Scarlet fever is an infection with group A streptococci (Streptococcus pyogenes) that usually starts as a throat infection with pus. What makes it special: certain strains produce a toxin that causes the typical fine rash and the strawberry tongue. It mainly affects children and teenagers between 5 and 15 years of age.¹
Scarlet fever is therefore a special form of strep throat. The general difference between viral and bacterial throat infections is explained in the article on tonsillitis; this article is about what sets scarlet fever apart: the rash, the rules on contagiousness for nursery and school, and the question of antibiotics.
Having had the illness only protects against that particular toxin and strain. Because there are several of them, you can get scarlet fever more than once.¹,² There is no vaccine.
Not every red rash with a sore throat is scarlet fever. Reddened skin alone is not enough for the diagnosis; it occurs with many harmless infections. Besides the throat infection with high fever, scarlet fever comes with other typical findings such as the strawberry tongue and the fine, velvety rash.¹
2. Forms: from mild to severe
Form
Typical picture
Assessment
Classic scarlet fever
Sudden high fever, severe sore throat, rash, strawberry tongue
The most common form in schoolchildren
Mild scarlet fever
Little fever, faint rash, hardly feeling ill
Often overlooked; according to the German GP guideline, an antibiotic is not essential here¹
Scarlet fever in adults
Often less typical, rash less pronounced
Less common, but possible — for example in parents of children who are ill
Wound scarlet fever
Rash starting from an infected wound or patch of skin rather than from the throat
Rare; scarlet fever can also occur without tonsillitis
Invasive streptococcal infection
Blood poisoning (sepsis), severe soft tissue infection, shock
Very rare, life-threatening — an emergency
Table scrolls to the right
3. Symptoms and complications
Scarlet fever usually starts suddenly with a high fever, sore throat and difficulty swallowing. Children in particular also complain of headache and tummy ache, and some vomit.¹
Throat: deep red lining of the throat, swollen tonsils that are often coated, swollen lymph nodes in the neck; more under sore throat.
Tongue: coated white at first, bright red after a few days with prominent papillae — the strawberry tongue.²
Rash: from the first or second day of illness, starting on the upper body and then spreading over the neck and limbs. Fine, densely packed small bumps that feel like sandpaper, particularly marked in the groin and armpits.¹,²
Spared areas: palms, soles of the feet and the triangle around the mouth and nose — the pale area around the mouth stands out against the flushed face.¹
Peeling: the rash disappears after about six to nine days; afterwards the skin peels, especially on the hands and feet.¹,²
Possible complications
Complications involving pus, such as an abscess next to the tonsil (peritonsillar abscess, quinsy), a middle ear infection or sinusitis, are rare.¹ Even rarer are secondary diseases weeks later — rheumatic fever and kidney inflammation (section 8) — and severe, invasive streptococcal infections.²,³
Get medical help immediately — for breathing difficulties or circulatory problems, call 112 (emergency number in Germany). Shortness of breath, increasing swelling on one side of the throat with a muffled voice and difficulty opening the mouth, constant drooling because swallowing is impossible, refusing to drink with signs of dehydration, confusion, circulatory weakness or rapidly spreading, very painful reddening of the skin are emergencies. If an abscess next to the tonsil is suspected: see a doctor the same day.¹ More on shortness of breath.
4. Pathogen, transmission and medicines
Transmission: mainly via droplets when coughing, sneezing and talking, and through close contact; less often via objects.²
Incubation period: short — usually one to three days, rarely longer.²
How long it is contagious: 24 hours after starting an effective antibiotic, a person is no longer contagious. Untreated, people with the illness can be contagious for up to three weeks.²
Healthy carriers: some children and adults carry streptococci in their throat without being ill.¹ Such carriers are usually not treated, and a positive test alone does not prove scarlet fever.
A rash after an antibiotic: scarlet fever or a drug reaction? If a rash only appears a few days after starting an antibiotic, something else is often behind it: a drug reaction — or glandular fever, in which amoxicillin in particular typically triggers a rash. Have it looked at by a doctor the same day instead of stopping or continuing the medicine on your own; more on rashes under skin rash.
5. Diagnosis: rapid test, swab, telling it apart
Scarlet fever is usually a clinical diagnosis: the rash, strawberry tongue and throat findings are so typical that the German GP guideline classifies it as a situation in which the decision is made individually rather than by points scores.¹
Looking at the throat and skin: tonsils, tongue, distribution and texture of the rash, the spared area around the mouth.
