Review
Copyright ©The Author(s) 2018.
World J Clin Pediatr. Oct 25, 2018; 7(4): 89-104
Published online Oct 25, 2018. doi: 10.5409/wjcp.v7.i4.89
Table 1 Studies/case series with perianal infectious dermatitis: Clinical and bacteriological patient characteristics
Name, yr, country, study designPopulation size; age; sexSymptoms/signs1;symptom durationEtiologyof PIDOtherfindings2
Amren, 1966, United States, PS[2]10; 1-8 yr, half < 5 yr; 90% MPainful defecation, constipation, anal pruritus, perianal pain, mucoid or bloody anal discharge; 1 F also with vulvo-vaginitisGAS (culture)Throat GAS positive: 28% (no symptoms)
Spear, 1985, United States, RS[28]14; mean age 3.9 yr (1-10 yr); 11 MPainful 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% MPerianal itching (78%), rectal pain (52%), and blood-streaked stool (35%)GAS and RADTThroat 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 MPerianal pruritus (8); painful defecation (4); anal fissure (2); bloody stool (1); 3 wk to 6 moGAS (culture)
Grant, 1993, United Kingdom, RS[10]20; 5 mo to 12 yr (mean 5 yr); 75% MPerianal 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, M1. Pruritus, tenesmus, constipation, acute GP and mild balanitisGAS (culture)1. Throat GAS negative; penile GAS: same antibiogram
2. 4 yr, F2. Anal pruritus, vulvar and perineal erythema, and GP; 4 mo2. Throat GAS negative
3. 5 yr, F3. PID and GP3. Throat GAS positive
4. 9 yr, M4. Painful defecation, GP; 1 mo4. Throat GAS positive
5. 7 yr, M5. PID and balanitis5. 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 MPainful defecation, bleeding ± anal pain, perianal pruritus, constipationCulture: 12 GAS, 1 GBS, 1 GCS
Mostafa, 1997, Egypt, PS[15]150; 2 mo to 11 yr (mean 3.8 ± 2.1 yr); 75% MPerianal 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 MPerianal pruritus (50%); painful defecation or constipation (44%); anal fissure (39%); purulent secretion (27%); rectal bleeding (16%); 2 GPGASGAS 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 F13 only PID; 2 PID + vulvo-vaginitis; 8 only vulvo-vaginitisGAS (culture)Throat GAS positive: 92% (± symptoms)
Mateo, 2002, Spain, RS[19]10; 9 mo to 7 yr; 6 MOozing and rectal bleeding, anal pruritus, pain on defecation; 1 M also GP; 20 d to 2 yrGASThroat GAS positive: 3/6
Petersen, 2003, Denmark, RS[27]17; mean age 6 yr (3-13 yr)Painful defecation, fresh blood on stoolGAS 12 (11 M) T28Throat GAS positive 12%; 6/12 with T28 from kindergarten
Landolt, 2005, Switzerland, RS[17]13; 7 FObstipation (58%), painful defecation (50%), perianal itching (25%), melena (25%); 10 cases with > 1 symptomGAS 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 yrEither typical erythema or at least 2 of: perianal itching, rectal pain, painful defecation, constipation, blood-streaked stool, rectal mucopurulent discharge, or anal fissureGAS
Jongen, 2008, Germany, RS[8]21; < 14 yr (mean age 6.3 yr); 76% MPerianal 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% MIrritability (all), perianal itching (6) and pain (3); < 28 dGAS (RADT)
Heath, 2009, United States, RS[26]26; 5 mo to 12 yr; 15 FAnal 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 skinS. 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 wkGAS
