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Scarlet fever in Child
Other Resources UpToDate PubMed

Scarlet fever in Child

Contributors: Samantha R. Pop MD, Eric Ingerowski MD, FAAP, Susan Burgin MD
Other Resources UpToDate PubMed


Scarlet fever is an acute toxin-mediated disease caused by infection with group A beta-hemolytic streptococci (Streptococcus pyogenes). Most cases follow a streptococcal pharyngitis or tonsillitis. However, streptococcal sepsis, cellulitis, puerperal infection, or surgical infection can initiate scarlet fever. Scarlet fever is most common in children younger than 10 years, but it can affect adults as well.

A 2-5 day incubation period precedes the onset of rash. Associated prodromal symptoms include fever and malaise. Sore throat and swollen, tender anterior cervical lymph nodes are typical. Abdominal pain, nausea, and vomiting are common in younger children. Petechiae may be present on the soft palate.

The characteristic rash begins within 12-48 hours of fever onset. The rash initially presents on the trunk and spreads to involve the extremities, sparing the palms and soles. The rash is often accentuated in flexural creases. It manifests as confluent tiny, erythematous papules with a "sandpaper-like" appearance. Enlarged tongue papillae may give the appearance of a "strawberry tongue." The rash tends to fade in a week and is followed by desquamation.

Once a fatal disease in the pre-antibiotic era, scarlet fever's associated complications are now fortunately rare with the existence of effective antibiotic therapy. However, meningitis, otitis media, sinusitis, pneumonia, arthritis, rheumatic fever, glomerulonephritis, and pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) can rarely occur.

In 2022-2023, the United Kingdom reported a surge in scarlet fever that coincided with an increase in invasive S pyogenes (invasive group A strep [iGAS]) infections. In the United States and elsewhere in Europe, iGAS infections in children, including necrotizing fasciitis and streptococcal toxic shock syndrome, have increased without a concomitant increase in cases of scarlet fever.


A38.9 – Scarlet fever, uncomplicated

30242009 – Scarlet fever

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Differential Diagnosis & Pitfalls

  • Toxic shock syndrome originates from Staphylococcus aureus infections arising in the setting of super-absorbent tampons, nasal packing, or surgical site infections. Patients are systemically ill and eventually desquamate.
  • Staphylococcal scalded skin syndrome (SSSS) usually occurs in young children following an S aureus infection. The affected skin is notably tender.
  • Kawasaki disease is characterized by strawberry tongue, conjunctival injection, cervical lymphadenopathy, and rash. This is also more common in children.
  • Viral exanthem (such as Roseola or Coxsackie viral infection, among others).
  • Exanthematous drug eruption will have a history of exposure.
  • Sunburn occur after sun exposure and are photodistributed.
  • Drug-induced photosensitive reaction and Drug-induced phototoxic reaction are photodistributed.
  • Photocontact dermatitis is photodistributed.
  • Measles has associated cough, coryza, conjunctivitis, and Koplik spots.
  • Rubella has occipital and postauricular lymphadenopathy.
  • Streptobacillus moniliformis rat-bite fever
  • Mononucleosis has associated lymphadenopathy.
  • Systemic lupus erythematosus has associated photosensitivity.

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Last Reviewed:02/07/2019
Last Updated:01/22/2023
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Scarlet fever in Child
A medical illustration showing key findings of Scarlet fever (First Phase) : Chills, Fever, Headache, Nausea/vomiting, Lymphadenopathy, Malaise, Pharyngitis
Clinical image of Scarlet fever - imageId=426336. Click to open in gallery.  caption: 'Patchy erythema on the hand and wrist.'
Patchy erythema on the hand and wrist.
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