Scarlet fever in children: the sandpaper rash, antibiotics and the 24-hour rule

Scarlet fever is a bacterial illness that mainly affects children and causes a distinctive pink-red rash. NHS inform says it usually follows a sore throat or a skin infection such as impetigo caused by particular strains of Streptococcus. Most cases are in children under 10, usually aged 2 to 8, though people of any age can get it. Outbreaks can happen in nurseries and schools where children are in close contact.

Symptoms of the illness develop only in people susceptible to toxins produced by the bacteria, and NHS inform says most children over 10 have developed immunity to those toxins. It is possible to have scarlet fever more than once but this is rare.

The NHS says the first signs can be flu-like: a high temperature, sore throat and swollen neck glands. A rash appears 12 to 48 hours later as small raised bumps, beginning on the chest and tummy and then spreading. The skin feels rough, like sandpaper. NHS inform says the rash looks like sunburn and may be itchy, usually starts on the chest and stomach and spreads to ears, neck, elbows, inner thighs and groin.

The rash does not usually spread to the face, but the cheeks look flushed and the area around the mouth stays quite pale. On darker skin the colour can be harder to see, though the rough texture should be apparent. The rash turns white when a glass is pressed on it. A white coating on the tongue peels after a few days, leaving a red, swollen, bumpy tongue, known as strawberry tongue. The rash usually fades after about a week, and the skin on hands and feet may peel for several weeks afterwards.

The NHS says GPs can often diagnose scarlet fever by looking at the tongue and rash, and sometimes wipe a cotton bud around the back of the throat to test for bacteria or arrange a blood test. Because it spreads very easily, the NHS advises checking with the GP before going in, as they may suggest a phone consultation.

A GP will prescribe antibiotics. The NHS says these help you get better quicker, reduce the chance of a serious illness such as pneumonia and make it less likely you pass the infection on. NHS inform says the usual treatment is a 10-day course, often penicillin or amoxicillin, with liquid for young children and erythromycin as an example alternative for penicillin allergy. Symptoms usually improve within 24 hours of starting. The whole course should be finished even if the child feels better.

While antibiotics are being taken, the NHS suggests:

• drinking cool fluids

• soft foods if the throat is sore

• paracetamol to bring down a high temperature (no aspirin for children under 16)

• calamine lotion or antihistamine tablets for itching

The NHS says complications are rare, can happen during or in the weeks after the infection, and include ear infection, throat abscess, sinusitis, pneumonia, meningitis and rheumatic fever. NHS inform adds that very rare later complications include bloodstream infection, septic arthritis, necrotising fasciitis and streptococcal toxic shock syndrome.

NHS inform says to contact the GP practice urgently if, in the first few weeks after the main infection has cleared, a person develops feeling very unwell, severe pain, severe headaches, vomiting or diarrhoea, and to phone 111 if the practice is closed. The NHS says to see a GP if a child does not get better in a week after seeing a GP, has scarlet fever and chickenpox at the same time, or is ill again weeks after scarlet fever got better.

UKHSA lists scarlet fever as requiring people to stay away from the setting until 24 hours after they started antibiotics, and asks settings to contact their local health protection team if scarlet fever, chickenpox or flu are circulating in the same group at the same time. The NHS says the same 24 hours applies to nursery, school or work.

The bacteria spread in airborne droplets, through touching the skin of someone with a streptococcal skin infection such as impetigo, and through shared towels, baths, clothes or bed linen. NHS inform says it can also be caught from people who carry the bacteria without symptoms. There is no vaccine. The NHS advises handwashing, tissues for coughs and sneezes and not sharing cutlery, cups, towels, clothes, bedding or baths.

Both the NHS and NHS inform say there is no evidence that scarlet fever in pregnancy harms the baby, though it can make you feel unwell. The NHS suggests avoiding close contact with anyone who has it and contacting a GP if symptoms develop, noting that many antibiotics used can be taken in pregnancy. NHS inform says to tell doctors and midwives if you are heavily pregnant and have been in contact.