Recently, an increase in the number of cases of scarlet fever, an infectious disease that mainly affects children, has been observed in France and other European countries. This is a worrying trend, and is raising concerns about its implications for public health. Known for its typical symptoms of sore throat, fever and a distinctive rash, scarlet fever, caused by group A streptococcus bacteria, was once a common and often mild childhood illness. However, the recent increase in the number of cases, particularly among the under-10s, highlights the need for increased surveillance.
This follows a period of declining incidence of scarlet fever, particularly during the COVID-19 pandemic, when social interaction was limited. However, with the resumption of normal activities and greater circulation of respiratory viruses, including seasonal influenza and respiratory syncytial virus, the risk of invasive group A streptococcal disease appears to be increasing.
What is scarlet fever?
Scarlet fever is a contagious, epidemic infectious disease affecting mainly children, resulting in the systematic spread of exotoxins that give rise to the rash characteristic of scarlet fever. The incubation period for scarlet fever is fairly short, between 1 and 5 days. The onset is sudden and combines high fever (up to 40), chills, vomiting, pharyngeal (throat) and abdominal pain. This is followed, after 2 months, by an exanthem and enanthem (in the mouth and throat), red and swollen tonsils, a sandy and then raspberry-red tongue, red angina, itchy skin, adenopathy and heart problems.
Scarlet fever mainly affects children aged between 5 and 10, usually during the winter. It is transmitted mainly by air (nasal droplets).
Scarlet fever, an infectious childhood disease, is caused by group A beta-haemolytic streptococcus. It mainly affects children aged between 5 and 10 in winter, but is rare in adults and very young children, who are protected by maternal antibodies. Scarlet fever is characterised by high fever, sore throat and a skin rash.
The disease is transmitted in several ways, including through the air (coughing, sneezing) and by contact with soiled objects. Symptoms are caused by toxins secreted by the bacteria. Without treatment, contagion lasts from 10 to 21 days, but this period is reduced to 24/48 hours with appropriate treatment, mainly antibiotics.
Despite its current rarity, scarlet fever has been on the rise again in France since the Covid-19 health crisis. This increase could be the result of an “immune debt” and a high incidence of viral respiratory infections. Infected people spread the virus even before symptoms appear, making isolation strategies ineffective. To limit the spread of the virus, experts recommend isolation for 24 to 48 hours after the start of treatment.
A little history
In the 19th century, doctors identified scarlet fever, also known as the third disease, as one of six skin rashes affecting young children. They ranked it third, following the study of measles and rubella, the first and second diseases respectively. The other diseases included scarlet fever (fourth disease), epidemic megalaemia (fifth disease), and infantile roseola (sixth disease). Giovanni Ingrassia, a physician in Naples, gave the first known description of scarlet fever in 1553, under the terms “rossalia” or “rosania”.
The English physician Thomas Sydenham was the first to differentiate scarlet fever from measles in 1676, calling it “scarlet fever”. Before the 19th century, scarlet fever was often confused with other similar diseases. In 1821, the French physician Pierre Bretonneau distinguished it from diphtheria.
The streptococcal origin of scarlet fever was suggested in 1887 by the Hungarian bacteriologist Emanuel Edward Klein. However, it wasn’t until 1923 that American bacteriologists George and Gladys Dick confirmed the role of streptococcus.
At the beginning of the 20th century, researchers experimented with various serums and vaccines. The first vaccination took place in 1905. With the advent of antibiotics, these treatments became obsolete. The Pasteur Institute developed some of these serums to treat scarlet fever. However, serious and sometimes fatal reactions led to them being abandoned.
What are the symptoms of scarlet fever?
Scarlet fever has an incubation period of 1 to 4 days, sometimes longer, before symptoms appear.
The first signs include sore throat and high fever (over 38.5°C), accompanied by chills, sore throat and difficulty swallowing (dysphagia). The throat becomes red and inflamed, the tonsils swollen and the glands in the neck swollen. Other symptoms may include headaches, nausea or vomiting, and stomach ache.