Rapid strep test: it is very specific — a positive result fits well — but not quite as sensitive; a negative result does not reliably rule out streptococci.²
Throat swab with culture: more accurate, but the result takes one to two days.²
Young children: in children under three, streptococci are a rare cause of sore throats, and testing is not routinely recommended in this age group.²
Telling it apart: viral infections with a rash, measles, glandular fever, Kawasaki disease in young children and drug rashes can look similar.¹
No follow-up swabs: if all is well after treatment, a repeat swab is not necessary; it only makes sense if symptoms persist.¹
Useful for the appointment: how long the fever has been going on, when the rash started, which medicines the child is taking and whether there are any allergies to antibiotics. Tips in the guide Prepare for a doctor's appointment.
6. Antibiotic or not?
The honest answer is: usually yes — but not because scarlet fever would be dangerous without an antibiotic. The two key recommendations in Germany put the emphasis in different places:
The Robert Koch Institute, Germany's national public health institute, recommends early antibiotic treatment, with penicillin as standard.²
The German S3 GP guideline stresses that scarlet fever is treated primarily for its symptoms. In uncomplicated, mild cases, it says, an antibiotic is not essential, because complications involving pus are very rare even without treatment. According to the guideline, there is insufficient evidence that antibiotics prevent rheumatic fever and kidney inflammation, and there is little evidence on antibiotic treatment for scarlet fever overall.¹
What the antibiotic achieves
What it does not achieve, or what it costs
No longer contagious after 24 hours — a quicker return to nursery or school²
In bacterial throat infections, it shortens the symptoms by only about 16 hours on average¹
Fewer infections within the family and group
Side effects such as diarrhoea, fungal infections or allergic reactions in about one in ten people¹
Somewhat fewer complications involving pus, which are rare anyway
No reliably proven protection against kidney inflammation¹
Important with an increased risk of rheumatic fever or in severe cases
In practice, typical scarlet fever is therefore usually treated with an antibiotic — not least because otherwise a child is barred from nursery or school for considerably longer. In mild cases, waiting and watching with good symptom relief is a reasonable alternative. The decision is made by the treating practice together with you.
First linePenicillin
Penicillin V (phenoxymethylpenicillin)
Narrow spectrum, works reliably against group A streptococci. There are two recommendations on the duration: the RKI gives ten days, while the German GP guideline gives five to seven days for strep throat and sees no reason to deviate from this for scarlet fever.¹,² The practice decides which duration applies.
Amoxicillin
Also suitable according to the RKI² and widely used in children, partly because the syrup often tastes better. Take care if the illness is actually glandular fever: amoxicillin then frequently triggers a rash.
If allergicAlternatives
Oral cephalosporins
In children, a shortened five-day course is described as equally effective.² If there has been a severe allergic reaction to penicillin in the past, the decision is weighed up individually.
Macrolides such as clarithromycin or azithromycin
For a genuine penicillin allergy. Drawback: in some regions, a relevant proportion of streptococci are resistant to macrolides.² Clarithromycin also has many interactions (section 7); more on azithromycin.
AlwaysRelieve symptoms
Pain and fever relief, fluids, soft food
Ibuprofen or paracetamol relieve sore throat and fever, dosed according to body weight in children.¹ Cool drinks and mushy food make swallowing easier. No aspirin for children and teenagers.
7. Taking antibiotics correctly
Spread doses evenly: penicillin V is usually taken three times a day, at intervals that are as even as possible. The package leaflet tells you how it relates to meals.
Stick to the prescribed duration: things often get much better after two days. Even so, do not stop the antibiotic early on your own — whether a shorter course is enough is decided by the practice, not by how you feel on day three. More in the guide Taking antibiotics correctly.
Missed a dose? Do not take a double dose; carry on as described in the package leaflet — see Missed a medication.
Syrup for children: shake before every dose, measure with the dosing aid supplied, store as instructed — often in the fridge — and note its limited shelf life once made up. Tips in the guide Medications for children.
The pill: diarrhoea or vomiting while on the antibiotic can reduce contraceptive protection — see Medications and contraception.
Interactions you should know about
Penicillins can delay the excretion of methotrexate and so increase its side effects. Clarithromycin inhibits the breakdown of many active ingredients; together with simvastatin it is not permitted because of the risk of severe muscle damage, and caution is also needed with blood thinners and certain heart medicines.⁴ If you take long-term medication, the complete list belongs with the prescription.
An allergic reaction? Do not wait. Swelling of the lips, tongue or throat, shortness of breath, circulatory problems or widespread hives shortly after taking a dose are an emergency — call 112 immediately. A mild rash without these signs should be seen at the practice the same day; there it will be decided whether to switch the medicine. Do not stop an antibiotic on your own — background in the guide Stopping medications.
