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Summary for primary care

Public Health Management of Scarlet Fever Outbreaks in Schools, Nurseries, and Other Childcare Settings

Latest Guidance Updates

03 April 2023: updated antibiotic treatment table to include clarithromycin as an option to treat non-pregnant adults and children aged 6 months to 17 years in the section, Recommended Actions.

24 January 2023: updated antibiotic prescribing table in the section, Recommended Actions, minor wording changes to signs and symptoms (rash development) in the Case Management section, and a new recommendation on household members with symptoms likely to be caused by group A streptococcus infection in the Recommended Actions section.

13 October 2022: new recommendation on treatment with antibiotics in the Recommended Actions section. In the full guideline, updates to appendices (not included in this summary).


This updated Guidelines summary covers the recommended actions to take in primary care to manage the increased incidence of scarlet fever cases in late 2022/early 2023, including complications of scarlet fever and how to manage them, and antibiotic treatment guidelines for scarlet fever in children and adults. For the complete set of recommendations, refer to the full guideline.

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  • Scarlet fever is a common childhood infection caused by Streptococcus pyogenes (also known as group A streptococcus [GAS]). These bacteria may be found on the skin, throat, and other sites where they can live without causing problems. Under some circumstances GAS can cause non-invasive infections such as pharyngitis, impetigo, and scarlet fever. On rare occasions they can cause severe disease, including streptococcal toxic shock syndrome, necrotising fasciitis, and septicaemia
  • Statutory notifications of scarlet fever, based on clinical symptoms consistent with this diagnosis, are submitted to local health protection teams.

Case Management

Signs and Symptoms

  • Symptoms can be nonspecific in early illness and may include:
    • sore throat
    • headache
    • fever
    • nausea
    • vomiting
  • Within 48 hours, a rash develops, typically first appearing on the chest and stomach, rapidly spreading to other parts of the body, giving the skin a sandpaper-like texture
  • On white skin the rash looks pink or red. On brown and black skin it might be harder to see a change in colour, but you can still feel the sandpaper-like texture of the rash and see the raised bumps
  • Patients typically have flushed cheeks and pallor around the mouth. This may be accompanied by a ‘strawberry tongue’
  • During convalescence, peeling of the skin may occur at the tips of fingers and toes and less often over wide areas of the trunk and limbs.


  • Although scarlet fever is usually a mild illness, some patients may require hospital admission to manage symptoms or complications. These include:
    • ear infection
    • throat abscess (quinsy)
    • cellulitis
    • pneumonia
    • sinusitis
    • meningitis
  • While such complications arise in the early stages, sequelae including acute glomerulonephritis and acute rheumatic fever can arise at a later stage
  • Prompt treatment with appropriate antibiotics significantly reduces the risk of complications
  • Clinicians should advise patients, or their parents/guardians, to be vigilant for any symptoms that might suggest these complications and to seek medical help immediately if concerned.
For recommendations on case definitions and notification and public health action, refer to the full guideline.

Good Practice for Clinicians Managing a Case of Scarlet Fever

  • Prescribe an appropriate treatment course of antibiotics
  • Advise exclusion from nursery, school, or work for at least 24 hours after the commencement of appropriate antibiotic treatment
  • Consider taking a throat swab to assist with differential diagnosis or if the patient is:
    • thought to be part of an outbreak to confirm aetiology
    • allergic to penicillin, to determine antimicrobial susceptibility. GAS can be resistant to non-penicillin options such as macrolides and clindamycin
    • in regular contact with vulnerable individuals (for example, healthcare workers) such as the immunocompromised, the comorbid, or those with compromised skin integrity. This will facilitate prompt public health action by differentiating the diagnosis from mimicking illnesses such as rubella and measles
  • If other household members present with symptoms likely to be caused by GAS infection (sore throat, mild fever, minor skin infection, [for example, impetigo]), consider clinical review, antibiotic treatment, and exclusion advice (as per scarlet fever)
  • Children or nursery/school staff who refuse treatment with antibiotics should be excluded until resolution of symptoms. Untreated infection increases risk of complications such as acute rheumatic fever, and can lead to long-term carriage. Healthcare staff and others in regular contact with vulnerable individuals who have not been treated should have a throat swab taken to ensure clearance of carriage
  • Further information on clinical management of scarlet fever can be found in the NICE Clinical Knowledge Summary on scarlet fever
  • Prescribe antibiotics without waiting for the culture result if scarlet fever is clinically suspected. Consult the British National Formulary for recommended doses.

Table 1: Antibiotic Treatment for Scarlet Fever

Patient GroupDrug Duration
First Line 
Child or adult Phenoxymethylpenicillin (penicillin V)10 days 
Second Line (Penicillin Allergy)
Birth to 6 monthsClarithromycin[A],[B] 10 days 
Non-pregnant adults and children 6 months to 17 yearsAzithromycin[A],[B] 5 days 
Non-pregnant adults and children 6 months to 17 yearsClarithromycin[A],[B]10 days
Pregnant or postpartum (within 28 days of childbirth) Erythromycin[A],[B] 10 days 
[A] Where susceptibilities are available, these should be reviewed to ensure the prescribed agent remains active. 

[B] Clinicians should check for potential significant interactions with other prescribed medications. 
  • Clinicians should be mindful of a potential increase in invasive GAS (iGAS) infection, which can follow trends in scarlet fever. It is important to maintain a high index of suspicion, especially in relevant patients (such as those with chickenpox and women in the puerperal period). Early recognition and prompt initiation of specific and supportive therapy for patients with iGAS infection can be lifesaving.