• Sign Up

Perianal Streptococcal Dermatitis


Perianal Streptococcal Dermatitis

Article Author:
Kevin Pennycook
Article Editor:
Tess McCready
Updated:
6/29/2020 1:24:26 AM
For CME on this topic:
Perianal Streptococcal Dermatitis CME
PubMed Link:
Perianal Streptococcal Dermatitis

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 interprofessional team approach can the management of perianal streptococcal dermatitis offer the best patient outcomes. [Level 5]


References

[1] Herbst R, Perineal streptococcal dermatitis/disease: recognition and management. American journal of clinical dermatology. 2003;     [PubMed PMID: 12862498]
[2] Lehman R,Pinder S, Streptococcal perianal infection in children. BMJ (Clinical research ed.). 2009 May 5;     [PubMed PMID: 19416994]
[3] Palha MJ,Limão S,Santos MC,Cunha F, Perianal streptococcal dermatitis. Pediatrics and neonatology. 2019 Apr 13;     [PubMed PMID: 31036462]
[4] 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 PMID: 28006879]
[5] Marks VJ,Maksimak M, Perianal streptococcal cellulitis. Journal of the American Academy of Dermatology. 1988 Mar;     [PubMed PMID: 3280624]
[6] Amren DP,Anderson AS,Wannamaker LW, Perianal cellulitis associated with group A streptococci. American journal of diseases of children (1960). 1966 Dec;     [PubMed PMID: 5928818]
[7] 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 PMID: 12586971]
[8] 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 PMID: 18324440]
[9] Mempel M,Schnopp C, [Selected bacterial infections of the skin in childhood]. Der Hautarzt; Zeitschrift fur Dermatologie, Venerologie, und verwandte Gebiete. 2015 Apr;     [PubMed PMID: 25783212]
[10] Block SL, Perianal dermatitis: much more than just a diaper rash. Pediatric annals. 2013 Jan;     [PubMed PMID: 23316826]
[11] Krol AL, Perianal streptococcal dermatitis. Pediatric dermatology. 1990 Jun;     [PubMed PMID: 2359737]