Three times a day, for several days — even when you have long been feeling better
brite reminds you of every antibiotic dose and checks for interactions with your long-term medicines.
8. Rheumatic fever and kidney inflammation: a realistic view
Fear of late effects is the reason scarlet fever used to be so dreaded. Two secondary diseases are known:¹,²
Acute rheumatic fever: an inflammatory reaction that can affect the joints, heart and nervous system. In Germany it is extremely rare today; the German GP guideline estimates its frequency at less than one case per million people.¹
Kidney inflammation after streptococci (glomerulonephritis): usually occurs one to three weeks after the infection. Whether antibiotics prevent it is not sufficiently proven.¹
For the weeks after scarlet fever, the rule is therefore: watch for warning signs instead of treating preventively. Contact the practice if you notice reddish or dark urine, swelling in the face or legs (water retention), passing much less urine, a returning fever, joint pain that moves from joint to joint, chest pain or shortness of breath on exertion. Practices differ on whether a urine check after a few weeks makes sense — ask if you are unsure.
When the antibiotic is particularly important. For people with a history of rheumatic fever, from regions where it is still common, with a serious underlying disease or a weakened immune system, the German GP guideline also provides for an individual decision that leans towards treatment.¹
9. Scarlet fever at nursery, school and home
Stay at home — under § 34 of the German Infection Protection Act (IfSG), which regulates exclusion from and readmission to communal facilities such as nurseries (Kita) and schools, anyone with scarlet fever may not attend them; this also applies to staff working there.²
Readmission with an antibiotic — 24 hours after starting effective treatment, once the symptoms have subsided.²
Readmission without an antibiotic — at the earliest 24 hours after the typical symptoms have subsided, so usually considerably later.²
Inform the facility — nurseries and schools must notify the local public health office (Gesundheitsamt). There is no nationwide requirement for doctors to report scarlet fever; individual federal states have additional rules.²
Siblings and parents — healthy contacts are not given an antibiotic just in case. Anyone who develops symptoms should be examined. Hand washing and separate glasses help; the popular tip to change your toothbrush is well meant but not backed by evidence.
Medicine cabinet — fever medicine for children, a thermometer, dosing aids. What else is useful is shown in the home pharmacy checklist.
Has the child already had the syrup at lunchtime?
When parents take turns: every dose documented, no double doses and no missed ones.
In mild, uncomplicated cases, as a rule not: complications involving pus are very rare even without an antibiotic, and rheumatic fever has become extremely rare in Germany. The RKI nevertheless recommends antibiotic treatment, partly because it shortens the contagious period to 24 hours. The decision is made by the practice together with you.
With an effective antibiotic, contagiousness ends after 24 hours. Without treatment, people with the illness can be contagious for up to three weeks. The incubation period is short, usually one to three days.
With an antibiotic, according to the Robert Koch Institute, 24 hours after starting effective treatment, once the symptoms have subsided. Without an antibiotic, at the earliest 24 hours after the typical symptoms have subsided. The nursery must be informed about the illness.
Yes. Having had the illness only protects against that particular toxin and strain of streptococci, and there are several of them. There is no vaccine against scarlet fever.
The recommendations differ: the RKI gives ten days for penicillin, while the German GP guideline considers five to seven days sufficient for strep throat; certain cephalosporins are given for five days. What matters is sticking to the prescribed duration and not stopping the medicine early on your own.
Yes, although it is less common, for example in parents of children who are ill. In adults the course is often less typical and the rash less pronounced. Anyone who works at a nursery, school or other communal facility may not work there until readmission is allowed.
Scarlet fever is a special form of bacterial streptococcal tonsillitis: certain strains produce a toxin that causes the typical rash and the strawberry tongue. Most cases of tonsillitis, by contrast, are caused by viruses, against which antibiotics do not help.
German S3 guideline on sore throat, DEGAM guideline no. 14, German College of General Practitioners and Family Physicians (AWMF reg. no. 053-010, 2020 version, editorially revised 2021) — German source. awmf.org
Robert Koch Institute (RKI): RKI guide on Streptococcus pyogenes infections (scarlet fever), as of February 2024. Accessed 2026 — German source. rki.de
Medical disclaimer: This article is for general information and does not replace medical advice, diagnosis or treatment. If there is shortness of breath, increasing swelling on one side of the throat, refusal to drink or circulatory problems, call 112 straight away; swelling, dark urine or joint pain in the weeks after scarlet fever should be checked by a doctor. Do not stop an antibiotic on your own. The choice of medicine and its dose are always set individually by the treating practice. Last updated: September 2026.
