Randomized, comparative efficacy trial of oral penicillin versus cefuroxime for perianal streptococcal dermatitis in children

Perianal streptococcal disease in childhood: systematic literature review

Group A Streptococcus has been associated with a perianal infection. We conducted a systematic review of the literature on childhood streptococcal perianitis in three databases: Excerpta Medica, National Library of Medicine, and Web of Science. The main purposes were to document the clinical features, the tendency to recur, the association with an asymptomatic streptococcal throat carriage, the accuracy of rapid streptococcal tests, and the mechanism possibly underlying the acquisition of this infection. More than 80% of cases are boys ≤7.0 years of age with defecation disorders, perianal pain, local itch, rectal bleeding, or fissure and a sharply demarcated perianal redness. Perianitis is associated with a streptococcal tonsillopharyngitis in about every fifth case. The time to diagnosis is ≥3 weeks in 65% of cases. Recurrences occur within 3½ months in about 20% of cases. An asymptomatic group A streptococcal throat carriage occurs in 63% of cases. As compared with perianal Streptococcus A culture, the rapid streptococcal tests have a positive predictive value of 80% and a negative predictive value of 96%. It is hypothesized that digital inoculation from nasopharynx to anus underlies perianitis. Many cases are likely caused directly by children, who are throat and nasal carriers of Streptococcus A. Some cases might occur in children, who have their bottoms wiped by caregivers with streptococcal tonsillopharyngitis or carriage of Streptococcus.Conclusion: Perianitis is an infection with a distinctive presentation and a rather long time to diagnosis. There is a need for a wider awareness of this condition among healthcare professionals. What is Known: • Group A Streptococcus may cause perianitis in childhood. • Systemic antimicrobials (penicillin V, amoxycillin, or cefuroxime) are superior to topical treatment. What is New: • The clinical presentation is distinctive (defecation disorders, perianal pain, local itch, rectal bleeding, or fissure and a sharply demarcated perianal redness). • The time to diagnosis is usually ≥3 weeks. Recurrences occur in about 20% of cases.

Perianal infectious dermatitis: An underdiagnosed, unremitting and stubborn condition

Perianal infectious dermatitis (PID) represents a superficial inflammation of the perianal skin, which is of bacterial origin (classically, group A beta-hemolytic streptococci). This narrative review aims to critically review and summarize the available scientific literature regarding pediatric PID, being the first of its kind, to the best of the author’s knowledge. It also reports the first cases of Romanian children with PID. Multiple databases were subjected to systematic literature search (from 1966 to April 30, 2018) to identify studies and case reports of children with PID. As such, this review provides updated information about essential aspects of PID (epidemiology, etiology, pathogenesis, as well as clinical features, required investigations and therapeutic options) and of diagnostic pitfalls. Although a well-defined entity, PID remains largely underdiagnosed. PID may mimic other common conditions with skin manifestations (like candidiasis, pinworms, eczema, irritant dermatitis, anal fissure, hemorrhoids, Crohn’s disease, psoriasis, seborrheic dermatitis, zinc deficiency dermatosis and even sexual abuse), with consequent unnecessary, sometimes expensive and invasive investigations and futile therapies, which cause patients and families discomfort and distress. Since PID has an unremitting course, early recognition is imperative, as it allows for prompt and efficacious antibiotic therapy. However, PID represents a stubborn condition and, even if properly treated, its recurrence rate remains high. Further well-designed prospective randomized controlled trials, with adequate follow-up, are required in order to formulate the optimum personalized antibiotic therapy (oral alone or in association with topical medication), able to prevent recurrences. Awareness of this condition by healthcare professionals should improve patient outcomes.

Differential diagnoses of diaper dermatitis

Diaper dermatitis is the most common contact eczema present in early childhood. The main cause is an irritant reaction to urine and feces, which is facilitated by the occlusive conditions under the diaper, leading to hyperhydration of the stratum corneum (diaper dermatitis). In addition, diaper pressure and friction can increase the risk of skin inflammation, which also opens the skin up to other irritant agents, allergens, and infectious agents, such as candida albicans. However, a variety of diseases are associated with inflammation of the skin in the diaper region, therefore the term "diaper dermatitis" is merely descriptive and does not reflect anything about the etiopathogenesis. The term diaper dermatitis refers only to an inflammation in the diapering area and should not be automatically equated with reactions to diapers. Making the correct diagnosis requires a thorough examination of the skin in its entirety and a detailed report of the patient's medical and family history. Once a specific pattern is identified, a precise diagnosis, and an appropriate therapy, can be determined.

Diagnosis and management of diaper dermatitis in infants with emphasis on skin microbiota in the diaper area

Diaper dermatitis is the most common inflammatory skin eruption within the diaper area in infants and toddlers. Although it rarely causes problems for prolonged periods of time, it causes considerable distress for both infants and parents. Diapered skin is exposed to friction, excessive hydration, varying pH, and is in constant contact with urine and feces, both of which are highly irritant to the skin. The three most common types of diaper dermatitis include chaffing dermatitis, irritant contact dermatitis, and diaper candidiasis. However, a variety of other skin conditions may manifest in the diaper area. Candida albicans and Staphylococcus aureus are most frequently isolated from the affected area and are thought to have a predominant role in diaper dermatitis. The review includes an overview of the epidemiology, etiology, and common skin microbiota in the diaper area. State-of-the-art strategies for diagnosis, management, and prevention of diaper dermatitis are also included. Appropriate skin care can help in the prevention of diaper dermatitis and can aid the reparation of the skin. This review discusses common causes, skin microbiota within the diapered area, differential diagnosis, and finally possible prevention and treatment recommendations. Recent findings have proven that the key to efficient eradication of irritant diaper dermatitis lies in its prevention.

