocytosis is typical.
    • During the second week an eosinophilia may develop.
Management
  • The aims of treatment are to:
    • Shorten the illness.
    • Prevent suppurative complications (such as peritonsillar abscess formation, mastoiditis, cellulitis and ethmoiditis).
    • Reduce the risk of spread to others.
    • Prevent progression to other complications. Unfortunately, however, although early use of penicillin may reduce rheumatic fever it does not prevent post-streptococcal glomerulonephritis.
  • Medical treatment:
    • Antibiotics. Penicillin or erythromycin if penicillin-allergic are the treatments of choice given for a full 10 days.11 There are no documented penicillin-resistant GpA BHS infections. A cephalosporin is an effective alternative to penicillin, but not if penicillin-allergic.
  • Referral and other treatment:
    • Recurrent infection would be an indication for ENT referral.
    • Difficulty swallowing may necessitate hospitalisation for intravenous fluids and antibiotics.
    • Management of complications may require hospitalisation.
  • Exclusion from School Advice is variable. Some recommend a minimum of 24 hours' antibiotics before patient can return to school,2 although the HPA suggests 5 days3 (may be more appropriate in nurseries where children are in closer proximity). It seems reasonable that milder cases in older children may be treated in line with other streptococcal sore throats (no specific exclusion).
Complications
  • Local spread:
    • Cervical lymphadenopathy
    • Sinusitis
    • Mastoiditis
    • Peritonsillar abscess
  • Distant spread:
  • Rare, but feared, late complications include rheumatic fever (0.3%) or acute renal failure (post-streptococcal glomerulonephritis).12,13
  • Minor late sequelae:
    • Beau lines on nails
    • Telogen hair loss
Prognosis

Scarlet fever follows a benign course in the vast majority of cases. Any morbidity is likely to arise from suppurative complications most often in untreated patients.

Historical

Second in the historical order of classic exanthems identified:

  1. Rubeola (measles).
  2. Scarlet fever.
  3. Rubella (German measles)
  4. Dukes' disease (coxsackie virus or echovirus) - no longer considered as a separate entity.
  5. Fifth disease, or erythema infectosum (parvovirus B19).
  6. Exanthem subitum or roseola infantum (herpes virus, HH6).

A disease previously confused with measles, the credit for a definitive, distinctive name must go to Thomas Sydenham (1624-1689), the English Hippocrates, and the father of English medicine.


Document references
  1. Ballentine J; Scarlet Fever. eMedicine, May 2009; Emergency medicine perspective.
  2. Dyne P; Scarlet Fever. eMedicine, December 2007; Paediatric perspective on Scarlet Fever.
  3. HPA; Health Protection Agency; Scarlet Fever
  4. Radikas R, Connolly C; Young patients in a young nation: scarlet fever in early nineteenth century rural New England. Pediatr Nurs. 2007 Jan-Feb;33(1):53-5. [abstract]
  5. Feeney KT, Dowse GK, Keil AD, et al; Epidemiological features and control of an outbreak of scarlet fever in a Perth primary school. Commun Dis Intell. 2005;29(4):386-90. [abstract]
  6. Health Protection Agency; Notifications of Infectious Diseases (NOIDs)
  7. Czarkowski MP, Kondej B; Scarlet fever in Poland in 2003. Przegl Epidemiol. 2005;59(2):235-40. [abstract]
  8. Tewfik TL, Al Garni M; Tonsillopharyngitis: clinical highlights. J Otolaryngol. 2005 Jun;34 Suppl 1:S45-9. [abstract]
  9. Mahajan VK, Sharma NL; Scarlet Fever. Indian Pediatr. 2005 Aug;42(8):829-30.
  10. Aber C, Alvarez Connelly E, Schachner LA; Fever and rash in a child: when to worry? Pediatr Ann. 2007 Jan;36(1):30-8. [abstract]
  11. De Meyere M, Mervielde Y, Verschraegen G, et al; Effect of penicillin on the clinical course of streptococcal pharyngitis in general practice. Eur J Clin Pharmacol. 1992;43(6):581-5. [abstract]
  12. Rodriguez-Iturbe B, Batsford S; Pathogenesis of poststreptococcal glomerulonephritis a century after Clemens von Pirquet. Kidney Int. 2007 Mar 7;. [abstract]
  13. Mosquera J, Romero M, Viera N, et al; Could streptococcal erythrogenic toxin B induce inflammation prior to the development of immune complex deposits in poststreptococcal glomerulonephritis? Nephron Exp Nephrol. 2007;105(2):e41-4. Epub 2006 Nov 30. [abstract]
Acknowledgements EMIS is grateful to Dr Richard Draper for writing this article. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2009.
Document ID: 2750
Document Version: 22
Document Reference: bgp1564
Last Updated: 2 Sep 2009
Planned Review: 2 Sep 2011

The authors and editors of this article are employed to create accurate and up to date content reflecting reliable research evidence, guidance and best clinical practice. They are free from any commercial conflicts of interest. Find out more about updating.

Patient UK Hearing Impairment Survey

Patient UK are grateful to the 550 people who took part in this survey.
To see the results click here.
If you'd like to leave your feedback, please go to our interactive forum.

Links to other pages within Patient UK which are related to this topic:
Experience | Leaflets | Patient+ | Guidelines | Weblinks | News | Products | Other
Print options:   Other options:   Bookmark and Share
Want to search some more? Use the Google Search box below to search our site.