Clegg, 2015, United States, RS[23]157; 18 d to 12.5 yr, mean 4.8 yr, 53% MPredominant site of involvement: M: perianal (86%) and F: perivaginal area (62%); 9.8 dGASThroat GAS positive: 95%; 100% concordance between perineal and pharyngeal GAS
Cohen, 2015, France, PS[16]132; mean age 46.6 ± 23.5 mo; 64% MPainful defecation, anal fissure, bloody stools; 4 also vulvo-vaginitis; 2 wkGAS (RADT and culture)
Garcia, 2015, Spain, RS[21]6; 9 mo to 5 yr (mean age 3 yr); 5 MPerianal rash (6), rectal pain (3), itching (2), vaginitis (1)GASGAS pharyngitis: 30%
Sterbenc, 2016, Slovenia, RS[24]89 cases < 15 yr (84.7%); median age 5 yrGAS, GBS, GCS, GGS
Table 2 Studies/case series with perianal infectious dermatitis: Therapy and follow-up of patients
Name, yr, countryTherapy of PID and resultsFollow-up of PID
Amren, 1966, United States[2]IM Pen, 10 d plus oral Pen, 10 d: disappearance of symptoms in 2-3 dAfter therapy: 2 cases GAS positive; 10 d of Pen (same type): Effective in eradicating GAS in both cases
Spear, 1985, United States[28]Oral Pen: rapid resolution of PIDRecurrence of infection: Not uncommon, requiring a repeated course of oral AB
Kokx, 1987, United States[4]Oral Pen or amoxicillin, 10 d: clinical and bacteriological clearance in 61%39% relapses, treated with IM or oral Pen; 4 children failed; 3 successfully treated with oral clindamycin, 10 d; 4th case successfully treated with oral Pen (10 d) and rifampin (last 4 d)
Krol, 1990, Canada[20]Oral Pen, 10 d plus topical mupirocin in 4 cases (these 4 without recurrence)2 cases: 2nd course of therapy within 1 mo
Grant, 1993, United Kingdom[10]Oral Pen, 3 wk: 14 responded (6 plus topical fucidin)6 cases: No complete response; successful 2nd course of oral Pen and topical fucidin
Patrizi, 1994, Italy[22]1. Oral erythromycin, 14 d1. 4 wk later, GP and PID disappeared and all swabs negative
2. Oral Pen, 2 wk2. Lesions improved, but swab positive: erythromycin, 2 wk: complete healing (including negative GAS)
3. Oral erythromycin, 2 wk3. Lesions disappeared in maximum 5 wk
4. Oral erythromycin and topical mupirocin, 2 wk4. 4 wk later, lesions and culture negative
5. Amoxicillin, 2 wk: good results5. 4 wk later, perianal GAS, no lesions; 2nd course of amoxicillin: good results
Wright, Australia, 1994[11]Oral amoxicillin - clavulanate plus topical bacitracin, 2 wk50%: Response to treatment in 2 wk; no recurrence
Barzilai, 1998, Israel[14]Oral amoxicillin, 10 d and topical mupirocin: 16 patients clinically cured; perianal cultures GAS negative: days 3-5 of therapy and weeks 2 to 3 post-therapyRecurrence: 2 cases (clinical and culture); successfully retreated 1 wk after finishing first therapy
Mateo, 2002, Spain[19]IM Pen (1), oral amoxicillin (5), topical mupirocin (4)All with favorable response and no recurrence
Petersen, 2003, Denmark[27]Oral Pen, 10 d: ineffective in 3 cases3 cases: Clarithromycin, 7 d; no recurrence
Landolt, 2005, Switzerland[17]10 with > 1 symptom: oral Pen, 10 d; 3: oral or IV amoxicillin-clavulanate4 with persistent symptoms: 2nd course of AB - oral Pen (3 cases), 14 d and oral clarithromycin (1 case), 10 d; 1 mo later: all 4 healed
Echeverría Fernández, 2006, Spain[6]Oral Pen, 10 dFavorable in 85%, perianal GAS negative in 95%
