Snapshot A 5-year-old boy presents to the emergency room with a rash. He has had a sore throat with fever for 2 days now. On physical exam, he has a diffuse erythematous sandpaper-like rash that blanches with pressure. His tongue is beefy-red. A rapid strep test was positive. As he is documented to be allergic to penicillin, he is prescribed cephalexin. Introduction Clinical definition acute bacterial infection with diffuse erythematous eruption associated with pharyngitis Epidemiology demographics children risk factors exposure to Streptococcus pyogenes or other erythrogenic strains Pathogenesis delayed-type hypersensitivity to S. pyogenes exotoxin A Associated conditions streptococcal pharyngitis Prognosis rash usually fades within a week desquamation may last several weeks Presentation Symptoms sore throat fever Physical exam strawberry tongue circumoral pallor diffuse blanching erythema sandpaper-like rash with small papules spreads from the groin and armpits and to the trunk and extremities spares the palms and soles the rash is followed by desquamation Studies Labs rapid streptococcal testing throat culture may reveal streptococcal pharyngitis Making the diagnosis based on clinical presentation Differential Kawasaki disease distinguishing factors hand and foot rash prolonged fever conjunctival injection no association with streptococcal pharyngitis Staphylococcal scalded skin syndrome distinguishing factors + Nikolsky sign Treatment Management approach identical to the treatment approach in patients with streptococcal pharyngitis additional treatment for the rash is not needed Medical penicillin indications for all patients prevention of acute rheumatic fever drugs penicillin V amoxicillin alternatives to penicillin indications for patients with penicillin allergies prevention of acute rheumatic fever drugs cephalosporins clindamycin macrolides Complications Acute rheumatic fever or rheumatic heart disease