Scarlet fever
Consultation guide for UK community pharmacy: clinical features, referral criteria, time frame to resolution and management strategy.
Clinical features
- Sore throat, headache, fever, nausea and vomiting are often the first symptoms
- After 12 to 48 hours a characteristic fine red rash develops which feels like sandpaper to the touch. It typically appears first on the chest and stomach and spreads rapidly to other parts of the body. On more darkly-pigmented skin the rash may be harder to see, although the ‘sandpaper’ feel should still be present
- A white coating on the tongue which peels after a few days, leaving the tongue looking red and swollen (‘strawberry tongue’)
- A flushed red face, but pale around the mouth (circumoral pallor). On more darkly-pigmented skin the face may look more ‘sunburnt’
- Swollen glands in the neck
- As the rash fades, skin peels on the fingertips, toes and groin area
- Most common in young children. NB: scarlet fever is a notifiable disease and requires prompt referral for antibiotic treatment — see Referral criteria (source: UKHSA scarlet fever factsheet)
Referral criteria
- All suspected cases of scarlet fever require prompt referral — it is not an OTC-managed condition. It is treated with a course of antibiotics and is a notifiable disease. The criteria below identify those needing especially urgent assessment
- People who are immunocompromised or have pre-existing valvular heart disease
- Those are at increased risk of developing invasive infection or complications (people with diabetes mellitus, injecting drug users, those who are alcohol dependent, those with skin lesions or breakdown, people at the extremes of age and postpartum women, those with an underlying malignancy, concurrent chickenpox or influenza)
- Those who have suspected complications of scarlet fever such as necrotizing fasciitis, streptococcal toxic shock syndrome, acute rheumatic fever, glomerulonephritis, pneumonia, meningitis, endocarditis and osteomyelitis
Time frame to resolution
- The incubation period is usually 2 to 5 days, but may be as short as 1 day or as long as 7 days. Once antibacterial therapy is initiated, the patient’s symptoms should improve in around 3-5 days but the rash can linger for several weeks. If symptoms worsen or have not improved after 7 days, it may be prudent to refer
Management strategy
Non-pharmacological advice
- Advise the patient to contact their health centre (medical practice) to be diagnosed and to seek guidance as to whether exclusion from work, school or nursery is necessary (and it is a notifiable disease). NB: The NHS mentions exclusion for at least 24 hours after starting appropriate antibiotic treatment
- Infection control measures: it is transmitted when a person's mouth, throat, or nose comes into contact with infected saliva or mucus or by aerosol transmission. People should wash their hands often, avoid sharing utensils and towels, and dispose of used tissues promptly. Avoid coming into contact with people at high risk of developing complications of scarlet fever (see under Referral criteria)
- Ensure adequate fluid intake (particularly if a fever is present) and rest
- Clean and cover any skin breaks (such as bites, cuts and wounds)
Pharmacological advice
- It should be treated promptly with antibiotics (to prevent complications) and therefore referral to get these prescribed is necessary
- Paracetamol or ibuprofen for symptomatic relief of pain and/or pyrexia