Perianal Streptococcal Dermatitis


Article Author:
Kevin Pennycook


Article Editor:
Tess McCready


Editors In Chief:
David Wood
Andrew Wilt
Hajira Basit


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
9/21/2019 8:24:25 PM

Introduction

Perianal streptococcal dermatitis is an infectious dermatologic disease that typically affects children between the ages of 6 months and 10 years old. The disease is more properly characterized as cellulitis because the most common causative agent is group A beta-hemolytic streptococci. Perianal streptococcal dermatitis classically presents as perianal erythema with well-defined margins. Superficial erosions, anal fissures, excoriations, and purulent discharge may also be present. Clinicians can make a definitive diagnosis with a bacterial culture after swabbing the lesion. A combination of oral antibiotics and topical antiseptics is the treatment of choice. The diagnosis of perianal streptococcal dermatitis should merits consideration when encountering a child who has changes in bowel movements and perineal complaints.[1][2][3]

Etiology

Perianal streptococcal dermatitis (PSD) is a slight misnomer. The term dermatitis is used to describe an irritated and inflamed epidermis. While an irritated epidermis is observable with PSD, the disease is actually most commonly caused by the infection of group A beta-hemolytic streptococci (GABHS). Therefore, PSD is more correctly a variant of cellulitis rather than dermatitis.[1][4]

Epidemiology

The most common age group affected by perianal streptococcal dermatitis are patients between the ages of 6 months and 10 years old. Males are more commonly affected than females with a ratio between 3 to 1 and 2 to 1. Interestingly, patients are more commonly affected in the winter and spring months. While perianal streptococcal dermatitis is typically thought to be a pediatric disease, there have been case reports in adults.[1][4]

Pathophysiology

Perianal streptococcal dermatitis classifies as cellulitis most commonly caused by GABHS. There are multiple hypotheses about the mode of infection of the perineum by GABHS. One hypothesis proposes the autoinoculation of the perineal tissues by digital contact with the oral cavity, nasal cavity, and the perineum. Patients transfer the bacteria to the perineum either by direct digital contact or swallowing the bacteria. This hypothesis garners support from the fact that 92% of PSD diagnoses had concomitant pharyngeal GABHS. There is also a belief that fomites could play a role in the transmission of GABHS to cause PSD. Previous studies have found there is a higher occurrence within families and daycare centers. Some attribute the higher occurrence rates to shared surfaces such as toilet seats or bathtubs.[1]

History and Physical

A complete history and physical exam are integral to the accurate and timely diagnosis of perianal streptococcal dermatitis. History from the pediatric patient needs include the parents. Spending time to conduct a precise history and physical exam will lead the physician to a relatively straightforward diagnosis. Clinicians should have a high index of suspicion for the diagnosis of PSD with any child who has perineal pain and changes in bowel habits. 

Typical symptoms of perianal streptococcal dermatitis include:

  • Perineal pain
  • Pain with defecation leading to constipation
  • Pruritus
  • Blood in stool
  • Purulent Exudate
  • Lack of systemic symptoms

For the diagnosis of PSD, the anus, perineum, and genitalia require examination. PSD classically presents with varying degrees of perianal erythema with well-defined margins. Superficial erosions, anal fissures, excoriations, and purulent discharge may also be present. Once the clinician considers a diagnosis of PSD, definitive tests are necessary.[2][1][3][5]

Evaluation

For a definitive diagnosis of perianal streptococcal dermatitis, bacterial swabs are necessary from the affected areas; ideally of the exudate. The swabs will be sent for culture to confirm the growth of GABHS.[1] Blood tests such as anti-streptolysin O antibodies and anti streptokinase titers have been deemed unreliable to diagnose PSD.[6] Finally, a urinalysis should be obtained to monitor for post-streptococcal glomerulonephritis during follow up appointments.[1]

Treatment / Management

After making the diagnosis of perianal streptococcal dermatitis, treatment is relatively straightforward. In minor cases of the disease, some sources recommend treating PSD with topical antimicrobials. However, oral antibiotics are the recommended first-line treatment of the disease. The most successful treatment regimens utilize a combination of systemic and topical antibiotics. Systemic antibiotics include penicillin V, erythromycin, azithromycin, clarithromycin, clindamycin, penicillinase-resistant penicillin, or cephalosporins. These oral antibiotics work best in conjunction with a topical antiseptic such as chlorhexidine, or an antibiotic such as mupirocin. Treatment duration is for 14 to 21 days, and perianal swabs and culture should be taken to ensure eradication of the bacteria.[1][7]

