Strawberry Tongue: Causes in Children and Adults

Quick answer

In a child with fever, a strawberry tongue often means scarlet fever or, rarely, Kawasaki disease; both need a doctor

Scarlet fever, caused by group A streptococcus bacteria, is the most common cause in children: sore throat, fever and a white-coated tongue that becomes red and bumpy, with a fine, rough, sandpaper-like rash. It is treated with antibiotics. Kawasaki disease, which mainly affects children under 5, causes a high fever lasting 5 days or more with red eyes, red cracked lips, a strawberry tongue, a rash and swollen hands and feet; it needs urgent hospital treatment to protect the heart. Toxic shock syndrome is a rare, serious cause with sudden high fever, rash and low blood pressure. In adults, a red, sore tongue is more often linked to vitamin B12 or iron deficiency, allergies or irritation. Any child with fever and a strawberry tongue should be seen by a doctor.

What a strawberry tongue looks like

White strawberry tongue: a white coating with red, swollen papillae poking through, often in the first days of scarlet fever.
Red strawberry tongue: the coating peels off, leaving a bright red, bumpy tongue.
The tongue may feel sore, swollen or sensitive to hot and spicy food.

For other tongue changes, see bumps on the back of the tongue and cracked tongue.

Scarlet fever

Scarlet fever is a bacterial infection caused by group A streptococcus, the same bacteria that cause strep throat. It is most common in children aged 5 to 15. Symptoms include sore throat, fever, headache, swollen neck glands, a strawberry tongue and a fine pink or red rash that feels like sandpaper, starting on the chest and tummy. The skin on the hands and feet may peel later.

It is treated with antibiotics, which speed recovery and reduce complications and spread. Children should stay off school until 24 hours after starting antibiotics. See strep throat.

Kawasaki disease

Kawasaki disease mainly affects children under 5. It causes a high temperature lasting 5 days or more that does not respond well to fever medicines, together with red eyes without discharge, red cracked lips, a strawberry tongue, a rash, swollen glands in the neck and red, swollen hands and feet that later peel.

It inflames blood vessels, including those supplying the heart, so it needs urgent hospital assessment and treatment. Early treatment greatly reduces the risk of heart complications.

Other causes

Toxic shock syndrome: rare and serious; sudden high fever, rash, vomiting, diarrhoea, dizziness and confusion. Call emergency services.
Vitamin deficiencies: low B12, folate or iron can cause a smooth, red, sore tongue (glossitis), which is sometimes confused with strawberry tongue.
Allergic reactions: to food or medicines, with swelling of the tongue or lips; difficulty breathing is an emergency.
Viral infections: some viruses cause a red, sore tongue.
Irritation: very hot or spicy food, or certain toothpastes.

Strawberry tongue in adults

Adults can get scarlet fever, although it is less common. More often, a red, sore tongue in adults is related to vitamin B12 or iron deficiency, allergies, irritation or infections. A doctor can examine the tongue and arrange blood tests if needed.

A sore throat with a red tongue in an adult can also be a throat infection; see sore throat without fever.

Treatment

Treatment depends on the cause: antibiotics for scarlet fever, hospital treatment for Kawasaki disease and supplements for deficiencies.
Fluids, soft cool foods and simple painkillers ease soreness.
Avoid very hot, spicy or acidic foods while the tongue is sore.
Keep up gentle tooth and tongue brushing.

Preventing spread

Scarlet fever spreads through coughs, sneezes and shared items. Wash hands often, use tissues and avoid sharing cups, cutlery and towels. Keep children with scarlet fever at home until 24 hours after starting antibiotics.

How doctors confirm the cause

A doctor looks at the tongue, throat, skin and eyes and asks how long the fever has lasted. A throat swab can confirm streptococcus in suspected scarlet fever. Kawasaki disease is diagnosed from the pattern of symptoms together with blood tests and a heart scan (echocardiogram). Blood tests also check for vitamin deficiencies in adults.

When to seek help

A child with fever and a strawberry tongue: see a doctor the same day.
Fever lasting 5 days or more in a young child, with red eyes or lips: seek urgent assessment.
Sudden high fever with rash, dizziness or confusion: call emergency services.
Swelling of the tongue or lips with difficulty breathing: call emergency services.
A red, sore tongue lasting more than 2 weeks in an adult.

Key points to remember

Strawberry tongue is a sign, not a disease.
In children, scarlet fever is the most common cause and responds to antibiotics.
Kawasaki disease and toxic shock syndrome are rare but urgent causes.
In adults, deficiencies and irritation are more common causes of a red, sore tongue.

Questions about strawberry tongue

These answers are general information and do not replace an examination or individual medical advice.

What causes a strawberry tongue?

Most often scarlet fever in children. Kawasaki disease, toxic shock syndrome and vitamin deficiencies are other causes.

Is strawberry tongue contagious?

The tongue itself is not, but scarlet fever, a common cause, is contagious.

How long does strawberry tongue last?

With scarlet fever, it usually improves within about a week of starting treatment.

Can adults get strawberry tongue?

Yes, though it is less common. Deficiencies and infections are possible causes.

Is strawberry tongue always serious?

Not always, but a child with fever and a strawberry tongue should see a doctor.

What does Kawasaki disease look like?

High fever for 5 days or more with red eyes, red cracked lips, strawberry tongue, rash and swollen hands and feet.

How is scarlet fever treated?

With a course of antibiotics, usually for 10 days. Finish the course even if your child feels better.

Can a strawberry tongue be caused by allergies?

Allergic reactions can cause a swollen, red tongue. Swelling with difficulty breathing is an emergency.

Sources

This guide is for general information and does not replace medical advice. How a problem is diagnosed and treated depends on your examination and medical history. If you think you have an emergency, contact your local emergency services.