Recent microbiological shifts in perianal bacterial dermatitis: Staphylococcus aureus predominance

Body distribution of impetigo and association with host and pathogen factors

Background

Impetigo or skin sores are estimated to affect >162 million people worldwide. Detailed descriptions of the anatomical location of skin sores are lacking.

Methods

We used prospectively collected data from a randomised control trial of treatments for impetigo in Aboriginal children in Australia. We generated heat-map distributions of skin sores on the human body from 56 predefined anatomical locations and stratified skin sore distribution by sex, age, causative pathogen and co-infection with scabies, tinea and head lice. We compared the distribution of sores between males and females, between sores with only Streptococcus pyogenes and sores with only Staphylococcus aureus; and across age groups with a Fisher’s exact test.

Results

There were 663 episodes of impetigo infections among 508 children enrolled in the trial. For all 663 episodes, the lower limbs were the most affected body sites followed by the distal upper limbs, face and scalp. On the anterior surface of the body, the pre-tibial region was the most affected while on the posterior surface, the dorsum of the hands and calves predominated. There was no observable difference between males and females in distribution of sores. Children up to 3 years of age were more likely to have sores on the upper posterior lower limbs and scalp than older age groups, with the distribution of sores differing across age groups (p = 3 × 10−5). Sores from which only Staphylococcus aureus was cultured differed in distribution to those with only Streptococcus pyogenes cultured (p = 3 × 10−4) and were more commonly found on the upper posterior lower limbs.

Conclusions

Skin sores were predominantly found on exposed regions of the lower leg and distal upper limbs. The distribution of sores varied by age group and pathogen. These results highlight key areas of the body for clinicians to pay attention to when examining children for skin sores.

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.

Perianal Lesions in Children: An Updated Review

Perianal lesions in children are common reasons for dermatology clinic visits and a well-defined approach to diagnosis and management is helpful to the practicing clinician. In this article, we review and update various etiologies of perianal lesions in the pediatric population, including infectious, papulosquamous, vascular, and neoplastic. We provide a standard initial approach to diagnosis and updates on current management. Infectious etiologies of perianal lesions discussed in this article include fungal, bacterial, parasitic, and viral. Perianal papulosquamous lesions often encountered in children, and discussed in this article, include acrodermatitis enteropathica, psoriasis, contact dermatitis, and many others. We also discuss the diagnosis and management of other entities including infantile hemangiomas, Langerhans cell histiocytosis, and fibrous hamartoma of infancy.

Differential Diagnosis of Diaper Dermatitis

Mild diaper dermatitis often occurs in children before toilet training is complete, particularly from 9 to 12 months of age, and the most common presentation is an irritant contact dermatitis. Diaper dermatitis may account for up to 25% of dermatology visits to health care providers during the first year of life. Fortunately, since the introduction of hypoallergenic, superabsorbent modern disposable diapers, the incidence and severity of irritant and allergic contact dermatitis has decreased dramatically. Diaper dermatitis broadly refers to skin disorders that occur in the diaper area, such as skin eruptions triggered by diapers, rashes exacerbated by the diaper, and other events that occur in the diaper area. A number of skin conditions that can occur anywhere on the skin may present with distinctive findings in the diaper area. The following discussion will review the most common triggers of diaper dermatitis and contact irritant dermatitis, while focusing on the skin conditions that may be associated or overlap clinically with contact dermatitis.

Typical and atypical clinical appearance of atopic dermatitis

Atopic dermatitis is a complex, systemic inflammatory disorder associated with a variety of clinical features. The original criteria of Hanifin and Rajka include major criteria and a list of about two dozen minor criteria however, even the minor criteria do not include some features of atopic dermatitis noted less commonly but still seen with some frequency. This contribution first reviews the common clinical appearance of atopic dermatitis in infancy, childhood, and adulthood, as well as the less typical appearances, including lichenoid atopic dermatitis; juvenile plantar dermatosis; nummular-type atopic dermatitis; follicular atopic dermatitis; alopecia of atopic dermatitis; eczema coxsackium; and psoriasiform, perineal, and lip licker's dermatitis. The clinician will be able to recognize and treat rarer forms of atopic dermatitis and incorporate this into their daily practice.

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 %].

Diaper dermatitis: clinical characteristics and differential diagnosis

A diverse group of diseases can cause skin conditions in the diaper area including those which are directly caused by diapers or the diaper environment, some which are not directly due to, but are worsened by, the wearing of diapers, and those which are independent of the presence of the diaper or its resulting environment. Many of these conditions are limited to this area of the skin, but others extend to skin outside this area, and some are signs of systemic disease. We review many of the important causes of eruptions in the diaper area and emphasize key points in the differential diagnosis.

Diagnosis and management of diaper dermatitis

This article presents an overview of diaper dermatitis for the pediatric community. The pathogenesis, differential diagnosis, and management of this common condition in infancy are reviewed. This information will assist in making the appropriate diagnosis and managing this irritant contact dermatitis of the diaper area. With conservative management, most cases of irritant diaper dermatitis are self-limited. When the condition persists, one must consider other diagnoses.

Diaper dermatitis: a review and update

PURPOSE OF REVIEW

Diaper dermatitis is the most common cutaneous diagnosis in infants. In this review, common causes of diaper dermatitis and similarly presenting conditions will be covered, as well as updates on treatments of common diaper dermatitides.

RECENT FINDINGS

There have been recent advancements in the treatment of diaper dermatitis. In addition, there are many newly recognized causes of diaper dermatitis that clinicians should be aware of.

SUMMARY

Irritant dermatitis is the most common cause of diaper dermatitis. However, there are multiple other common causes of diaper dermatitis and it is thus imperative that the clinician be aware of cutaneous mimickers of irritant diaper dermatitis as well as their treatments.

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.