Meury, 2008, Switzerland[12]15 cases: oral Pen, 10 d and 14 cases: oral cefuroxime, 7 dClinical improvement: More rapid in the cefuroxime group (P = 0.028) and perianal GAS negative the last day of therapy in 93% on cefuroxime vs 47% on Pen (P < 0.01)
Jongen, 2008, Germany[8]Oral Pen ± local polihexanid, 10-14 d1 case: New GAS associated PID 5 mo later; successfully treated with oral AB
Shouval, 2008, Israel[18]Oral amoxicillin, 10 d and topical mupirocin (8/11); complete healing in 73%Recurrence: 3/11; 2nd course of AB administered
Heath, 2009, United States[26]Oral cephalexin for S. aureus: Successful in all but one; 4 cases with S. aureus cleared on topical mupirocin and 1 on bleach baths and topical steroids1 case with MRSA: 2nd course of oral AB required
Olson, 2011, United States[25]Oral AB alone: 81.4%; topical agent alone: 2.5%; both: 16%; duration: oral beta-lactams 10 d, azithromycin 5 d, cephalexin 5 d, oral Pen 14 dRecurrence 32.1%; recurrence within 6 wk 69.2%; recurrence rate: After Pen or amoxicillin 38.1% vs 27.8% after a beta-lactamase resistant AB (adjusted odds ratio: 2.02)
Clegg, 2015, United States[23]Amoxicillin 82.2%; cephalexin 11%; other AB 7%; topical therapy: 6%Recurrence rate (symptomatic PID) 6 mo after the initial episode: 13.4% after any AB, 12.4% after amoxicillin, 29.4% after cephalexin, and 0% after all other AB (oral Pen, amoxicillin-clavulanate, azithromycin, clarithromycin, cefprozil and cefdinir)
Garcia, 2015, Spain[21]Oral AB (Pen 5, amoxicillin 1), plus 4 topical mupirocin and 3 clotrimazoleSatisfactory; 1 recurrence
Sterbenc, 2016, Slovenia[24]All BHS: susceptible to Pen; all GAS susceptible to clindamycin, 1.4% resistant to erythromycin; GBS resistant to erythromycin in 14.8% and clindamycin in 7.4% of cases
Table 3 Case reports with perianal infectious dermatitis: Clinical and bacteriological patient characteristics
Name, yr, countryCase age, sexSymptoms/signs1; symptom durationEtiology of PIDOther findings2
Hirschfeld, 1970, United States[59]1-2. 6 yr, F and 3 yr brother1-2. Painful defecation; several daysGAS (culture)1-2. Both had sore throats 2 wk prior
3-4. 5 yr and 3 yr brothers (unrelated family)3-4. Same history and symptoms3-4. Throat GAS positive (1 case)
Farmer, 1987, United Kingdom[65]1. 4 yr, M1. White anal discharge, perianal pustules; 3 wkGAS (culture)
2. 5 yr, F2. Perianal itching, pain on defecation, dysuria; vulva affected; 3 wk
Rehder, 1998, United States[61]1. 3 yr, M1. Rectal irritation; 6 moGAS (culture)1. Sibling, 6 yr: GAS pharyngitis recently
2. 3 yr, M2. Perianal pain and itching; 5 wk2. Patient: throat GAS positive; sibling with recent sore throat
3. 4 yr, M3. Perirectal pain; 6 wk3. Identical GAS from anus and throat
4. 1 yr, F4. GP; 3 wk
Honig, 1988, United States[62]4; 15 mo, 6, 8 and 12 yr; 3 MAnal pruritus, bloody anal discharge; GP: 2 cases, appeared 9 mo after onset of PID; 1 M with PID history of 2 yrGAS (culture)
Marks, 1988, United States[63]5 yr, MPerianal irritation and pruritus, bloody discharge; 2 wkGAS (culture)
Guerrero - Vázquez 1989, Spain[64]2 casesPerianal irritation in both; seropurulent anal and balano-preputial discharge in 1 caseGAS (culture)