Next, a rash usually appears one or two days after the onset of the sore throat. It appears as a diffuse red discolouration on the skin, with more intense red spots, making the skin rough to the touch. The rash often starts in the armpits and flexion creases (elbow, groin), then spreads to the upper chest, lower abdomen, face (except around the mouth) and extremities (except palms and soles).
A characteristic appearance of the tongue is also observed: initially covered with a white coating, it becomes raspberry red after a few days.
Mild forms of scarlet fever, common in children, have a lower fever and a rash that is more pink than red. Throat and tongue symptoms remain similar.
Children are contagious before symptoms appear, facilitating transmission in groups. The rash reaches its peak between the 2nd and 3rd day, diminishing rapidly around the 6th day. Peeling occurs between days 7 and 15, with the palms and soles being the last to be affected.
How is the disease diagnosed?
Scarlet fever is diagnosed primarily clinically, by a doctor during a medical consultation. He or she examines the patient’s throat and looks for signs of the characteristicrash, often accompanied by high fever, throat inflammation, loss of appetite and headache. To confirm the presence of the Streptococcus pyogenes bacteria that cause scarlet fever, a throat culture is taken. The sample is then analysed in the laboratory to identify the bacteria.
The rapid antigen test is another method for detecting the presence of Streptococcus pyogenes, providing results in just a few minutes. This test, also known as Trod angina, is recommended for children aged 3 and over. It involves a swab being taken from the tonsils, followed by a chemical reaction indicating the presence or absence of group A streptococcus.
In pharmacies, pharmacists also carry out Trod angina for children aged over 10 and adults. If the result is positive, they refer the patient to their doctor. This test is partially reimbursed by the Assurance Maladie.
It is important not to confuse scarlet fever with other conditions such as streptococcal toxic shock, staphylococcal infections, Kawasaki disease, or viral infections such as rubella. The characteristic chronology ofenanthema helps the doctor to orientate his diagnosis. Complications from scarlet fever are rare, and appropriate treatment with antibiotics is generally effective.
What causes scarlet fever?
Scarlet fever is caused by a group A haemolytic streptococcus called : Streptococcus pyogenes, which spreads its toxins throughout the body. This creates a purulent focus in the pharynx and tonsils (a form of angina), and this is the start of the toxic infection. In the best cases, the disease progresses in 2 to 3 weeks, but it can be complicated by nephritis.
The agent responsible for scarlet fever is a bacterium called Streptococcus pyogenes, also known as group A beta-haemolytic streptococcus. In rare cases, group C or G streptococci may also be the cause.
The infection is transmitted by air, through contact with the oropharyngeal secretions of an infected person or a healthy carrier. Although the pharynx is the main route of entry, other areas such as the skin orfemale genital tra ct can also be affected.
Incubation of the disease is relatively rapid, lasting from 2 to 5 days. The streptococcus is located in the throat. The scarlet fever rash is caused by an erythrogenic toxin or pyrogenic exotoxin. Certain subtypes of streptococci secrete this toxin. There are several forms of this toxin: A, B, C and D. They are immunogenic and cause vasodilatation, dermal oedema and lymphocytic infiltration. Toxins B and C correspond to mild forms of scarlet fever. Toxin A is associated with more severe cases.
Following infection, specific immunity develops to the subtype of streptococcus involved. Recurrence is therefore possible if a person is exposed to another subtype of streptococcus.
Can scarlet fever be prevented?
There is no vaccine against scarlet fever. However, adopting simple hygiene measures is crucial to preventing contamination and the spread of the streptococcus responsible.
Preventive measures against transmission:
- Avoid contact with infected people.
- Wash your hands frequently, especially after coming into contact with a sick person or potentially contaminated objects.
- Regularly clean and disinfect objects used by patients, such as toys, cutlery, glasses and utensils.
- Clean and disinfect frequently touched surfaces (door handles, light switches, counters).
It’s also advisable to get vaccinated against diphtheria and tetanus, two diseases that can cause complications in scarlet fever sufferers.
Hand and nose hygiene:
- Wash your hands with liquid soap for 30 seconds, then rinse and dry them thoroughly.
