PassFinals
Paediatrics

Scarlet Fever

A toxin-mediated group A streptococcal infection causing fever, sore throat, a fine sandpaper rash and strawberry tongue, treated with antibiotics and public-health exclusion.

In a nutshell

Scarlet fever is toxin-mediated group A streptococcal infection: fever and sore throat followed by a fine sandpaper rash, circumoral pallor and strawberry tongue. It is treated with an appropriate current antibiotic, is notifiable in England and requires exclusion for at least 24 hours after the first dose.

Classic presentation

A child with fever and sore throat, flushed cheeks with circumoral pallor, a sandpaper-textured rash and strawberry tongue.

Key points

  • Group A streptococcal exotoxin produces the rash.
  • The rash may be harder to see on darker skin; texture and palpation still matter.
  • Look for strawberry tongue, circumoral pallor and accentuation in skin folds.
  • Treat with the current NICE/BNF antibiotic regimen; do not rely on memorised historic doses.
  • Exclude from school or nursery for at least 24 hours after the first antibiotic dose.
  • Notify suspected cases in England.
  • Watch for invasive GAS, deep-neck infection, pneumonia and later post-streptococcal renal or cardiac complications.

First-line investigation

Clinical diagnosis; use throat testing when uncertainty, atypical disease or public-health circumstances make confirmation useful.

Management

Recognise and treat the streptococcal illness

  • Diagnose clinically when the cluster is typical and prescribe the current NICE/BNF antibiotic regimen, checking age, weight, allergy and local policy.3,1,4

Notify and exclude

  • Report suspected scarlet fever in England and keep the child away from nursery or school until at least 24 hours after the first antibiotic dose.5,2

Relieve symptoms and safety-net

  • Encourage fluids and soft foods, use age-appropriate symptom relief and explain urgent red flags including dehydration, breathing difficulty, toxic appearance and severe pain.2,4

Manage severe disease and outbreaks

  • Escalate invasive GAS, airway or deep-neck infection, pneumonia, meningitis, severe dehydration or toxic appearance; involve health protection teams for clusters and outbreaks.3,6

Watch for delayed complications

  • Give return precautions for recurrent illness, migratory joint symptoms, cardiorespiratory features, oedema, haematuria or reduced urine output after the acute infection.1,2

Exam traps

  • Scarlet fever is bacterial and needs antibiotics; the other common exanthems in this group are viral.
  • Do not dismiss a sandpaper rash because erythema is subtle on darker skin.
  • The return-to-school rule is at least 24 hours after the first antibiotic dose, not immediately after starting treatment.
  • Quinsy, deep-neck infection, airway compromise and invasive GAS require escalation, not routine primary-care follow-up.
  • New illness weeks later with joint, cardiac, renal or systemic features may be a post-streptococcal complication.

Illustrations

Scarlet fever rash with flushed cheeksA clinical photograph of a young child with scarlet fever, showing deeply flushed cheeks and a fine, closely spaced red punctate rash over the shoulder, trunk and arm.www.badobadop.co.uk, Wikimedia Commons · CC-BY-SA-3.0
White strawberry tongueThe tongue of a child with scarlet fever showing the white strawberry tongue: a white coat through which swollen red papillae project. The coat later sheds to leave the red strawberry tongue.Dr Graham Beards (with thanks to Tamii Render), Wikimedia Commons · CC-BY-SA-4.0
Circumoral pallorFlushed cheeks with a striking pale ring around the mouth (circumoral pallor), a characteristic facial appearance in scarlet fever.Alicia Williams, Wikimedia Commons · CC-BY-2.5
Sandpaper rash in darker skinThe same sandpaper rash on the neck and upper trunk of a child with darker skin. Erythema is much harder to appreciate; the fine, closely spaced papular texture is the finding to look for, and the rash is often easier to feel than to see.Whispyhistory, Wikimedia Commons · CC-BY-SA-4.0

Key sources

  1. UKHSA: Scarlet fever, symptoms, diagnosis and treatment (UKHSA guidance on symptoms, diagnosis, treatment, exclusion and complications.)Updated 29 Mar 2019
  2. NHS: Scarlet fever (Current NHS information on presentation, testing, antibiotics, contagious period, exclusion and safety-netting.)
  3. NICE NG84: Sore throat, acute antimicrobial prescribing (Current NICE guidance relevant to acute streptococcal sore throat, antibiotic prescribing and escalation.)Updated 1 Nov 2025
  4. BNF online (Current UK prescribing information for antibiotics, antipyretics and allergy-specific alternatives.)
  5. UKHSA: Notifiable diseases and how to report them (Current England notification requirements; suspected scarlet fever is routine-notifiable.)Updated 19 May 2026
  6. UKHSA: Scarlet fever outbreaks in schools and nurseries (UKHSA outbreak-management guidance for childcare and school settings.)Updated 3 Apr 2023

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.