Related pages in Patient UK

Your Experience (^ top of page)

 Please add your experience about this condition / medicine
 View Patient Experience for 'Scarlet Fever' (37 there)
 Scarlet Fever

 Notifiable Diseases

 Guidelines on Scarlet Fever

 Scarlet Fever

Recent related news items

 Strep throat may have killed Mozart: study - Reuters
 Victorian diseases: Back from the dead
 The return of scarlet fever
 Scarlet fever, scourge of the 19th century, is coming back

All news by related topic

 Scarlet Fever news

Medical equipment


Visit the Patient UK Medical Equipment shop

Books


Visit the Patient UK shop

Other - Useful resources (^ top of page)

Pictures, diagrams, photos, images, etc.
Evidence based medicine
Online textbooks and journals
UK Guidelines
Online Videos
Medline
Other good health sites

Want to search some more? Use the Google Search box below to search our site.

Advertisements











Disclaimer: Patient UK has no control over the content of any external links above. Inclusion does not imply endorsement by Patient UK.

Want to advertise on this site? Find out how >>

Clicking here will take you to the foot of this page where you'll find a list of Information Leaflets which are related to the topic you are currently viewing
Clicking here will take you to the foot of this page where you'll find a list of Support Groups which are related to the topic you are currently viewing
Clicking here will take you to the foot of this page where you'll find a list of Medicines & Drugs which are related to the topic you are currently viewing
Clicking here will take you to the foot of this page where you'll find a list of diagrams which are related to the topic you are currently viewing
Clicking here will take you to the foot of this page where you'll find a list of PatientPlus (detailed reference) articles which are related to the topic you are currently viewing
Clicking here will take you to the foot of this page where you'll find a list of UK Guidelines which are related to the topic you are currently viewing
Clicking here will take you to the foot of this page where you'll find a list of other selected websites which are related to the topic you are currently viewing
Clicking here will take you to the foot of this page where you'll find a list of Poems and Stories which are related to the topic you are currently viewing
Clicking here will take you to the foot of this page where you'll find a list of Operations and Procedures which are related to the topic you are currently viewing
Clicking here will take you to the foot of this page where you'll find a list of Online Videos which are related to the topic you are currently viewing
Clicking here will take you to the foot of this page where you'll find links through to our interactive forum.
Here you can follow a link to view existing patient experiences on this subject, or to add your own
Clicking here will take you to the foot of this page where you'll find links to news stories on this subject in our Online Newspaper
Clicking here will take you to the foot of this page where you'll find links to related products
Clicking here will take you to the foot of this page where you'll find links to other useful sources of information
Click here to open a printer-friendly version of this document, in a new window, together with the print dialogue box
Click here to open this document in PDF format
This will offer you the usual PDF options i.e. document navigation, search, zoom and formatted print
Note: this is the best way to print the document
Click here to listen to the MP3 audio recording of this document
Click here to download the audio recording of this document as a podcast, for listening to at your leisure
Click here to open our Dictionaries and Glossaries page
Click here to see related products in our Online Pharmacy
Note: this will open in a new window
Click here to add this page to a social bookmarking site of your choice
Click here if you want to find out more about social bookmarking. This link will take you to the Wikipedia explanation
Note: this will open in a new window
Clicking here will take you to the foot of this page where you'll find a list of Information Leaflets which are related to the topic you are currently viewing
Clicking here will take you to the foot of this page where you'll find a list of Support Groups which are related to the topic you are currently viewing
Clicking here will take you to the foot of this page where you'll find a list of Medicines & Drugs which are related to the topic you are currently viewing
Clicking here will take you to the foot of this page where you'll find a list of diagrams which are related to the topic you are currently viewing
Clicking here will take you to the foot of this page where you'll find a list of PatientPlus (detailed reference) articles which are related to the topic you are currently viewing
Clicking here will take you to the foot of this page where you'll find a list of UK Guidelines which are related to the topic you are currently viewing
Clicking here will take you to the foot of this page where you'll find a list of other selected websites which are related to the topic you are currently viewing
Clicking here will take you to the foot of this page where you'll find a list of Poems and Stories which are related to the topic you are currently viewing
Clicking here will take you to the foot of this page where you'll find a list of Operations and Procedures which are related to the topic you are currently viewing
Clicking here will take you to the foot of this page where you'll find a list of Online Videos which are related to the topic you are currently viewing
Clicking here will take you to the foot of this page where you'll find links through to our interactive forum.
Here you can follow a link to view existing patient experiences on this subject, or to add your own
Clicking here will take you to the foot of this page where you'll find links to news stories on this subject in our Online Newspaper
Clicking here will take you to the foot of this page where you'll find links to related products
Clicking here will take you to the foot of this page where you'll find links to other useful sources of information
Click here to open a printer-friendly version of this document, in a new window, together with the print dialogue box
Click here to open this document in PDF format
This will offer you the usual PDF options i.e. document navigation, search, zoom and formatted print
Note: this is the best way to print the document
Click here to listen to the MP3 audio recording of this document
Click here to download the audio recording of this document as a podcast, for listening to at your leisure
Click here to open our Dictionaries and Glossaries page
Click here to see related products in our Online Pharmacy
Note: this will open in a new window
Click here to add this page to a social bookmarking site of your choice
Click here if you want to find out more about social bookmarking. This link will take you to the Wikipedia explanation
Note: this will open in a new window
Click here to return to the home page
Click here to read our 'About Us' page
Go to the Emis Access website, where you can book an appointment with your GP, order a repeat prescription or view you medical record online.
Note: this will open in a new window
View and/or join in discussion about health, lifestyle and disease in our interactive forum.
Note: this will open in a new window
Visit our pharmacy product price comparison website
Go to our online newspaper for current medical news and commentary.
Note: this will open in a new window
Adverts on this site do not influence the medical content. Click to read more.
Adverts on this site do not influence the medical content. Click to read more.