What is the treatment for strep rash, particularly in cases associated with Scarlet Fever?

Treatment for Streptococcal Rash Associated with Scarlet Fever

Penicillin or amoxicillin is the first-line treatment for streptococcal rash associated with scarlet fever due to their proven efficacy, safety, narrow spectrum of activity, and low cost. 1, 2

First-Line Treatment Options

For patients without penicillin allergy:

• Oral penicillin V for 10 days 1, 2:

  • Children: 250 mg two or three times daily
  • Adolescents and adults: 250 mg four times daily or 500 mg twice daily

• Oral amoxicillin for 10 days 1, 2:

  • 50 mg/kg once daily (maximum = 1,000 mg) or
  • 25 mg/kg twice daily (maximum = 500 mg)

• Intramuscular benzathine penicillin G (single dose) for patients unlikely to complete a full 10-day oral course 1, 2:

  • Patients < 60 lb (27 kg): 600,000 units
  • Patients ≥ 60 lb: 1,200,000 units

Treatment for Penicillin-Allergic Patients

For patients with penicillin allergy:

• Non-anaphylactic penicillin allergy 1, 3:

  • First-generation cephalosporins for 10 days:
    • Cephalexin: 20 mg/kg per dose twice daily (maximum = 500 mg per dose)
    • Cefadroxil: 30 mg/kg once daily (maximum = 1 g)

• Anaphylactic penicillin allergy 1, 3:

  • Clindamycin: 7 mg/kg per dose three times daily (maximum = 300 mg per dose) for 10 days
  • Clarithromycin: 7.5 mg/kg per dose twice daily (maximum = 250 mg per dose) for 10 days
  • Azithromycin: 12 mg/kg once daily (maximum = 500 mg) for 5 days

Important Considerations

• A full 10-day course of antibiotics (except for azithromycin which is 5 days) is essential to eradicate the organism and prevent complications such as rheumatic fever 1

• Macrolides (azithromycin, clarithromycin) should be used with caution due to variable resistance patterns that differ geographically 1, 4, 5

• Penicillin remains the drug of choice due to the absence of documented resistance of Group A Streptococcus to penicillin 1, 6

Adjunctive Therapy

• Acetaminophen or NSAIDs can be used for moderate to severe symptoms or high fever 1, 2

• Aspirin should be avoided in children due to the risk of Reye syndrome 1, 2

• Corticosteroids are not recommended for routine use 1

Special Considerations for Scarlet Fever

• Scarlet fever is a toxin-mediated disease caused by Group A Streptococcus that requires antibiotic treatment regardless of severity to 7, 8:

  • Speed recovery
  • Reduce the length of time the infection is contagious
  • Reduce the risk of complications including invasive disease and toxic shock syndrome

• The characteristic scarlatiniform rash is sandpaper-like and typically occurs in children aged 5 to 15 years 7, 8

Common Pitfalls to Avoid

• Failing to complete the full course of antibiotics, which may lead to treatment failure and complications 6

• Using macrolides in areas with high resistance rates 9, 5

• Stopping antibiotics when symptoms improve before completing the full course 6

• Failing to recognize potential complications of scarlet fever, which can include invasive disease and toxic shock syndrome in rare cases 10