- Teach your child to wash his hands and keep his fingernails short.
- Use single-use tissues to blow their nose.
- Teach your child to cover his mouth and nose with a handkerchief or his sleeve if he sneezes or coughs.
Limit contact in the event of scarlet fever:
- Avoid hugs and close contact.
- Keep sick children at home and inform their school.
- Avoid letting the sick child get too close to healthy people.
- Do not share your sick child’s personal belongings.
- Regularly clean objects used by the sick child.
Maintaining a healthy home:
- Avoid exposure to tobacco smoke.
- Ventilate your home daily.
- Maintain a room temperature of between 18 and 20°C.
Are there any medicinal plants to combat scarlet fever?
The antibiotic of choice for GAS infections is penicillin. To date, there is no evidence of resistance. For invasive infections, doctors recommend adding clindamycin. This choice is justified by clindamycin’s anti-toxin effect, its efficacy independent of the size of the inoculum and its post-antibiotic effect. However, to enhance the efficacy of antibiotic therapy, the use of certain medicinal plants remains essential.
Echinacea has a dose-dependent antibacterial preventive and curative action, inhibiting the growth of certain germs. Its antibacterial effect therefore acts directly on Streptococcus pyogenes. Echinacea is, however, contraindicated for children under the age of 12.
Echinacea stimulates the immune system’s defences against infection, thanks in particular to its lipophilic ethanol fraction (alkylamides) and its hydrophilic polysaccharide fraction. Phenolic derivatives such as cichoric acid play a key role. It increases splenocyte proliferation, boosts natural killer (NK) cells and modifies T lymphocytes and cytokine levels.
Echinacea has antiviral, antibacterial, antifungal and anti-inflammatory properties. It acts against various viruses, including coronaviruses, and has antifungal activity against Candia albicans. Its anti-inflammatory action is due to alkylamides and polysaccharides, modulating macrophage activation and inhibiting inducible nitric oxide synthase (iNOS). It is used to treat various skin conditions and respiratory infections.
The broad-spectrum antibacterial effect oftea tree oil is linked to the MT alcohols (active against antibiotic-resistant Staphylococcus aureus, Escherichia coli, Steptococcus pneumoniae and pyogenes, and Hemophilus influenza). However, tea tree essential oil is contraindicated for children under the age of 7.
Medical literature and clinical trials
- Birt DF, Widrlechner MP, Lalone CA, Wu L, Bae J, Solco AK, Kraus GA, Murphy PA, Wurtele ES, Leng Q, Hebert SC, Maury WJ, Price JP. Echinacea in infection
- Ultee A, Bennik M, Moezelaar R. The phenolic hydroxyl group of carvacrol is essential for action against the food-borne pathogen Bacillus cereus. Appl Environ Microbiol. 2002
- Ultee A, Kets W, Smid E. Mechanisms of action of carvacrol on the food-borne pathogen Bacillus cereus. Appl Environ Microbiol. 1999
- Carson CF, Mee BJ, Riley TV. Mechanism of action of Melaleuca alternifolia (tea tree) oil on Staphylococcus aureus determined by time-kill, lysis, leakage, and salt tolerance assays and electron microscopy. Antimicrob Agents Chemother. 2002
- Halcón L, Milkus K. Staphylococcus aureus and wounds: a review of tea tree oil as a promising antimicrobial. Am J Infect Control. 2004
- Nelson RR. In-vitro activities of five plant essential oils against methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus faecium. J Antimicrob Chemother. 1997
- Ferrini AM, Mannoni V, Aureli P, Salvatore G, Piccirilli E, Ceddia T, Pontieri E, Sessa R, Oliva B. Melaleuca alternifolia essential oil possesses potent anti-staphylococcal activity extended to strains resistant to antibiotics. Int J Immunopathol Pharmacol. 2006
- Papadopoulos CJ, Carson CF, Hammer KA, Riley TV. Susceptibility of pseudomonas to Melaleuca alternifolia (tea tree) oil and components. J Antimicrob Chemother. 2006
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