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Scarlet Fever

Updated: Jun 28, 2022

Scarlet fever is a nonsuppurative complication of group A streptococcal infection. While it usually occurs following a throat infection, a minority of cases result from a skin infection.


Scarlet fever usually begins with fever, sore throat, and systemic symptoms (e.g., nausea, vomiting, malaise). The patient may also complain of headache, abdominal and myalgias. A characteristic rash with diffuse erythema and small papular elevations usually appears within 48 hours of illness onset. The patient may also develop a bright red tongue with prominent papillae (a.k.a., strawberry tongue). Resolution of the rash is followed by desquamation of the skin.


  • The strawberry tongue is NOT pathognomonic; it can occur in other conditions as well (e.g., Kawasaki disease, toxic shock syndrome, multisystem inflammatory syndrome in children).

Images from patients with scarlet fever

Rash characteristics

Diffuse erythema that blanches with pressure

Most marked in the skin folds, where Pastia lines (i.e., confluent petechia) may appear

Numerous small papular elevations give a sandpaper quality on palpation

Visually likened to a boiled lobtser or a bad sunburn

Circumoral pallor

​The palms and soles are usually spared


The diagnosis is made clinically. Microbiologic testing (e.g., throat culture, rapid antigen detection test) can confirm infection with group A streptococcus.


Treatment is the same as for a streptococcal throat infection; antibiotics must target Streptococcus pyogenes. Twenty-four hours after the child begins taking antibiotics, they may return to school or daycare without posing a risk to the other children.


  • The rash does NOT need to be treated separately.

Recommended Reading

Video Lectures


  1. Wessels MR. Pharyngitis and Scarlet Fever. 2016 Feb 10 [Updated 2016 Mar 25]. In: Ferretti JJ, Stevens DL, Fischetti VA, editors. Streptococcus pyogenes : Basic Biology to Clinical Manifestations [Internet]. Oklahoma City (OK): University of Oklahoma Health Sciences Center; 2016-. Available from:

  2. Basetti S, Hodgson J, Rawson TM, Majeed A. Scarlet fever: a guide for general practitioners. London J Prim Care (Abingdon). 2017;9(5):77-79. Published 2017 Aug 11. doi:10.1080/17571472.2017.1365677

  3. Kliegman, Robert. Nelson Textbook of Pediatrics. Edition 21. Philadelphia, PA: Elsevier, 2020.

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