Clinical child health

Managing scarlet fever

in children
S
Scarlet fever is a carlet fever is a common infectious
disease affecting 2000–4000 children
notifiable disease in under 10 years old each year in the UK
(Public Health England (PHE), 2014a). It is
the UK. Deborah the causative factor in up to 30% of sore
Duncan provides an throats in children under the age of ten
(Bisno, 1996). Scarlet fever is also known as
overview of the ‘scarlatina’ and is commonly caused by the
bacteria Streptococcus pyogenes, a group A
signs, symptoms Streptococcus (PHE, 2014a). There are also
and management of rare forms of scarlet fever caused by group C
or G Streptococci (Iurian et al, 2012).
the disease Group A Streptococcus are found in the
throat or on the skin and generally cause no
concern for the host (James et al, 1960). They
are transmitted by the aerosol route, but may
also be spread by direct skin contact. There
have also been some reports of food-borne
infections (Yang et al, 2007; Dong et al,
2008). The exotoxin-mediated group A strep-
tococcal (GAS) infections may cause localized
skin disorders, such as impetigo. GAS can,
however, develop into streptococcal toxic
shock syndrome or invasive GAS infection
(PHE, 2014d). Patients can have genetic fac-
tors that cause them to be susceptible to this
infection, particularly in its invasive form
(Chapman and Hill, 2012; Parks et al, 2012).
It is important for practice nurses to recog-
nise the signs and symptoms of scarlet fever,
particularly due to the increased incidence of
the disease in 2014. This article will provide
information on diagnosis and management of
the disease.
Routine national surveillance data
Scarlet fever is a notifiable disease under the
Health Protection (Notification) Regulations
2010 (PHE, 2010). The statutory notifica-
tions of scarlet fever can be made based on
Deborah Duncan, tutor, King’s College clinical symptoms identified by the nurse or
London GP. Routine national surveillance data is col-
lected for both invasive and non-invasive
Submitted 16 July 2014; accepted for GAS infections (PHE, 2014b).
publication following peer review PHE is involved in the recording of out-
that there are regular four yearly peaks in the
incidence of disease (Lamagini et al, 2005). In
the last decade there has also been an overall
rise in cases in those under 5 years old
(Lamagni et al, 2005; PHE, 2010).
The 2013–14 scarlet fever season had
13 183 notifications, the highest for a quarter
of a century (PHE, 2014c). It is therefore
important to be able to identify the pattern of
disease to predict the services that will be
needed in the future to treat it. There has
been a lot of interest in the rise of the disease
in the media (Bennett, 2014; Metcalfe, 2014).
Signs and symptoms
Scarlet fever is difficult to identify in the early
stages of the illness. The symptoms are non-
specific and can include sore throat, headache,
fever, nausea and vomiting. The rash does not
manifest itself until 12–48 hours after the ini-
tial symptoms. The characteristic red pinhead
rash is what the disease derives its name from.
It appears first on the chest and abdomen, and
then spreads to the rest of the body. On darkly
pigmented skin, the rash may not be easily
seen. However, the skin develops a sandpaper-
like texture, which can be felt on all skin types.
The skin can then peel after the acute period,
on about day 6 (PHE, 2014a).
Often parents present at the surgery with
their children who have flushed cheeks and
pallor around the mouth. They may also have
a ‘strawberry-like tongue’.
Late complications
If scarlet fever is not treated with the appropri-
ate antibiotics patients can go on to develop
late complications. The erythrogenic toxin is
produced by the Streptococcus pyogenes bacte-
ria. The toxin is released into the host’s blood-
stream when the bacteria are broken down by
specific bacteriophages. Other significant con-
ditions can develop as the toxins permeate the
bloodstream. These include quinsy, lower respi-
ratory tract infection, meningitis, acute glomer-
© 2015 MA Healthcare Ltd

10 February 2015
Key words: scarlet fever, anti-bacterial
agents, Streptococcus pyogenes, disease
outbreaks
breaks and the monitoring of the characteris-
tics of strains of the disease. Cyclic patterns
have been identified since 1889 when house-
holds notified their local medical officers
(Lamagini et al, 2005). These patterns show
ulonephritis, endocarditis and acute rheumatic
fever. Although antibiotics are effective for the
list of conditions above, there is debate as to
whether they can also prevent post-streptococ-
cal glomerulonephritis (Johnston et al, 1999).

