How to spot if your child has scarlet fever and what to do about it

In the early 20th century, scarlet fever was one of the leading causes of infant death, sometimes wiping out an entire family’s children. Over 2,800 deaths were recorded at the height of the 1914 epidemic. 

One hundred years later, in 2014, fewer than 5 per cent of affected children were admitted to hospital, and none of them died of scarlet fever, thanks to modern medicine and hygiene standards. But cases are still surprisingly common today: over 8,000 cases have been confirmed in the 2023/24 season so far, with 1,011 of these in the first two weeks of 2024. 

Unfortunately, scarlet fever can still be serious – but thanks also to antibiotics it’s now less common and easier to treat, and the risk of complications is vastly reduced. 

Here’s how to spot and treat it, and how to tell the difference between scarlet fever and viruses such as measles and chickenpox.

What is scarlet fever?

“Unlike measles and chickenpox, which are caused by viruses, scarlet fever is caused by bacteria and primarily affects the throat and skin,” explains the GP Dr Thuva Amuthalingam. “These bacteria produce toxins that lead to scarlet fever symptoms including the distinctive rash. This feels like sandpaper and typically starts on the neck and chest, before spreading to other parts of the body.”

Although anyone can be affected, it’s most common in children aged between two and eight – and cases tend to rise through the winter months, peaking in April and May.

The signs and symptoms of scarlet fever

“The first signs of the illness can be flu-like symptoms, including a high temperature, a sore throat and swollen neck glands (a large lump on the side of your neck),” says Dr Colin Brown, the deputy director for clinical and emerging infections at UK Health Security Agency (UKHSA). “Within 12 to 48 hours, a rash appears as small, raised bumps. This usually starts on the chest and tummy, before spreading across the body. The rash does not appear on the face, but the cheeks can look red. Scarlet fever can also cause ‘strawberry tongue’, where a white coating appears on the tongue, which peels and leaves the tongue red, swollen and covered in little bumps.”

It’s important to be aware that the rash can look different, depending on skin tone. On white skin it tends to look pink or red. On brown or black skin it might not be so easy to see a change in colour but the skin will feel rough and you will be able to see raised bumps. The rash lasts for several days, and may then start to peel. This peeling process can continue for several weeks. 

How to tell the difference between scarlet fever, measles and chickenpox

“Unlike measles or chickenpox, scarlet fever usually does not present with respiratory symptoms like coughing or sneezing,” says Dr Amuthalingam. The rash and strawberry tongue are the telltale signs to look out for, as this is what typically distinguishes scarlet fever from other viruses.

What causes scarlet fever?

“Scarlet fever is caused by a bacteria called Group A streptococcus (group A strep),” explains Dr Colin Brown. 

The bacteria is very contagious and spreads from person to person very easily. You can catch it by breathing in droplets when an infected person coughs or sneezes, or from touching surfaces that an infected person has touched. After becoming infected, it takes between two and five days to develop symptoms. 

Diagnosis

A doctor can often diagnose scarlet fever simply by looking at the rash, throat and tongue. Sometimes they may also take a swab from the back of the throat in order to get a bacterial culture, and arrange a blood test. These will then be sent to the lab to confirm the diagnosis.

How is scarlet fever prevented?

The best way to prevent scarlet fever infections is to observe the good hygiene habits that we all adopted during the height of the Covid-19 pandemic. The most important step is to wash your hands regularly, particularly after coughing or sneezing, and before preparing food or eating. If this isn’t possible, using an alcohol-based hand sanitiser is the next best thing. 

The following tips will also help to prevent infections:

• Cover your mouth and nose with a tissue when you cough or sneeze.
• Put used tissues in the bin.
• If you don’t have a tissue, cough or sneeze into your upper sleeve or elbow.
• Keep rooms well ventilated.
• Thoroughly wash glasses, utensils, and plates after someone who is sick uses them. These items are safe for others to use once washed.

There’s some evidence that there have been fewer group A strep infections in areas of the country where all children have been offered the live attenuated influenza vaccine (LAIV) via a nasal spray. This is available to children from the age of two, via a GP, or through the school vaccination service. 

If you suspect that your child has scarlet fever, be aware that they can pass it on to someone else until 24 hours after their first dose of antibiotics. If they don’t take antibiotics, they could be contagious for two or three weeks after symptoms first start. It’s possible to get scarlet fever more than once, so having it doesn’t protect you from getting it again in the future. 

How should you treat scarlet fever

“Scarlet fever is treated with antibiotics, typically a penicillin,” says Dr Amuthalingam. “It’s important to complete the full course of antibiotics as prescribed by a doctor. While mild cases may be managed at home with rest and supportive care, it’s essential to consult a healthcare professional for proper diagnosis and treatment, especially in severe or complicated cases.” He adds: “Early identification and treatment of streptococcal infections in household contacts can help prevent the spread of scarlet fever.”

While the antibiotics take effect, most symptoms can be managed by drinking cool fluids, eating soft foods if you have a sore throat and taking painkillers like paracetamol to bring down a high temperature. Calamine lotion and antihistamine tablets can also be helpful to relieve itching. 

Complications of scarlet fever

Complications are rare, but they can happen during the height of the infection or for a few weeks afterward. These include ear infections, throat abscesses and sinusitis, along with more serious issues like pneumonia, meningitis and rheumatic fever. If left untreated, there’s also a risk that the bacteria which causes scarlet fever could spread to the heart, lungs and kidneys. 

The most serious complication is sepsis, caused by invasive group A strep (iGAS). Thankfully this is very rare, especially in children. There have been 919 cases of iGas reported in the 2023/24 season, 116 of which were in 2024, but the majority of these were in older age groups – particularly those aged 75 and over. 

According to Great Ormond Street Hospital, sometimes iGAS can cause scarlet fever, which is why it’s vital to seek treatment if you suspect your child has any of the telltale symptoms, and to stay vigilant for signs of complications.  

“If a parent thinks their child is getting worse, for instance, if they are feeding or eating less than normal, are dehydrated, have a high temperature that won’t go down, are very hot and sweaty or seem more tired or irritable than normal, then contact your GP or call NHS 111,” advises Dr Brown. “An ambulance should be called if their child has difficulty breathing, will not wake up, has a spotty, purple or red rash anywhere on their body that does not fade when you press a glass against it, or has a seizure for the first time. Parents should trust their instincts and always seek help if they notice worrying behaviour in their child.”

Dr Amuthalingam adds: “Prompt diagnosis and treatment can help prevent these complications.”