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

Give penicillin or amoxicillin to patients with microbiologically confirmed GAS infection and no history of penicillin allergy.[2][3][42]

  • Scarlet fever should not be treated with antibiotics on clinical suspicion alone. Antibiotics should be given only to patients with clinical features or risk factors for scarlet fever and microbiologically confirmed GAS infection (i.e., a positive rapid antigen test, polymerase chain reaction test, or throat/skin swab culture).[2][3] See Diagnosis.

  • Oral penicillin V for 10 days is the treatment of choice in children and adults.[2][3][10][43][44] [ Cochrane Clinical Answers logo ] Oral amoxicillin may be substituted in young children, as its taste is more palatable than that of penicillin V.[42]

  • For patients who are unable to complete a 10-day course of oral antibiotics, a single intramuscular dose of penicillin G benzathine can be given.[2][3][10]

Give a 10-day course of a first-generation cephalosporin (e.g., cephalexin, cefadroxil) to patients with microbiologically confirmed GAS infection and a history of nonanaphylactic penicillin allergy.[2][3][10] Shorter duration of cephalosporin treatment (5 days) may be considered when used in this setting.[43]

  • True penicillin allergy is rare and occurs in less than around 1% of the population.[45]

Give clindamycin or a macrolide (azithromycin or clarithromycin) to patients with true penicillin allergy (i.e., type 1 immediate hypersensitivity/anaphylaxis). A 10-day course is recommended for clindamycin and clarithromycin, and a 5-day course is recommended for azithromycin.[2][3]

  • These are preferred agents; however, there is some evidence of antibiotic resistance (5% to 20%) and increased rates of treatment failure with clindamycin and macrolides.[3][46] Test for macrolide resistance by taking a throat swab for culture if these medications are required for patients with true penicillin allergy.[3] CDC: antibiotic use and stewardship Opens in new window

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 penicillin V for treating children with acute GAS pharyngitis.[47] However, only a few studies reported rates of development of acute rheumatic fever and acute poststreptococcal glomerulonephritis, and conclusions could not be drawn regarding these complications.[47] A subsequent systematic review and meta-analysis of 50 randomized 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).[43] 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 for when the first-line choice fails, long-course penicillin V should remain as the first-line antibiotic for the management of patients with GAS pharyngitis.[43][48]

Supportive care

Advise patients to rest, drink plenty of fluids, and practice good hygiene measures to minimize the risk of cross-infection.[49]

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

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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