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Symptoms and Signs of Scarlet Fever

Doctor's Notes on Scarlet Fever

Scarlet fever (also termed scarlatina) is a childhood disease usually occurring in children 2 – 10 years of age (although it can occur in older children and adults) that is characterized by fever, sore throat and characteristic rash. The symptoms and signs of scarlet fever begin about four days after exposure to a streptococcal infection and may include sore throat with a white coating on the tonsils, headaches, fever, chills, malaise, abdominal pain, nausea, vomiting and swollen lymph nodes on the sides of the neck that may be tender to touch. The typical rash, consisting of multiple scarlet-red punctate lesions that are small and rough like sandpaper, begins on the chest, neck and armpits and then spreads to other areas of the body. The rash is darker appearing in skin creases; ruptured capillaries in these areas may appear to be lines (termed Pastia lines). The face may appear flushed and there may be paleness around the mouth. The white coating on the tongue starts in the first one or two days of illness and then it sloughs off revealing a red-colored tongue with prominent papillae (termed strawberry tongue). As the patient resolves the infection, the rash fades and the skin begins to peel off; this peeling may last for several weeks.

Scarlet fever is caused by infection with group A beta – hemolytic streptococci bacteria that secretes a toxin responsible for the scarlet-colored rash.

Medical Author:
Medically Reviewed on 3/11/2019

Scarlet Fever Symptoms

The symptoms and signs of scarlet fever usually begin one to four days after exposure to the streptococcal infection (incubation period). As previously mentioned, scarlet fever typically occurs in association with a pharyngeal streptococcal infection, therefore many of the symptoms and signs initially will be similar to that of strep throat and may include any of the following:

Approximately one to four days after the onset of illness, a characteristic skin rash will appear with the following properties.

  • The rash typically begins on the chest, neck, and armpit area and then spreads to other areas of the body.
  • The rash is often more pronounced and reddened in areas of skin creases, such as the axilla, the neck, the inguinal area, and in the creases of the elbow (antecubital fossa) and the knee (popliteal fossa). Ruptured capillaries in these areas may cause the resultant rash to appear as lines (termed Pastia lines).
  • The rash is described as fine and rough-textured (like sandpaper), consisting of multiple red punctate lesions. The rash blanches when pressed upon.
  • The face may appear flushed, and the area around the mouth may appear pale (circumoral pallor).
  • The rash may last anywhere between two to seven days. After the rash has faded, the skin begins to peel (desquamation), and this may last up to several weeks. The extent and duration of skin peeling is directly related to the initial severity of the rash. Areas commonly affected include the fingers, toes, palms, axilla, and the groin.
  • During the first one to two days of illness, the tongue may have a white-colored coating with protruding, swollen, and red papillae on the surface. After about four to five days, the white coating sloughs off revealing a red-colored tongue with prominent papillae (strawberry tongue).

Scarlet Fever Causes

Scarlet fever is caused by infection with exotoxin-producing group A beta-hemolytic streptococci (GABHS), notably Streptococcus pyogenes.

  • The release of a particular toxin is responsible for the characteristic scarlet-colored rash seen with scarlet fever (giving the disease its name).
  • In the majority of cases, scarlet fever occurs as a result of a pharyngeal streptococcal infection (strep throat), though it can less commonly occur as result of streptococcal infections at other sites, such as the skin.
  • It is estimated that scarlet fever develops in up to 10% of individuals who develop streptococcal pharyngitis.
  • Scarlet fever can occur at any time of the year, though it is more common during the winter and spring.
  • The streptococcal bacterium is typically spread via airborne respiratory droplets transmitted by infected individuals or by individuals who carry the bacteria but do not experience any symptoms (asymptomatic carriers).
  • Streptococcal infections can also be transmitted by coming in direct contact with infected secretions and rarely by food-borne outbreaks.
  • Transmission is enhanced in crowded environments in which individuals come in close contact with each other (for example, schools or day-care centers).

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Kasper, D.L., et al., eds. Harrison's Principles of Internal Medicine, 19th Ed. United States: McGraw-Hill Education, 2015.