Duhra, 1990, United Kingdom[29]5 yr, MPainful defecation, micturition, bloody stool; penile erythema swelling; 4 wkGAS (culture)GAS positive from penile skin; members of patient's family: severe sore throat recently
Goodyear, 1991, United Kingdom[30]4 yr, MPainful defecation, blood-streaked liquid stool; fecal incontinence; 6 wkGAS (culture)
Medina, 1992, Spain,[31]4 yr, MPerianal pruritus and bleeding; 3 moGAS (culture)
Montemarano, 1993, United States[32]3 yr, MPainful perianal area, satellite pustules; 2 moS. aureus (culture)S. aureus positive in anterior nares and satellite pustule
Guppy, 1993, Australia[33]1. 7 yr, M1. Perianal excoriation; 8 wkGAS (culture)The three siblings bathing together
2-3. His 2 brothers, 5 and 2.5 yr2-3. Similar history
4. 4 yr, M4. Typical PID; penis lesions later; 4 wk
Paradisi, 1993, Italy[34]3 yr, MPerianal itching; 2 moGAS (culture)
Paradisi, 1994, Italy[35]1. 3 yr, F 2. 5 ½ yr, M, brotherPainful defecation, perianal itching, rectal bleeding, constipationGAS
van Zeijl, 1996, Netherlands[36]4; 3 M (1, 6 and 8 yr, the last 2 brothers); 1 F (2 yr)Constipation, painful defecation, diarrheaGAS (culture)Brothers shared same toilet
Saxen, 1997, Finland[37]1. 3 yr, M1. Itchy anus and bloody stool; 1 wGAS (T28)
2-3. Other cases2. Same symptoms2. Throat GAS positive, identical (T28)
Berlin, 1997, United States[38]3 yr, MConstipation, myositisGAS (culture)His mother had sore throat GAS positive
Bugatti, 1998, Italy[39]12 yr, MPerianal discharge, 1 moGAS (culture)
Adams, 1999, Canada[40]1 yr, MTypical PIDGAS (culture)
Roos, 1999, Sweden[41]5 yr, MAnal pruritusGAS T28 (culture)Case: throat GAS negative; mother: GAS tonsillitis positive; anal and throat GAS identical
Velez, 1999, Spain[42]2 yr, MFever 39-40 °C, erythema: perianal, genitalia and proximal thighsGAS (culture)Throat negative
Herbst, 2000, Germany[9]4 yr, MGP; 6 w history; PID discovered at physical examGAS (culture)Patient and family members: Negative GAS throat
Brilliant, 2000, United States[43]1. 4 yr, M1. Rectal itching and pain, scant mucoid dischargeGAS (RADT + culture)
2-3. 2 mo and 30 mo2-3. Several days later with similar symptoms2-3. Siblings of case 1
4. 4 yr, F4. Plus vulvitis4. Neighbor of the 3 cases
Balasubramanian, 2000, India[44]1. 13 mo, M1. Fever, painful defecation, anal pruritus; 2 dGAS (culture)
2. 11 mo, M2-3. Fever, painful defecation
3. 13 mo, F
Heidelberger, Germany, 2000[45]1. 6 yr, M1. Anal itching and burning; 3 moGAS (culture)
2. 9 yr, M2. Balanitis and impetigo
Nowicki, 2000, United States[46]7 yr, MPerianal itching, painful defecation; 10 dGAS (culture)Throat GAS negative
Soulliet, 2000, France[13]7 yr, FVulvar erythema, perirectal pain, painful defecation, constipation; perioral impetigo; 3 wkGAS (culture)Perioral GAS positive
Lunghi, 2001, Italy[47]Brother (4 yr) and sister (6 yr)1 also vulvo-vaginitis; 4 moGAS (culture)Throat GAS positive in both patients
Romano, 2002, Italy[48]12 yr, MPID and GPGAS
Huang, 2003, Taiwan[49]6 yr, MPerianal itching, painful defecation, scant mucoid dischargeGAS (culture)Throat GAS positive
Reimer, 2004, Sweden[50]1. 4 yr, M1. Perianal discomfort1. GAS (RADT)
