Approach

Management of scarlet fever involves treating the underlying group A streptococcus (GAS) infection, whether that is GAS pharyngitis or GAS skin or wound infection (e.g., impetigo, pyoderma, surgical wounds) and providing supportive care for symptomatic relief.[2][3]

The goals of treatment are to:[3]

  • Prevent rheumatic fever and suppurative complications (e.g., invasive GAS disease, pneumonia, sepsis, mastoiditis, peritonsillar/retropharyngeal abscess) as scarlet fever is typically a self-resolving illness.

  • Shorten the duration of symptoms and period of transmissibility.

Antibiotics

Treatment recommendations and availability of antibiotics varies across countries. Refer to your local protocol for specific guidance in your area. The following guidance is in line with guidance from the UK Health Security Agency (UKHSA).[25]

Prescribe antibiotics promptly to patients with suspected (presence of the triad of sore throat, fever and a scarlatiniform rash) or confirmed scarlet fever, regardless of the severity of illness. Prompt initiation of antibiotics significantly reduces the risk of complications such as rheumatic fever and invasive GAS infection.[25]​​

In the UK, test confirmation of GAS infection is not required before starting antibiotics. However, a throat swab for GAS culture may be considered in certain patients before starting treatment, but without waiting for the culture result if scarlet fever is clinically suspected.[25] In countries where rapid antigen detection tests for scarlet fever are available, a positive test result may be required before starting antibiotics. See Diagnosis.

Give phenoxymethylpenicillin to patients with no history of penicillin allergy:[2][3]​​​[25]​​​​​[48]

  • Oral phenoxymethylpenicillin for 10 days is the treatment of choice in children and adults.[2][3]​​​[25]​​​​[49][50] [ Cochrane Clinical Answers logo ]

For patients who are allergic to penicillin, give:[25]

  • Clarithromycin for 10 days: from birth to 6 months of age

  • Azithromycin for 5 days: from 6 months to adult (non-pregnant)​

  • Erythromycin for 10 days: in pregnant or postnatal (within 28 days of childbirth) women.

Have a low threshold for prompt referral to secondary care of any child presenting with persistent or worsening symptoms, particularly in regions in which an outbreak is ongoing.

There is evidence that shorter courses (i.e., 3-6 days) of oral antibiotics (including penicillins, macrolides, and cephalosporins) are as effective as a 10-day course of oral phenoxymethylpenicillin for treating children with acute GAS pharyngitis.[51] However, only a few studies reported rates of development of acute rheumatic fever and acute post-streptococcal glomerulonephritis, and conclusions could not be drawn regarding these complications.[51] A subsequent systematic review and meta-analysis of 50 randomised controlled trials of adults and children with acute GAS pharyngitis showed higher rates of treatment failure with shorter courses (≤5 days) of the recommended first-line antibiotics (mainly penicillin) compared with longer-courses (≥7 days).[49] A short-course of a macrolide was shown to be equally effective as a long-course of penicillin in terms of early clinical cure and bacterial eradication, whereas a short-course of a cephalosporin was more effective for achieving these outcomes than a long-course of penicillin. More patients in the short-course antibiotic therapy group (17.7%) developed moderate adverse events than those in the long-course antibiotic therapy group (12.3%). The study concluded that because macrolides and cephalosporins are considered critically important antimicrobials for human medicine by the World Health Organization and should be reserved when the first-line choice fails, long-course phenoxymethylpenicillin should remain as the first-line antibiotic for the management of patients with GAS pharyngitis.[49][52]

Supportive care

Advise patients to rest, drink plenty of fluids, and practise good hygiene measures to minimise the risk of cross-infection.[23][53]

Give analgesics/antipyretics to treat moderate to severe symptoms of acute pharyngitis such as sore throat, headache, and fever. Paracetamol and ibuprofen are appropriate options.[2][23]

In practice, consider:

  • Oral antihistamines (e.g., diphenhydramine, loratadine, cetirizine) or over-the-counter topical emollient ointments and thick creams for patients with significant pruritus associated with the scarlatiniform rash.

  • Advising patients with pyoderma (impetigo) to keep the infected area clean and protected with dressings. Twice-daily washing with soap and water is good general skin care. In severe cases, debridement of the infected skin may be required.

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