Differential Diagnosis

The following differential diagnoses merit consideration[1][8]:

  • Irritant dermatitis - heavy wiping or manipulation
  • Candidiasis
  • Seborrheic dermatitis
  • Atopic dermatitis
  • Psoriasis
  • Allergic contact dermatitis
  • Pinworm infection
  • Inflammatory bowel disease
  • Histiocytosis
  • Sexual abuse

Prognosis

With proper antibiotic use, perianal streptococcal dermatitis usually resolves within 14 to 21 days. However, there is a chance for recurrence due to children's poor hygiene and habitual behaviors.[9] Pediatric patients and their parents need to be counseled on proper hand hygiene and breaking the process of autoinoculation.

Complications

Prolonged discomfort due to delayed diagnosis and treatment is the leading complication of perianal streptococcal dermatitis. There are also extremely rare cases, such as proctitis and abscess formation, caused by concurrent PSD. A prolonged disease course also increases the risk of bacterial transmission to close contacts, particularly siblings and parents. Rheumatic fever is a theoretical complication of PSD. However, there are no case reports published describing this sequela. Cellulitis caused by GABHS, including PSD, can cause post-streptococcal nephritis. Therefore, follow up urinalysis is essential to monitor kidney function.[1][10]

Deterrence and Patient Education

Perianal streptococcal dermatitis is a rather simple dermatologic disease to treat. However, patient education is an absolutely essential piece of the treatment plan that often gets overlooked. Patients and their parents require counseling on the importance of follow up appointments. A repeat perineal swab needs to be obtained to ensure complete eradication of GABHS. Performing this step will reduce the chance of PSD recurrence. During the follow-up appointment, a urine specimen also needs to be collected and sent for analysis to monitor for post-streptococcal nephritis. Finally, patients and families need to be educated on proper hygiene techniques to reduce the transmission of the causative organism.[1][10][9]

Enhancing Healthcare Team Outcomes

The management of rashes in the pediatric population requires an interprofessional team. There are many causes of rashes in infants, and the presentation is diverse. Thus, when in doubt, the primary care clinicians and nurses should refer these patients to a pediatrician or a dermatologist. Not all rashes that occur in the perineum area are due to candida and delays in diagnosis and treatment only leads to more morbidity.

Laboratory technicians need to be included in the healthcare team to enhance healthcare team outcomes while treating PSD. With routine perineal swabs, laboratories may plate the specimen on MacConkey agar in search of enteric stool pathogens. This medium will not grow GABHS and will miss the diagnosis of PSD. Therefore, the clinician needs to communicate with the laboratory to search for GABHS and ensure the laboratory plates the specimen on blood agar. This simple communication will minimize an unnecessary delay in identifying the causative organism and therefore, any delay in treatment.[11][1] [Level-V]

Nursing and pharmacy both play an essential role in the management of perianal streptococcal dermatitis. Nursing can administer medication and also counsel patients and parents about applying topical agents properly. The pharmacist can also consult on appropriate antimicrobial agent selection and also offer additional patient (parental) counseling on drug therapy. Both nursing and pharmacy need an open communication channel with the treating clinician to report any concerns they may have. Only with this type of open and collaborative team approach can management of perianal streptococcal dermatitis offer the best patient outcomes. [Level V]


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Perianal Streptococcal Dermatitis - Questions

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A 5-year-old female presents to the clinic with her mother. The mother states that the patient has been complaining of anal pain and pruritus for the past week. The patient reports that this morning, she experienced blood in her stool. On physical examination, a beefy red plaque around the anus with multiple excoriations are present. The skin lesion is tender to palpation. The clinician correctly diagnoses the patient’s condition and prescribes a course of penicillin. What is the expected duration of antibiotic treatment typically required to resolve this condition?



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A 10-year-old male presents to the clinic with his mother for evaluation of pain with defecation over the past few days. The patient also reports blood in his stool and anal pruritus during this time. On physical exam, perianal erythema is present along with purulent exudate draining from the anus. What test can be used to confirm this patient’s diagnosis?