2. 6 yr, M2. Purulent discharge plus balanitis2. GAS2. Penis culture GAS positive; father treated for GAS pharyngitis; brother, 4 yr with GAS PID and brother 2 yr with GAS pharyngitis
3. 4 yr, F3. Perianal pain, vulvar erythema and pain3. GAS
Takeshita, 2006, Japan[51]1. 2 yr, F1. PID; 2 wkGAS (culture)
2. 6 mo, M2. PID; 1 wk
Usuki, 2006, Japan[52]5 yr, FPIDGAS (RADT)4 d later: Father with symptoms of PID and GAS positive
Ulger, 2007, Turkey[53]3 yr, MPain on defecation, anal pruritus; 8 d; GP: 2 dGAS (culture)Sore throat 2 wk before; no culture, no therapy needed
Greisser, 2008, Swiss[54]7 yr, MPerianal pain and pruritus, yellow discharge; 3 dGAS (RADT + culture)Throat GAS negative
Lehman, 2009, United Kingdom[7]3 yr, FItchy bottom and painful defecation; 2 wkGAS (culture)
Ledoux, 2009, France[55]4 yr, MPID for 2 wk; lesions of GP since second weekGAS (culture)
Rasi, 2009, Iran[56]4 yr, MRectal itching and burning, pain on defecation; plaque type psoriasis; 3 moGAS (RADT)
Block, 2013, United States[57]1. 2 mo, F1. PID and vulvar erythemaGAS1. 8 yr sibling: previous GAS pharyngitis
2. 4 mo, F2. Blood in diaper
Theotokatou, 2014, Greece[58]1. 8 yr, M1. Perianal itching, constipation, blood-streaked stool; 3 wkEnterococcus faecalis (culture) in both)
2. 10 yr, M, brother2. Perianal itching and mucous discharge (2 wk after onset of symptoms of his brother)
Zhang 2016, Canada[3]1. 4 yr, M1. Painful defecation, GP, penile erythema1. GAS and S. aureus1. Throat GAS positive
2. 4 yr, M2. Painful defecation, GP2. GBS2. Throat culture negative
3. 3 yr, F3. Perivulvar erythema, small amount of greenish-yellowish vaginal discharge3. GCS3. Throat culture negative; vulvar culture few GCS and scant S. aureus
Garritsen, 2017, Netherlands[60]19 mo, MPID and 1 wk later: GPGAS
Serban, present study, Romania1. 9 yr 4 mo, M1. Perianal pain and pruritus, anal mucous and bloody discharge, painful defecation; 6 wk1. GBS and S. aureus (culture)1. Throat GAS, GBS and S. aureus negative
2. 9 yr 6 mo, M2. Anal pruritus, painful defecation, anal mucous and bloody discharge2. GAS (culture)2. Throat GAS positive
3. 11 yr 9 mo, M3. Anal pruritus, mucous and bloody discharge, painful defecation, constipation3. GAS (culture)3. Throat GAS negative
Table 4 Case reports with perianal infectious dermatitis: Therapy and follow-up of patients
Name, yr, countryCase age, sexTherapy of PID and resultsFollow-up of PID
Hirschfeld, 1970, United States[59]1-2. 6 yr, F and 3 yr brotherOral Pen
3-4. 5 yr and 3 yr brothers (unrelated family)
Farmer, 1987, United Kingdom[65]1. 4 yr, M1. Oral Pen: prompt and complete recovery
2. 5 yr, F2. Oral Pen, 1 wk: asymptomatic
Rehder, 1998, United States[61]1. 3 yr, M1. Oral Pen, 2 wk1. 2 wk later, erythema and GAS positive: erythromycin, for 1 mo; no recurrence (including culture)
2. 3 yr, M2. Oral Pen, 2 wk2. No recurrence (including cultures)
3. 4 yr, M3. Oral Pen, 3 wk3. Perianal cultures positive after 2 and 3 wk: erythromycin, 10 d: negative culture
4. 1 yr, F4. Oral Pen, 3 wk: both conditions cleared4. All negative
Honig, 1988, United States[62]4; 15 mo, 6, 8 and 12 yr; 3 MOral Pen, 10 d; PID cleared in 3 cases within 10-14 dThe 4th case with PID history of 2 Y: 10 d of erythromycin, cleared PID and negative culture; psoriasis cleared 14-35 d after institution of therapy
