Typically, scarlet fever is associated with an acute pharyngitis. As a result, fever, sore throat, pain with swallowing, and cervical adenopathy is present. If there is no pharyngitis, the source of infection can be a wound or burn which is infected with GAS. The two vectors of infection can both cause scarlet fever and are not distinguishable from one another. The rash itself is a blanching, papular rash. It is distinguished from the macular rash found an allergic reaction by its insidious emergence and lack of confluence of the lesions. This lack of confluence is the primary reason it feels like sandpaper. Also of note, there are no vesicles or pustules present. Vesicles are more associated with the “dew on a rose petal” appearance of chicken pox in its initial stages. Pustules are more indicative of a local infection such as impetigo or erysipelas. The rash develops within 2 to 3 days after infection but can be delayed up to 7 days. The trunk, underarms, and groin are affected first, and then it spreads to the extremities. Usually, the palms and soles are spared. The circumoral area is also spared, making it pallor-like. The “strawberry tongue” begins with a white coating of the tongue with hyperplastic papillae. As the white coating resolves, the papules remain, giving the appearance of a strawberry. Pastia lines are found in the folds of the skin such as the neck, antecubital fossa, and groin. This appears as a linear accumulation of papules around pressure points. After the initial rash begins to resolve, a period of desquamation can occur and last up to two weeks in some cases. 

When evaluating a person suspected of having scarlet fever, there are several things to consider. After carefully taking a history and physical, the next steps of the evaluation can be considered. In cases associated with pharyngitis, lack of a cough, exudates, cervical nodes, temperature, and age (less than 15 years) help determine the likelihood of strep throat. This is known as the CENTOR criterion.[7][8][9]

Testing available to the clinician includes throat culture and the rapid strep test. Both test for the presence of GAS. The throat culture takes longer (days) and is more specific, and the rapid test is immediate (minutes) and less specific. The use of the rapid strep test with older persons (greater than 45 years) is controversial since they are more likely to be a carrier state and have lower prevalence in that age group. This combination may increase exposure to inappropriate antibiotics and increased resistance.

Therefore, in young patients with a high CENTOR score, rapid strep is recommended to confirm the infection and treatment is initiated. Depending on your practice environment and follow up, your decision to treat may be influenced. 

Since scarlet fever is due to an infection caused by GAS, it is treated with antibiotics. Penicillin or amoxicillin is the first-line treatment. If the affected person has an allergy to penicillin, a first-generation cephalosporin can be used. The use of antibiotics has reduced the morbidity and mortality of scarlet fever when compared to the early 20th century when the mortality was approximately 30%. [10][11][12]

GAS has its reservoir in the nasal mucosa, adenoids, tonsils. Asymptomatic individuals who test positive for GAS are generally referred to as carriers. Current practice deters treatment of carriers with antibiotics.

The differential diagnosis of a fever and a rash are broad. In the clinical scenario of a sandpaper rash in the presence of a sore throat and fever, GAS infection should be seriously considered. Use of the CENTOR criteria and testing can be utilized. Pustules are more indicative of a local infection such as impetigo or erysipelas. Some viral illnesses which should be considered in the affected population are measles (rubeola), chicken pox (herpes zoster), and hand-foot-and-mouth disease (Coxsackie), which all have specific presentations that distinguish them from scarlet fever. Good immunization, travel, and medical history should be considered when a patient presents with fever and a rash.

When compared to the prognosis of scarlet fever in the early 20 century, the prognosis of scarlet fever is excellent. This mainly due to the introduction of antibiotics and hygiene. After the diagnosis is made and treatment is initiated, the patient can return to normal activity 24 hours after the fever has resolved. Left untreated, the prognosis decreases and the likelihood of complications stemming from group A strep infection increases. Suppurative and non-suppurative complications abscess near the local area of infection to kidney injury.

Historically, scarlet fever was a disease with a high complication rate and even death among children. With the development of antibiotics and treatment regimens, scarlet fever is now considered a relatively mild disease. However, complications from delayed or untreated GAS are significant. The complications fall into two categories, suppurative and non-suppurative. Typically, suppurative complications result from a worsening, an extension, or a spread of the original area of infection. As an example, a bacterial pharyngitis can spread to the ear, causing otitis media; the sinuses, causing a sinusitis; and then to the meninges, causing bacterial meningitis. Non-suppurative complications generally are mediated through an immune response after the original infection resolves. Rheumatic fever, a disease affecting the heart valves, is a complication of GAS infection that results in long-term morbidity.

Although not directly caused by scarlet fever, below is a partial list of complications due to GAS infection.

Suppurative

• Peritonsillar/pharyngeal abscess
• Otitis media
• Sinusitis
• Necrotizing fasciitis
• Streptococcal bacteremia
• Meningitis or brain abscess
• Jugular vein septic thrombophlebitis 

Non-Suppurative

• Acute rheumatic fever
• Poststreptococcal reactive arthritis
• Streptococcal toxic shock syndrome
• Acute glomerulonephritis
• Pediatric autoimmune neuropsychiatric disorder associated with group A streptococci

Scarlet fever and most diseases which are transmitted via close contact can be avoided by using good hand hygiene, covering your coughs and sneezes, regular disinfection of shared fomites, and avoiding others when infected. Reminders in public areas in the form of posters and public service announcements in the media are some of the ways to increase these good hygiene practices. The public also should be aware of the risks associated with the overuse of antibiotic administration which may introduce resistant strains of GAS. 

Scarlet fever is best managed by an interprofessional team. The key to treatment is patient education. The pharmacist should emphasize to the patient that full recovery occurs when antibiotic compliance is complete. In addition, the nurse should educate the patient on hand and personal hygiene to prevent transmission of the bacteria to others. Patients should be educated about the skin infection and the general exfoliation, and when to seek medical assistance. The skin symptoms are frequently relieved with the use of emollients and oral antihistamines.[13][14] (Level V)

Outcomes

For the majority of patients treated promptly, the outcome is excellent. Recovery is usually complete in 3-6 days but the skin symptoms may take 14-21 days to subside. In a few people, the infection can recur. In the era of antibiotics, mortality from scarlet fever is less than 1%. The morbidity of scarlet fever is most likely due to glomerulonephritis, rheumatic fever, sinusitis, and other infections. Complications, though, are rare.[15][2] (Level V)