Sudden red spots – what lies behind them?

What is scarlet fever?

Scarlet fever is a common bacterial infection that especially affects children. It is caused by group A streptococci, bacteria that mainly settle in the mouth and throat.

Under normal circumstances they cause no problems, but when these bacteria produce certain toxins, a disease can develop marked by inflammation, fever and characteristic skin redness. These toxins increase the permeability of blood vessels, which helps explain the typical symptoms of the illness.

Interestingly, there are different variants of the toxins produced by streptococci. Because of this variety it is possible that a person can get scarlet fever more than once, since the body develops immunity only to the specific toxin responsible for each episode.

Scarlet fever: what symptoms are typical?

Scarlet fever typically appears one to three days after exposure with a range of symptoms that mainly affect the throat, the skin and the general condition. The most common initial signs are severe sore throat, with pain on swallowing, and fever, often accompanied by chills. A marked fatigue may also occur.

In younger children, abdominal pain and sometimes nausea with vomiting often form part of the clinical picture. Swollen tonsils and enlarged lymph nodes in the neck area are also common, indicating the body’s active immune response to the infection.

A characteristic symptom of scarlet fever is the so-called “strawberry tongue”. It starts with a white coating that after a few days changes to a bright red appearance. Around two days after the first symptoms a skin rash usually develops, consisting of many small spots that are initially pink and later intensely red. These spots are often rough and feel similar to sandpaper. The rash usually begins on the torso and spreads over a few days to the neck, hands and feet, typically sparing areas such as the mouth‑chin triangle, the palms and the soles.

Particularly notable is the redness of the cheeks, which contrasts with the paler skin around the mouth. While the rash slowly fades after about a week, a skin peeling is often seen in the following weeks, especially on the palms, fingertips, soles and tips of the toes. Depending on the person, these symptoms can be mild and barely troublesome or severe, with intense malaise, sore throat, high fever and a very visible rash.

How is scarlet fever transmitted?

Scarlet fever is caused by group A streptococci which are present in large numbers in the throat of affected people during the acute illness. These pathogens spread mainly through tiny droplets released when talking, coughing or sneezing. If others inhale these infectious droplets, the bacteria can enter their body and cause infection. This makes scarlet fever easy to transmit and explains why it often occurs in communal settings such as schools or day care centres.

The risk of infection is higher especially in the colder months, when many people gather indoors and respiratory infections are more common. Even when a person shows no obvious symptoms, the bacteria can already be transmitted.

Besides airborne transmission, contact with contaminated secretions also plays a role: touching a contaminated object and then touching the mouth or nose can also lead to infection. Less commonly, the disease is spread through contaminated food or water. 

How long is scarlet fever contagious?

For scarlet fever, the duration of contagiousness depends largely on whether antibiotic treatment is given. Without treatment, the risk of infection persists for up to three weeks, as the bacteria can continue to be spread during this time. Once antibiotic therapy is started, the risk of passing the infection to others is already significantly reduced after about 24 hours.

To shorten the contagious period and prevent the spread of the disease it is important to take the medication exactly as prescribed. Generally children with scarlet fever may return to kindergarten or school after two days of treatment, as they are then no longer contagious.

Is scarlet fever dangerous?

Scarlet fever is one of those infections for which a medical assessment is advisable, because without targeted treatment it can lead to complications. Although the illness is often mild, without appropriate therapy there is a risk that the bacteria spread in the body and cause inflammation in various organs and tissues. Timely use of antibiotics relieves symptoms, prevents worsening of the infection and stops transmission to others.

In very rare cases scarlet fever can lead to serious health problems beyond the usual course of the illness. These include, besides purulent tonsillitis, lung or middle ear infections and inflammatory reactions in joints and the heart caused by an excessive immune response.

Particularly critical are cases in which bacteria enter the bloodstream and trigger a life‑threatening blood infection (sepsis) or a toxic shock syndrome. Such complications are rare but require immediate medical treatment. 

What to do about scarlet fever: effective tips

• It is important to keep the body well hydrated when someone has scarlet fever. Especially with fever, water, diluted fruit juices or herbal teas, for example linden flower tea sweetened with a little honey, are recommended. This helps prevent dehydration and supports recovery.
• Soft or liquid foods such as soups, purees or yoghurt are particularly helpful if swallowing is painful, as they do not further irritate the throat. Opt for low‑salt and moderate‑protein foods to avoid overloading the digestive system.
• Bed rest is an essential part of recovery, particularly if you have a fever. Rest gives the body the opportunity to fight the infection effectively and to relieve symptoms more quickly.
• During the first two days of antibiotic treatment you should avoid contact with others as much as possible to prevent spreading the bacteria. This protects the people around you.
• When coughing or sneezing, keep your distance from others, turn away and avoid handshakes or direct contact. Use disposable tissues or the crook of your arm to cover your coughs and sneezes.
• Dispose of used tissues promptly in a bin with a lid to avoid contaminating surfaces or other people.
• Regular and thorough hand washing with soap is one of the most effective measures to limit the spread of infection. Wash your hands especially after coughing, sneezing or blowing your nose.
• Avoid sharing items such as drinking glasses, cutlery, towels or toys during the illness to reduce the risk of bacterial transmission.
• If you have a sore throat, gargling with herbal solutions such as sage or marshmallow can provide relief. Warm compresses around the neck may also help reduce pain and inflammation.
• Antibiotics can disturb the balance of gut flora. To counteract this, include yoghurt or other probiotic foods in your diet during and after treatment. Make sure to take them at a different time than the antibiotic.
• Regular ventilation at home can also help reduce the concentration of pathogens in the air. Ensure fresh air several times a day to support recovery.
• Change the bedding, towels and clothing of the sick person frequently and wash them at at least 60 °C to effectively kill germs.
• Follow your doctor's instructions precisely and do not stop antibiotics on your own, even if symptoms improve quickly. Only in this way can recovery be completed safely and the risk of complications minimised.

Thanks to targeted antibiotic treatment, scarlet fever is now well treatable and has largely lost its former scare. For an uncomplicated course it is however essential to recognise the symptoms early and to consult a doctor promptly.