Marks, 1988, United States[63]5 yr, MOral Pen, 14 d; rash progressively healed (completely in 17 d)
Duhra, 1990, UK[29]5 yr, MOral Pen, 3 wk: clearance of penile lesion (2 wk), but not perianal, also with positive GASOther 2 wk of oral Pen cleared PID and GAS
Goodyear, 1991, United Kingdom[30]4 yr, MOral Pen, 10 d; completely resolved in 2 wkFollow up 2 mo later: clinically well
Medina, 1992, Spain,[31]4 Y, MTopical mupirocin, 10 d: Completely resolvedNegative cultures 1 wk and 1 mo later
Montemarano, 1993, United States[32]3 Y, MOral erythromycin, 10 d: Rapid cure
Guppy, 1993, Australia[33]1. 7 yr, M1. Oral Pen, 10 d1. After stopping Pen, rectal bleeding: Cefaclor, 10 d, no recurrence
2-3. His 2 brothers, 5 and 2.5 yr2. Oral Pen, 10 d2. No recurrence
3. Oral Pen, 10 d, initially improved3. 3 mo later: Persistent perianal infection: erythromycin
4. 4 yr, M4. Oral Pen, 2 wk, incomplete resolution4. Erythromycin, 4 wk: Complete resolution
Paradisi M, 1993, Italy[34]3 yr, MTopical erythromycin, 15 d: Complete clinical and bacteriologic resolutionNo recurrence
van Zeijl, 1996, Netherlands[36]4; 3 M (1, 6 and 8 yr, the last 2 brothers); 1 F (2 yr)Oral Pen, 10 d ± mupirocin or fucidin Oral amoxicillin + fucidin
Saxen, 1997, Finland[37]1. 3 yr, M1. Oral Pen, 10 d: clearance within 2 d1. 1 wk after stopping Pen: PID recurrence, with GAS positive; oral cephalexin: good results
Berlin, 1997, United States[38]3 yr, MIV antibiotics (not mentioned)Symptoms resolved entirely after 2 wk
Bugatti, 1998, Italy[39]12 yr, MAmoxicillin, 10 d: Rapid resolution of symptoms
Adams, 1999, Canada[40]1 yr, MOral Pen and topical mupirocin, 10 d
Roos, 1999, Sweden[41]5 yr, MCefadroxil plus topical fucidin, 10 dNo recurrence
Velez, 1999, Spain[42]2 yr, MCefaclor, 10 ds: complete healing2 wk after therapy: Acral (hands and feet) scarlatiniform desquamation
Herbst, 2000, Germany[9]4 yr, M,Oral Pen and topical fucidin, 2 wk: Complete healing (including culture)
Brilliant, 2000, United States[43]1. 4 yr, M1. Oral amoxicillin, dramatic improvement 1 d
2-3. 2 mo and 30 mo2-3. Same effective therapy
4. 4 yr, F4. Same effective therapy
Balasubramanian, 2000, India[44]1. 13 mo, MOral Pen, 10 d; symptoms clearance in 3 d
2.11 mo, M
3. 13 mo, F
Heidelberger, Germany, 2000[45]1. 6 yr, M1: Oral Pen, 10 d
2. 9 yr, M2. Same plus topical clioquinol; in both cases, all lesions disappeared
Nowicki, 2000, United States[46]7 yr, MOral Pen: Symptoms and signs disappeared1 wk following Pen, peeling from his fingers tip (toes not involved)
Soulliet, 2000, France[13]7 yr, FAmoxicillin, 10 d; perianal lesions cleared by day 2
Lunghi, 2001, Italy[47]Brother (4 yr) and sister (6 yr)IM Pen, 4 wk, plus local mupirocinComplete resolution (with negative culture) within 4 wk; no relapse in 4 mo
Huang, 2003, Taiwan[49]6 yr, MOral Pen and topical mupirocin, 14 d: clinical healing after 4 dAfter starting Pen: desquamation of fingers and perioral skin
Reimer, 2004, Sweden[50]1. 4 yr, MOral Pen in all cases: quickly healed
2. 6 yr, M
3. 4 yr, F
Takeshita, 2006, Japan[51]1. 2 yr, FOral antibiotics: rapid resolution of the condition
2. 6 mo, M
Usuki, 2006, Japan[52]5 yr, FOral and topical antibiotics