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An 8-month-old male is brought to the clinic by his mother for evaluation of rash. She reports that she noticed the rash in the diaper area a few days ago, and it is worsening. The patient has been crying for the past few days and seems to be uncomfortable. On physical examination, there is perianal erythema, and purulent exudate is draining from the anus. The mother confirms the child is meeting all other developmental milestones timely. What is the most appropriate management of this patient’s condition?



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A 7-month-old baby is brought to the clinic by his mother for a rash. The patient’s mother reports her son has redness around his anus that is draining pus. On physical exam, perianal erythema and purulent exudate are present. The patient is given appropriate oral and topical medication. What is the most likely underlying cause of this patient’s condition?



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A mother brings her 3-year-old child into the office. She reports her child is constipated and has a rash in his diaper area. The mother also reports that the child cries when she attempts to clean the area. On physical exam, there is a sharply demarcated area of erythema surrounding the child’s anus with superficial erosions. What is the most appropriate method to confirm the diagnosis?



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A 5-year-old boy presents to the office with his mother. For the past week, the child has been complaining of “pain around his bottom.” On physical exam, there is an erythematous skin lesion surrounding the anus with superficial erosions. An anal fissure is also noted posteriorly. Which of the following is most often associated with this condition?



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A 7-year-old girl is brought to the clinic for a well-child visit. For the past week, she has developed a painful rash on her bottom. Most recently, the patient has experienced increasing pain with defecation that has resulted in constipation. On physical exam, the clinician notes an inflamed, beefy red plaque around the anus. There are also multiple excoriations and purulent exudate. The skin lesion is tender to palpation. What is the best initial therapy for this patient?



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A patient is brought to the clinic with a painful skin lesion. The lesion has been present for the past week, and now the patient is experiencing constipation due to pain with defecation. On physical exam, there is a well-defined area of erythema surrounding the anus, with excoriations and translucent discharge from superficial erosions. The skin lesion is tender to palpation. After bacterial swabs from the lesion confirm the diagnosis, oral antibiotics are prescribed for 21 days. Which of the following best identifies the demographic information of the patient?



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Perianal Streptococcal Dermatitis - References

References

Herbst R, Perineal streptococcal dermatitis/disease: recognition and management. American journal of clinical dermatology. 2003;     [PubMed]
Lehman R,Pinder S, Streptococcal perianal infection in children. BMJ (Clinical research ed.). 2009 May 5;     [PubMed]
Palha MJ,Limão S,Santos MC,Cunha F, Perianal streptococcal dermatitis. Pediatrics and neonatology. 2019 Apr 13;     [PubMed]
Šterbenc A,Seme K,Lah LL,Točkova O,Kamhi Trop T,Švent-Kučina N,Pirš M, Microbiological characteristics of perianal streptococcal dermatitis: a retrospective study of 105 patients in a 10-year period. Acta dermatovenerologica Alpina, Pannonica, et Adriatica. 2016 Dec;     [PubMed]
Marks VJ,Maksimak M, Perianal streptococcal cellulitis. Journal of the American Academy of Dermatology. 1988 Mar;     [PubMed]
Amren DP,Anderson AS,Wannamaker LW, Perianal cellulitis associated with group A streptococci. American journal of diseases of children (1960). 1966 Dec;     [PubMed]
Petersen JP,Kaltoft MS,Misfeldt JC,Schumacher H,Schønheyder HC, Community outbreak of perianal group A streptococcal infection in Denmark. The Pediatric infectious disease journal. 2003 Feb;     [PubMed]
Jongen J,Eberstein A,Peleikis HG,Kahlke V,Herbst RA, Perianal streptococcal dermatitis: an important differential diagnosis in pediatric patients. Diseases of the colon and rectum. 2008 May;     [PubMed]
Mempel M,Schnopp C, [Selected bacterial infections of the skin in childhood]. Der Hautarzt; Zeitschrift fur Dermatologie, Venerologie, und verwandte Gebiete. 2015 Apr;     [PubMed]
Block SL, Perianal dermatitis: much more than just a diaper rash. Pediatric annals. 2013 Jan;     [PubMed]
Krol AL, Perianal streptococcal dermatitis. Pediatric dermatology. 1990 Jun;     [PubMed]

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