Perianal infectious dermatitis: An underdiagnosed, unremitting and stubborn condition

Table 1 Studies/case series with perianal infectious dermatitis: Clinical and bacteriological patient characteristics

Name, yr, country, study design	Population size; age; sex	Symptoms/signs1;symptom duration	Etiologyof PID	Otherfindings2
Amren, 1966, United States, PS[2]	10; 1-8 yr, half < 5 yr; 90% M	Painful defecation, constipation, anal pruritus, perianal pain, mucoid or bloody anal discharge; 1 F also with vulvo-vaginitis	GAS (culture)	Throat GAS positive: 28% (no symptoms)
Spear, 1985, United States, RS[28]	14; mean age 3.9 yr (1-10 yr); 11 M	Painful defecation (14), constipation (6), bloody stool (7), anal fissure (5); mean duration: 6.2 mo (range: 1-12 mo)	GAS (culture)
Kokx, 1987, United States, RS[4]	31; 7 mo to 8 yr (mean 4.25 ± 1.8 yr); 77% M	Perianal itching (78%), rectal pain (52%), and blood-streaked stool (35%)	GAS and RADT	Throat GAS positive: 64%; identical perianal and pharyngeal T-type (T28, 5 cases; T4, 4; T2, 1)
Krol, 1990, Canada, RS[20]	8; 8 mo to 10 yr; 6 M	Perianal pruritus (8); painful defecation (4); anal fissure (2); bloody stool (1); 3 wk to 6 mo	GAS (culture)
Grant, 1993, United Kingdom, RS[10]	20; 5 mo to 12 yr (mean 5 yr); 75% M	Perianal discomfort (14) and itch (13), fresh blood per rectum (12), pain on defecation (10), perianal pain (4), anal mucus discharge (2); 3 wk to 1 yr (mean 3 mo)	GAS (culture)
Patrizi, 1994, Italy, RS[22]	1. 10 yr, M	1. Pruritus, tenesmus, constipation, acute GP and mild balanitis	GAS (culture)	1. Throat GAS negative; penile GAS: same antibiogram
	2. 4 yr, F	2. Anal pruritus, vulvar and perineal erythema, and GP; 4 mo		2. Throat GAS negative
	3. 5 yr, F	3. PID and GP		3. Throat GAS positive
	4. 9 yr, M	4. Painful defecation, GP; 1 mo		4. Throat GAS positive
	5. 7 yr, M	5. PID and balanitis		5. GAS tonsillitis 3 mo before; penile GAS and mother with cervical GAS (child and mother bathing together)
Wright, Australia, 1994, PS[11]	22; 5 mo to 8 yr (mean 41 mo); 13 M	Painful defecation, bleeding ± anal pain, perianal pruritus, constipation	Culture: 12 GAS, 1 GBS, 1 GCS
Mostafa, 1997, Egypt, PS[15]	150; 2 mo to 11 yr (mean 3.8 ± 2.1 yr); 75% M	Perianal itching (15%), gastroenteritis (34%)	BHS: 35.3%, S. aureus 3.4%	Throat: BHS 44% (GAS 21.3%, non-GAS 22.7%); PID caused by GAS: 53.8% with same GAS in the throat
Barzilai, 1998, Israel, PS[14]	18; 7 mo to 5.4 yr; 10 M	Perianal pruritus (50%); painful defecation or constipation (44%); anal fissure (39%); purulent secretion (27%); rectal bleeding (16%); 2 GP	GAS	GAS in other locations: 72%; 4 siblings throat GAS positive (no symptoms)
Mogielnicki, 2000, United States, RS[5]	23; mean age 5 yr (1-11 yr); 13 F	13 only PID; 2 PID + vulvo-vaginitis; 8 only vulvo-vaginitis	GAS (culture)	Throat GAS positive: 92% (± symptoms)
Mateo, 2002, Spain, RS[19]	10; 9 mo to 7 yr; 6 M	Oozing and rectal bleeding, anal pruritus, pain on defecation; 1 M also GP; 20 d to 2 yr	GAS	Throat GAS positive: 3/6
