Introduction
The first case of perianal streptococcal dermatitis in children was reported in 1966. A few adult cases near the umbilicus were occasionally reported. Perianal streptococcal dermatitis diseases are frequently misdiagnosed. Early diagnosis and treatment significantly reduce patient discomfort and parental stress. This article briefly describes perianal streptococcal dermatitis in pediatric patients with aspects of etiology, disease mechanism, symptoms, diagnosis, and treatment.
What Is Perianal Streptococcal Dermatitis?
Perianal streptococcal dermatitis is a bacterial infection around the anal skin which occurs in children. At times, it is called cellulitis of the perineum. It is caused by infection from group A beta-hemolytic type streptococcus bacteria in the epidermis. Infection from Staphylococcus aureus or nongroup A beta-hemolytic Streptococcus can also develop perianal streptococcal dermatitis.
What Are the Incidences of Developing Perianal Streptococcal Dermatitis?
The skin condition in children develops, particularly in the winter and spring. The median age group affected is six months to 10 years old. The infection has a slight male predominance with a ratio of three to one. Although perianal streptococcal primarily affects children, few cases are reported among adults.
Risk factors for developing perianal streptococcal dermatitis are perianal skin lesions, poor hygiene, poor living conditions, overcrowded houses, chronic dialysis, atopic dermatitis, and malnutrition.
What Causes Perianal Streptococcal Dermatitis?
There are multiple hypotheses on the perineum becoming infected with streptococcal bacteria. One theory suggests that perineal tissues become auto-inoculated by streptococcal bacteria through digital contact of the perineum or oral and nasal cavities. Affected individuals transferred bacteria to the perineum by digital contact or swallowing the bacteria. This hypothesis could be confirmed by most cases of perianal streptococcal dermatitis demonstrating pharyngeal streptococcal infection. However, there is less possibility of developing perianal streptococcal dermatitis by swallowing pharyngeal streptococcus as most bacteria become neutralized by gastric acids. According to another theory, fomites play a role in transferring streptococcal bacteria to induce perianal streptococcal dermatitis.
Higher incidences of developing perianal streptococcal dermatitis have been reported in daycare centers or within families. It could be because of shared surfaces such as bathtubs or toilet seats. Some children may be carriers of streptococcal bacteria in the anus or genitals without producing disease symptoms.
What Are the Symptoms of Perianal Streptococcal Dermatitis?
The classical presentation of perianal streptococcal dermatitis is perianal erythema with a well-defined margin. It includes redness, swelling, perineal pain, itch, superficial erosions, excoriations, purulent discharge, and inflammation of the vulva or genitals. Some affected individuals also experience pain while passing bowels leading to constipation, anal cracks, and blood or pus discharge from the anus. In girls with perianal streptococcal dermatitis, the perianal infection can extend into vulvovaginitis (inflammation of the vulva and vagina), which has been reported, whereas boys develop balanitis (inflammation of the head of the penis). Few children have also reported fever, irritability, diarrhea, and muscular pain. Affected children lack manifestation of systemic symptoms.
Small papules or pustules developing in the buttocks area indicate Staphylococcus infection. Some studies have reported acral desquamation due to streptococcal exotoxin in fingers, toes, and perioral skin.
The symptoms of perianal streptococcal dermatitis typically last for three weeks to six months. When the child presents with symptoms of systemic toxicity, infection in deep skin layers is suspected.
If the above symptoms develop, the individual must immediately consult a doctor for diagnosis and treatment.
How Is Perianal Streptococcal Dermatitis Diagnosed?
Perianal streptococcal dermatitis must be diagnosed with accuracy and a thorough medical history and physical examination. It is necessary to inspect the affected patients' genitalia, anus, and perineum.
Children complaining of perineal pain and changing bowel habits must be suspected of the disease. Rapid streptococcal test helps in quicker diagnosis of bacterial infection. Definitive skin condition diagnosis is possible after a bacterial culture from swabbing the lesion or the exudate. Urine tests may be advised during subsequent follow-up to monitor the development of post-streptococcal glomerulonephritis.
What Is the Differential Diagnosis for Perianal Streptococcal Dermatitis?
The differential diagnosis for perianal streptococcal dermatitis includes candidiasis, diaper dermatitis, psoriasis, seborrheic dermatitis, pinworm infection, sexual abuse, trauma from frequent wiping, and inflammatory bowel disease. A rapid streptococcal test of the perineal area can help in differential diagnosis.
How Is Perianal Streptococcal Dermatitis Treated?
Early diagnosis and treatment can dramatically improve the symptoms of perianal streptococcal dermatitis. The disease does not resolve on its own. Perianal streptococcal dermatitis is managed with both topical and oral antimicrobials. Oral antibiotics are the first line of treatment, which can be used as standalone drugs or with topicals.
Doctors will prescribe an oral antibiotic for 14 days to treat perianal streptococcal dermatitis. Commonly prescribed antibiotics are Penicillin V, Erythromycin, Azithromycin, Clarithromycin, Clindamycin, Penicillinase-resistant penicillin, or Cephalosporins. Because amoxicillin tastes better when prepared, children can tolerate it better. The antibiotic works effectively when used with antiseptics like Chlorhexidine or antibiotics like Mupirocin.
After the completion of the antibiotic course, a perianal swab and culture are done to ensure the eradication of bacteria. Some children may need a repeat course of antibiotics.
What Are the Complications of Perianal Streptococcal Dermatitis?
The leading complication of perianal streptococcal dermatitis is discomfort caused by delay in diagnosis and treatment. Some children develop constipation, impetigo, post-streptococcal myalgia, and guttate psoriasis. Rarely do some children develop proctitis or abscess formation.
A long disease course increases the risk of transferring the bacteria to close contacts like siblings or parents. Cellulitis resulting from the streptococcal infection can produce post-glomerulonephritis. Rarely, when the streptococcal infection in the perianal region enters the bloodstream, it causes severe infection to develop, such as necrotizing fasciitis or toxic shock syndrome.
When antibiotics are taken promptly, symptoms of the bacterial infection resolve within 14 to 21 days. However, the infection can recur in one-third of children within three months due to a child’s poor hygiene or habits. A repeat course of antibiotics is given, and the doctor must counsel the child and their parents on food hygiene and break the cycle of autoinoculation.
Conclusion
Perianal streptococcal dermatitis is an infectious bacterial disease in children caused by Streptococcus bacteria. Even with clinically well-defined characteristics, the disease is often misdiagnosed. Laboratory tests of bacterial culture help with diagnosis. Early intervention with antibiotics enables swift resolution of symptoms.