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 Clinical child health

Examination findings pyrexia and systemic toxicity, the dose can be

The child may present with commonly occur-
ring symptoms. On examination they may
have a low grade fever or a temperature of
38°C or above. They can have enlarged cervi-
cal or axillae glands.
On examination the throat often appears
red and painful. The tonsils and back of the
throat can be inflamed. In the early stages of
the infection there may be a whitish coating
or pockets of pus in the tonsil area. However,
pharyngitis is uncommon in children under
the age of five (Nussinovitch et al, 1999).
The rash is the distinctive feature of the dis-
ease, although the causative factor is known in
only 50% of childhood rashes (Ramsay et al,
2012; PHE, 2014a). It is, therefore, important
to know the time-frame and pattern of the
disease. It is important to consider other causes
of rashes when examining a patient (Table 1).
The rash in scarlet fever is the identifiable
feature, as it usually appears first on the neck
and face leaving a paler area around the
mouth. It then spreads to the chest and trunk,
eventually affecting the creases in the groin and
axillae. The rash forms classic red streaks
known as Pastia lines. On non-Caucasian skin
these lines are darker than the rest of the skin.
The rash pales when compressed and then
fades by day 6 when it can also
Table 1. Other causes of rashes peel.
Localized rashes
Infection Site of rash Management
Erythema infectiosum Cheeks
Most mild cases of scarlet fever
will clear up on their own.
Hand, foot and mouth Hands, feet, perioral and
disease buccal cavity However, the patient can be infec-
tious for up to 2 weeks post-infec-
Herpes simplex Lips, mouth, genitals
tion. Parents are therefore encour-
Lyme disease. Around the bite
aged to see a clinician to identify
Psittacosis Face risk and reduce disease spread.
Pityriasis rosea Mainly trunk An appropriate treatment course
Exanthem Axilla and outer abdomen of antibiotics needs to be pre-
Generalized rashes scribed. Patients need to be advised
Infection Presentation about completing the full 10-day
Adenovirus Petechial/purpuric rash course to ensure complete eradica-
tion of the bacteria from the throat.
Chickenpox Vesicular rash
It is advisable to adhere to local
Other associated problems,
e.g. respiratory symptoms guidelines when prescribing.
Drug interaction
First-line treatment is usually
phenoxymethylpenicillin (penicil-
Meningococcal septicaemia Petechial rash
lin V) to be taken four times a day
Leukaemia Petechial/purpuric rash for 10 days. Erythromycin four
doubled. A second-line antibiotic, such as a
cephalosporin, may also be considered.
Sulfonamides and trimethoprim-sulfamethoxa-
zole should not be used for the treatment of
scarlet fever as they do not eradicate the bacte-
ria in patients with acute pharyngitis (Coonan
and Kaplan, 1994; Gerber, 1995).
Other medication to be considered includes
the use of an analgesic and/or antipyretic
agent such as paracetamol or a non-steroidal
anti-inflammatory drug.
Advice about reducing spread of the disease
should also be given. This includes supportive
measures for hand washing at the nursery or
school of the infected patient. Advice about
coughing and sneezing can also be given and
all open cuts or grazes should be covered. The
patient will need to be excluded from nursery,
school or work for 24 hours after the com-
mencement of appropriate antibiotic treat-
ment. PHE (2014) advises this is given in a
letter to parents from the school or nursery.
Finally, one should also consider the confir-
mation of differential diagnosis by using a
throat swab if there is clinical uncertainty.
This is also required during an outbreak of
scarlet fever.
During an outbreak
During an outbreak of scarlet fever there
needs to be an initial risk assessment to con-
firm the aetiology of the bacterial cause of the
outbreak. This decision is based on the clini-
cal presentation and throat swabs of the first
five cases. PHE suggest an initial risk assess-
ment and notification take place within 24
hours of the first suspected case (PHE,
2014d). The risk of spread also needs to be
reviewed and is based on the number of cases,
age, class and year group of the cohort and
the common denominator. The risk assess-
ment of severe cases also needs to consider
the risk of complications, hospitalizations,
and co-morbidity such as the presence of
other infectious diseases like chickenpox
(Shulman et al, 2012; PHE, 2014d).
Future research
In June 2014 the STREP GENE study was
announced to look at the genetic susceptibility
individuals have to severe streptococcal infec-
© 2015 MA Healthcare Ltd

Measles Other associated problems, times a day or clarithromycin tions with a particular interest in S. pyogenes
e.g. cough, conjunctivitis
twice a day can be prescribed in (Oxford University, Public Health England and
Rubella patients with a penicillin allergy. In Imperial College London, 2014). There is a real
Roseola infantum High fever that dispels the instance of a severe infection, interest in this area as more infections become
when rash appears which can be characterized by high resistant to our commonly used antibiotics.

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 Conclusions
With the increase in antibiotic resistance,
increased spread of disease and its potentially
life-threatening complications, scarlet fever is
still a disease that practice nurses need to be
aware of.
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CALL FOR PAPERS
Do you have a research, education or clinical issue you would
interested in writing on topics of importance to nurses
© 2015 MA Healthcare Ltd
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Practice Nursing 2015, Vol 26, No 3 123
Metcalfe L (2014) Scarlet fever at a 32-year high: How
to prevent your child joining the rash of cases.
Express. http://tinyurl.com/qf2k45e (accessed 9
Key Points
February 2015)
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Group A beta-hemolytic streptococcal pharyngitis in ➤➤ The 2013–14 scarlet
preschool children aged 3 months to 5 years. Clin fever season had the
Pediatr (Phila) 38: 357–60
highest notifications of
Oxford University, Public Health England, Imperial
College London (2014) Strep Gene. http://strep.
the disease for a
nsms.ox.ac.uk/ (accessed 9 February 2015) quarter of a century
Parks T, Hill AVS, Chapman SJ (2012) The perpetual
challenge of infectious diseases. N Engl J Med 367: ➤➤ Scarlet fever is a
90–0. doi: 10.1056/NEJMc1204960#SA2 notifiable disease
Public Health England (2010) Health protection regula-
tions 2010. http://tinyurl.com/qxk4u42 (accessed 9 ➤➤ It is caused by
February 2015)
Streptococcus pyogenes
Public Health England (2014a) Scarlet fever frequently
asked questions. http://tinyurl.com/p8jagfp (accessed ➤➤ Scarlet fever is difficult
9 February 2015)
to diagnose in the early
Public Health England (2014b) Scarlet fever levels show
a decline across England. http://tinyurl.com/ntk6utd stages of the disease
(accessed 9 February 2015)
Public Health England (2014c) Health Protection Report.
➤➤ There are significant late
Volume 8 Number 44. http://tinyurl.com/paxkhht complications if this
(accessed 9 February 2015) disease is not treated
Public Health England (2014d) Interim guidelines for the appropriately
public health management of scarlet fever outbreaks
in schools, nurseries and other childcare settings.
http://tinyurl.com/qxw2qww (accessed 9 February
2015)
Ramsay M, Reacher M, O’Flynne C (2002) Causes of
morbilliform rash in a highly immunised English
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practice guideline for the diagnosis and manage-
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