Ulger, 2007, Turkey[53]3 yr, MOral Pen, 2 wk; topical corticosteroids for GP; all lesions healedNo recurrence
Greisser, 2008, Swiss[54]7 yr, MOral amoxicillin, 6 d: Rapid improvementNo recurrence
Ledoux, 2009, France[55]4 yr, MJosamycin 1 mo and desonide for GP: All symptoms subsidedNo relapse in 6 mo
Rasi, 2009, Iran[56]4 yr, MOral amoxicillin, 10 d: Clinical response within 3 d, healed in 3 wk; GAS negative after 3 wkNo improvement of psoriatic lesions
Block, 2013, United States[57]1. 2 mo, FAmoxicillin, 10 d, in both patientsNo recurrence in both cases
2. 4 mo, F
Theotokatou, 2014, Greece[58]1. 8 yr, MOral cefuroxime and topical mupirocin for both brothers: effective by day 4
2. 10 yr, M, brother
Zhang 2016, Canada[3]1. 4 yr, M1. Oral cefuroxime, 7 d plus topical fucidin1. 3 mo later: Throat and anus GAS negative; PID cleared
2. 4 yr, M2. Oral cefuroxime, 7 d plus betamethasone for GP2. 2 wk later, perianal GBS positive: topical Fucidin; 3 mo later: GBS negative and cleared GP
3. 3 yr, F3. Oral cefuroxime, 7 d plus topical fucidin; persistent erythema and discharge3. Vulvar culture: GCS and GBS, perianal culture: GCS; culture from vaginal introitus: positive GAS: oral amoxicillin, 10 d
Garritsen, 2017, Netherlands[60]19 mo, MOral Pen plus mometasone for GP; 4 wk: PID and GP significantly improved
Serban, present study, Romania1. 9 yr 4 mo, M1. Spiramycin and topical mupirocin, 2 wk: improvement after 2 d; perianal culture negative on day 7; completely healed after 12 d1. No recurrence after 2 yr
2. 9 yr 6 mo, M2. Spiramycin, 2 wk: improvement since day 2; negative perianal culture on day 7; completely healed after 1 wk2. No recurrence after 7 mo
3. 11 yr 9 mo, M3. Spiramycin and topical bacitracin plus neomycin, 3 wk: improvement after 5 d; negative perianal culture on day 7; healed completely after 2 wk3. No recurrence after 2 mo
Table 5 Previous investigations, diagnoses and therapies in children with perianal infectious dermatitis
Name, yr, countryPopulation size; age; sexPrevious performed investigations and/or suspected diagnosisPrevious therapy
Spear, 1985, United States[28]14; mean age 3.9 yr (range: 1-10 yr); M/F: 3.7/12 proctoscopies under general anesthesia, upper gastrointestinal x-ray series, barium enema; anal fissure, IBD, behavior disturbance, psychogenic stool holding, psoriasis, candidiasis, ammoniacal diaper dermatitisLaxatives, suppositories, hydrocortisone, polymyxin, bacitracin and neomycin, povidone-iodine, triamcinolone
Farmer, 1987, United Kingdom[65]1. 4 yr, M1. Anal pinworms (negative)1. Piperazine, miconazole, and hydrocortisone cream
2. 5 yr, F2. Anal pinworms (negative)2. Clotrimazole cream
Kokx, 1987, United States[4]31; 7 mo to 8 yr, mean 4.25 ± 1.8 yr; M 77%Hemorrhoids, poor hygiene, perianal allergy to toilet paper perfumes, rectal fissures, and/or constipation
Rehder, 1998, United States[61]1. 3 yr, M1. Soaks, topical antifungals and corticosteroids
2. 3 yr, M2. Topical hydrocortisone, nystatin, triamcinolone and zinc oxide
3. 4 yr, M3. Pinworms3. Oral cefaclor, with clearing of erythema, but recurrence
Marks, 1988, United States[63]5 yr, MPinworms and stool for ova and parasites: negativeTopical A and D ointment, hydrocortisone, ketoconazole