Petersen, 2003, Denmark, RS[27]	17; mean age 6 yr (3-13 yr)	Painful defecation, fresh blood on stool	GAS 12 (11 M) T28	Throat GAS positive 12%; 6/12 with T28 from kindergarten
Landolt, 2005, Switzerland, RS[17]	13; 7 F	Obstipation (58%), painful defecation (50%), perianal itching (25%), melena (25%); 10 cases with > 1 symptom	GAS positive in 12
Echeverría Fernández, 2006, Spain, PS[6]	19; 6 mo to 4 yr (median age 12 mo)	Anal pruritus (19), constipation (9), anal fissures (5), rectal bleeding (4), vulvo-vaginitis (2)	GAS (RADT and culture)	Throat GAS positive: 80%; GAS pharyngitis: 1 case
Meury, 2008, Switzerland, RCT[12]	35; 1-16 yr	Either typical erythema or at least 2 of: perianal itching, rectal pain, painful defecation, constipation, blood-streaked stool, rectal mucopurulent discharge, or anal fissure	GAS
Jongen, 2008, Germany, RS[8]	21; < 14 yr (mean age 6.3 yr); 76% M	Perianal itching, sore anus, bleeding and pain at defecation; mean duration of 6.6 months (2 wk to 2 yr)	17 GAS, 4 (culture)
Shouval, 2008, Israel, RS[18]	11; 6 mo to 4 yr (mean 24 mo); 73% M	Irritability (all), perianal itching (6) and pain (3); < 28 d	GAS (RADT)
Heath, 2009, United States, RS[26]	26; 5 mo to 12 yr; 15 F	Anal erythema or recurrent buttocks dermatitis; in PID caused by S. aureus: specific small papules and pustules of the buttocks or extension of the erythema to adjacent buttock skin	S. aureus 82%, GAS, GBS
Olson, 2011, United States, RS[25]	81; mean age, M: 4.1 yr and F: 4.6 yr; 58% M	(86.4%) perianal involvement; (22.2%) symptoms for at least 2 wk (6.2% with symptoms for at least 4 wk); the rest: duration < 1 wk	GAS
Clegg, 2015, United States, RS[23]	157; 18 d to 12.5 yr, mean 4.8 yr, 53% M	Predominant site of involvement: M: perianal (86%) and F: perivaginal area (62%); 9.8 d	GAS	Throat GAS positive: 95%; 100% concordance between perineal and pharyngeal GAS
Cohen, 2015, France, PS[16]	132; mean age 46.6 ± 23.5 mo; 64% M	Painful defecation, anal fissure, bloody stools; 4 also vulvo-vaginitis; 2 wk	GAS (RADT and culture)
Garcia, 2015, Spain, RS[21]	6; 9 mo to 5 yr (mean age 3 yr); 5 M	Perianal rash (6), rectal pain (3), itching (2), vaginitis (1)	GAS	GAS pharyngitis: 30%
Sterbenc, 2016, Slovenia, RS[24]	89 cases < 15 yr (84.7%); median age 5 yr		GAS, GBS, GCS, GGS

¹Besides typical perianal erythema;

²Especially throat culture and infections in the family/community. AB: Antibiotic; BHS: Beta-hemolytic streptococci; F: Female; GAS: Group A beta-hemolytic streptococci; GBS: Group B beta-hemolytic streptococci; GCS: Group C beta-hemolytic streptococci; GP: Guttate psoriasis; M: Male; Pen: Penicillin; PID: Perianal infectious dermatitis; PS: Prospective study; RADT: Rapid antigen detection test; RCT: Randomized controlled trial; RS: Retrospective study; S. aureus: Staphylococcus aureus; T2: T-type 2 of GAS; T28: T-type 28 of GAS; T4: T-type 4 of GAS.