The ABCs of Perineal Streptococcal Dermatitis

Perineal streptococcal dermatitis (PSD) is largely known to be caused by group A β-hemolytic Streptococcus (GAS). We would like to bring cases of non-GAS PSD to the attention of dermatologists, as there are implications for workup and therapy. We report 3 pediatric cases of PSD: 1 caused by GAS, 1 caused by group B β-hemolytic Streptococcus (GBS), and 1 associated with group C β-hemolytic Streptococcus (GCS). GBS and GCS are very rarely reported in pediatric cases of PSD. The literature on non-GAS PSD is reviewed, which additionally revealed several instances of PSD caused by group G β-hemolytic Streptococcus (GGS) and Staphylococcus aureus. GBS, GCS, GGS, and S aureus are significant causes of PSD to consider, particularly among adult patients, based on our encountered cases and the literature. If using rapid antigen tests to expedite the diagnosis of GAS, we recommend supplementing with a lesional swab for bacterial culture and sensitivity as the rapid antigen test does not detect non-GAS organisms. Therapy should be tailored to the microbiologic cause.

[Group A streptococcal perineal infection in children]

Perineal diseases in children are usually caused by group A streptococcus (GAS). If the natural course of untreated cases is not known, it is well known that symptoms do not resolve spontaneously and can persist often for many months, until appropriate diagnosis and effective treatment are instituted. Furthermore, failures and recurrences after penicillin treatment are frequent. From 2009 to 2014, 165 perineal infections (median age: 48 months, extremes: 0.4-139) were enrolled by 15 pediatricians: 4 balanitis, 29 vulvo-vaginal diseases and 132 perianal infections. Painful defecation, anal fissures and macroscopic blood in stools were significantly more frequent in GAS perianal infections than negative GAS infections (p<0.01). The performance of GAS-rapid antigen test compared to the GAS culture was : sensitivity 97 % [CI 95 %: 89-100 %], specificity 76 % [CI 95 %: 66-84 %], negative predictive value 97 % [CI 95 %: 91-100 %], positive predictive value 71 % [CI 95 %: 60-80 %].

Diagnostic accuracy of clinical symptoms and rapid diagnostic test in group A streptococcal perianal infections in children

From 2009 to 2014, we prospectively enrolled 132 children with perianal infections. The presentation of painful defecation, anal fissures, and macroscopic blood in stools was highly suggestive of group A streptococcal perianal infection (probability 83.3%). We found a high sensitivity of a group A streptococcal rapid diagnostic testing (98%) but relatively low specificity (72.8%).

Paediatric vulvar disease

Paediatric vulvar skin conditions are relatively common but often cause diagnostic difficulties for clinicians, which can lead to anxiety within the children's families. Vulvar skin conditions can be caused by various underlying aetiologies. Most are general dermatologic conditions that occur in the vulvar area, such as eczema, psoriasis, skin lesions or infections. However, other conditions such as lichen sclerosus and napkin dermatitis ('nappy rash') only affect the genital region. Every affected child needs a sensitive evaluation of the complaint including an assessment of the impact of the condition on the patient and her family. Paediatric vulvar disease often influences bowel and bladder habits and may lead to behavioural problems. General measures such as avoidance of irritants or soap substitution and regular use of emollients are helpful for all patients. Specific therapy depends upon the underlying diagnosis. Time spent reassuring the families, reinforcing regimens and providing written documentation can all be very helpful in successful management of paediatric vulvar skin conditions.

Outcomes in children treated for perineal group A beta-hemolytic streptococcal dermatitis

OBJECTIVES

To evaluate reports that describe relapse or recurrence following treatment of perineal streptococcal dermatitis (PSD), we studied a large cohort of children with these perianal or perivaginal infections to determine whether outcomes are related to the antimicrobial agent selected for initial treatment.

METHODS

We audited laboratory logs and medical records to retrospectively identify incident cases of culture-confirmed PSD in children at a large university-affiliated health system during 2006-2008. We estimated rates of recurrence (defined as any return visit with a clinical diagnosis of perineal dermatitis within 6 months) and, then, incorporated these rates into a meta-analysis that included 8 previous studies.

RESULTS

A total of 81 children had incident PSD during the study period, and 26 (32.1%) had a recurrence. Most (18/26 [69.2%]) had their first recurrence within 6 weeks. Among children treated with an oral agent, the recurrence rate was 16/42 (38.1%) following penicillin or amoxicillin and 10/36 (27.8%) following a beta-lactamase resistant agent (adjusted odds ratio: 2.02 [95% confidence interval {CI}: 0.69-5.92]). In the meta-analysis, recurrence rates following penicillin or amoxicillin were consistent across studies (fixed-effect test for heterogeneity, P = 0.35), and the pooled rate (37.4% [95% CI: 28.8%-46.5%]) was higher than observed following a beta-lactamase resistant agent (odds ratio: 2.39 [95% CI: 1.18-4.81]).

CONCLUSIONS

Perineal streptococcal dermatitis initially treated with penicillin or amoxicillin is consistently associated with a high risk of clinical recurrence. Whether treatment with a beta-lactamase resistant agent reduces this risk is uncertain and should be subjected to a clinical trial.