Duhra, 1990, United Kingdom[29]5 yr, MConsidered as possible case of sexual abuse; threadworms, candidiasis, psoriasis and eczemaTreatment for threadworms, candidiasis, psoriasis and eczema
Goodyear, 1991, United Kingdom[30]4 yr, MExamination under anesthesia and proctoscopyStool softeners, stimulant laxatives, topical anesthetics, steroid and antifungal creams
Montemarano, 1993, United States[32]3 yr, MTopical and oral nystatin
Grant, 1993, United Kingdom[10]20; 5 mo to 12 yr; 75% M2 cases: suspected Crohn’s disease 1 case: suspected sexual abuse3 patients treated for worms, 7 treated for constipation, 5 topical treatment (steroids, lignocaine, eosin, fucidin)
Guppy, 1993, Australia[33]1. 7 yr, M1. Topical antifungal, antibacterial and steroid creams, oral pyrantel embonate and metronidazole
2-3. 5 and 2.5 yr2-3. Various antifungal, antibacterial and steroid creams, oral pyrantel embonate
4. 4 yr, M4. Local nystatin, hydrocortisone; oral pyrantel embonate
Patrizi, 1994, Italy[22]5; 4-10 yr; 3 MTopical agents, including steroid cream
Bugatti, 1998, Italy[39]12 yr, MTopical antifungal agents
Adams, 1999, Canada[40]1 yr, MTopical corticosteroids and clotrimazole
Roos, 1999, Sweden[41]5 yr, MTopical steroids
Herbst, 2000, Germany[9]4 yr, MVarious ointments for the last several months
Brilliant, 2000, United States[43]1. 4 yr, M1. Topical ointment and baby powder, topical antifungal
4. 4 yr, F4. Topical antifungal
Heidelberger, 2000, Germany[45]1. 6 yr, M1. Tannolact seat baths and topical tetracycline
2. 9 yr, M2. Tannolact seat baths and topical clotrimazole
Soulliet, 2000, France[13]7 yr, FCandidiasisNystatin unsuccessful for suspected candidiasis
Lunghi, 2001, Italy[47]Brother (4 yr) and sister (6 yr)Both: Local and oral antifungal drugs for 4 mo
Mateo, 2002, Spain[19]10; 9 mo to 7 yr; 6 M4 cases: 2 steroids cream, 1 clotrimazole cream and 1 betamethasone and clotrimazole cream
Reimer,2004, Sweden[50]1. 4 yr, M1. Pinworms (negative)
3. 4 yr, F3. Local ointment (kenacutan)
Jongen, 2008, Germany[8]21; < 14 yr (mean age 6.3 yr), 76% MAnoscopy and rectoscopy: negativeTopical agents (zinc paste, corticosteroids, antimycotic ointments)
Rasi, 2009, Iran[56]4 yr, MTopical antibiotics, steroids and antifungal creams, 3 mo
Zhang, 2016, Canada[3]1: 4 yr, M1. Topical terbinafine and hydrocortisone acetate
3: 3 yr, F3. Gentle skin care, zinc barrier cream, topical antifungals, corticosteroids, and mupirocin
Garritsen, 2017, Netherlands[60]19 mo, MTopical corticosteroids and antimycotic agents
Serban, present paper, Romania1. 9 yr 4 mo, M1. Psoriasis, pinworms, candidiasis, eczema; Hospitalization in 6 public clinics and 2 private hospitals; upper and lower endoscopy under general anesthesia; magnetic resonance enterography – all negative; considered as Crohn’s disease and sent to our clinic1. Topical antibiotics, steroids, antifungal and anesthetics creams; oral antiallergics
2. 9 yr 6 mo, M2. Pinworms, intestinal dysbiosis2. Oral probiotics and therapy against worms; topical baneocin and neomycin, cortisone and anti-hemorrhoids
3. 11 yr 9 mo, M3. Eczema, anal fissure, constipation3. Oral probiotics, osmotic laxatives and stool softeners; topical hydrocortisone, cicatrizants