What is the treatment for strep rash associated with Scarlet Fever?

Treatment of Strep Rash in Scarlet Fever

Penicillin V or amoxicillin for 10 days is the first-line treatment for scarlet fever rash caused by Group A Streptococcal infection. 1

First-line Treatment Options

• Amoxicillin:

  • Preferred option due to better taste and convenient dosing
  • Dosage: 50 mg/kg once daily (maximum 1000 mg) or 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days 1
  • Once-daily dosing has been shown to be as effective as multiple daily doses, which may improve compliance 2

• Penicillin V:

  • Traditional first-line therapy
  • Must be administered for a full 10-day course to eliminate the organism and prevent sequelae of streptococcal disease 3
  • Cultures should be taken following completion of treatment to confirm eradication 3

Alternative Treatments for Penicillin-Allergic Patients

For patients with penicillin allergy, alternative options include:

• Azithromycin:

  • Dosage: 12 mg/kg once daily (maximum 500 mg) for 5 days 1
  • Note: Some strains may be resistant to azithromycin, so susceptibility testing is recommended 4
  • Not recommended as first-line therapy due to increasing resistance patterns

• Clindamycin:

  • Dosage: 300-450 mg orally three times daily for 10 days 1
  • Useful for patients with severe penicillin allergy or treatment failures

Treatment Failure Considerations

If symptoms worsen or do not improve after 48-72 hours of antibiotic therapy:

• Consider switching to amoxicillin-clavulanate to address potential beta-lactamase producing organisms 1
• For continued failure, clindamycin (20-30 mg/kg/day in 3 divided doses for children; 600 mg/day in 2-4 divided doses for adults) may be effective 1

Symptomatic Relief

• NSAIDs or acetaminophen for fever and pain management 1
• Avoid aspirin in children due to risk of Reye syndrome 1
• Supportive measures:
  • Cold liquids and ice chips
  • Gargling with cold water
  • Avoiding hot liquids and spicy foods

Important Clinical Considerations

• The rash of scarlet fever is toxin-mediated (caused by streptococcal superantigens) and typically presents as an erythematous, sandpaper-like rash 5
• Complete the full antibiotic course even if symptoms improve to prevent complications like rheumatic fever 1, 3
• Household contacts of scarlet fever patients have a 12.2-fold increased risk of invasive Group A Streptococcus disease within 60 days, particularly infants and elderly individuals 6
• Although scarlet fever had declined in prevalence and severity since the late 19th century, outbreaks have reemerged in multiple geographical regions over the past decade 5

Treatment Pitfalls to Avoid

• Incomplete treatment course: Skipping doses or not completing the full course may decrease effectiveness and increase antibiotic resistance 3
• Relying on oral antibiotics in severe cases: The oral route should not be used in patients with severe illness, nausea, vomiting, or intestinal hypermotility 3
• Failure to confirm eradication: Cultures should be taken following treatment completion to ensure streptococci have been eliminated 3
• Overlooking potential complications: Be vigilant for signs of invasive disease, especially in high-risk household contacts 6, 7