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World Journal of Clinical Pediatrics World Journal of W J C P Clinical Pediatrics Submit a Manuscript: http://www.f6publishing.com World J Clin Pediatr 2018 October 25; 7(4): 89-104 DOI: 10.5409/wjcp.v7.i4.89 ISSN 2219-2808 (online) REVIEW Perianal infectious dermatitis: An underdiagnosed, unremitting and stubborn condition Elena Daniela Serban Elena Daniela Serban, 2nd Department of Pediatrics, “Iuliu ficial inflammation of the perianal skin, which is of bac­ Hatieganu” University of Medicine and Pharmacy, Emergency terial origin (classically, group A beta­hemolytic strepto­ Hospital for Children, Cluj-Napoca 400177, Romania cocci). This narrative review aims to critically review and summarize the available scientific literature regarding ORCID number: Elena Daniela Serban (0000-0003-0906-1232). pediatric PID, being the first of its kind, to the best of Author contributions: Serban ED contributed to the paper’s the author’s knowledge. It also reports the first cases of conception and design, the data collection, extraction, analysis Romanian children with PID. Multiple databases were and evaluation, the interpretation of results, and the manuscript’s subjected to systematic literature search (from 1966 preparation, critical revision, editing and final submission. to April 30, 2018) to identify studies and case reports of children with PID. As such, this review provides up­ Conflict-of-interest statement: The author declares there are no dated information about essential aspects of PID (epi­ potential conflicts of interest relevant to this publication. demiology, etiology, pathogenesis, as well as clinical Open­Access: This article is an open-access article which was features, required investigations and therapeutic options) selected by an in-house editor and fully peer-reviewed by external and of diagnostic pitfalls. Although a well-defined entity, reviewers. It is distributed in accordance with the Creative PID remains largely underdiagnosed. PID may mimic Commons Attribution Non Commercial (CC BY-NC 4.0) license, other common conditions with skin manifestations (like which permits others to distribute, remix, adapt, build upon this candidiasis, pinworms, eczema, irritant dermatitis, anal work non-commercially, and license their derivative works on fissure, hemorrhoids, Crohn’s disease, psoriasis, sebor­ different terms, provided the original work is properly cited and rheic dermatitis, zinc deficiency dermatosis and even the use is non-commercial. See: http://creativecommons.org/ sexual abuse), with consequent unnecessary, sometimes licenses/by-nc/4.0/ expensive and invasive investigations and futile therapies, Manuscript source: Invited manuscript which cause patients and families discomfort and distress. Since PID has an unremitting course, early recognition Correspondence to: Elena Daniela Serban, MD, PhD, Asso­ is imperative, as it allows for prompt and efficacious nd ciate Professor, Pediatric Gastroenterologist, 2 Department of antibiotic therapy. However, PID represents a stubborn Pediatrics, “Iuliu Hatieganu” University of Medicine and Pharmacy, condition and, even if properly treated, its recurrence Emergency Hospital for Children, 5 Crisan Street, Cluj-Napoca rate remains high. Further well­designed prospective 400177, Romania. [email protected] randomized controlled trials, with adequate follow­up, are Telephone: +40-264-532216 Fax: +40-264-590478 required in order to formulate the optimum personalized antibiotic therapy (oral alone or in association with topical Received: June 24, 2018 medication), able to prevent recurrences. Awareness of Peer­review started: June 25, 2018 this condition by healthcare professionals should improve First decision: August 2, 2018 patient outcomes. Revised: August 23, 2018 Accepted: October 8, 2018 Key words: Perianal dermatitis; Perianal streptococcal Article in press: October 9, 2018 Published online: October 25, 2018 dermatitis; Beta­hemolytic streptococci; Staphylococcus aureus; Perineal streptococcal dermatitis; Perianal swab culture; Differential diagnosis; Antibiotic therapy; Perianal streptococcal disease Abstract © The Author(s) 2018. Published by Baishideng Publishing Perianal infectious dermatitis (PID) represents a super­ Group Inc. All rights reserved. WJCP|www.wjgnet.com 89 October 25, 2018|Volume 7|Issue 4| Serban ED. PID: Underdiagnosed and unremitting Scholar (starting from 2004), and Research Gate (starting Perianal infectious dermatitis (PID) represents a Core tip: from 2008) databases. Titles, abstracts and full-texts were superficial inflammation of the perianal skin, which is of searched without any language restriction. The reference bacterial origin. This narrative review aims to summarize lists from the selected studies were manually examined the available literature regarding pediatric PID, being the first of its kind, to the best of the author’s knowledge. to identify additional research studies. Duplicates were An updated insight into the main features of PID is excluded. The search included the following items/key provided, including diagnostic pitfalls. PID may mimic words: “perianal cellulitis“, “perianal dermatitis”, “perianal other common conditions with skin manifestations, with disease”, “perianal infection”, “perineal dermatitis”, consequent application of a treatment that is wrong. The “perianal streptococcal cellulitis”, “perianal streptococcal unremitting course of PID makes early recognition and infection”, “perianal streptococcal dermatitis”, “perianal antibiotic therapy crucial. Recurrence rates of PID remain streptococcal disease”, “perineal streptococcal disease”, high. Awareness of this condition should improve patient “perineal streptococcal dermatitis”, “anitis”, and “anusitis”. outcomes. Only papers clearly presenting PID [as case reports, case series/observational studies or randomized controlled trials (RCTs)] and focused on children were retained for detailed Serban ED. Perianal infectious dermatitis: An underdiagnosed, analysis. unremitting and stubborn condition. World J Clin Pediatr 2018; 7(4): 89-104 Available from: URL: http://www. Data extraction wjgnet.com/2219-2808/full/v7/i4/89.htm DOI: http://dx.doi. The following data were extracted: Last name of the org/10.5409/wjcp.v7.i4.89 first author; publication year; country; authors’ field of medical practice and working department; study design; characteristics of the included population (i.e., sample size, age, sex); symptoms and signs; etiology of the PID; INTRODUCTION presence or absence of pharyngitis or other site infections; Perianal infectious dermatitis (PID) represents a superficial results of throat culture and other relevant laboratory inflammation of the perianal skin, which is of bacterial investigations; duration until diagnosis; important data origin[1]. The first cases of pediatric PID, all caused concerning infections in family/community; previous in- by group A beta-hemolytic streptococci (GAS), were vestigations, diagnoses and therapies; type and duration published more than 50 years ago[2]. Still today, the clinical of medication used to cure the PID; presence and rate of hallmark of PID is represented by a characteristic well- recurrence; medication used for recurrences; potential demarcated perianal edematous erythema, extending limits of the studies; and, any other relevant data re- 2-4 cm around the anus[1-10], sometimes with white exu- garding PID. date, pseudo-membranes and superficial anal fissures or cracks[1,10-12]. Despite its typical features, PID is still Characteristics of included studies unrecognized by many healthcare professionals[13]; as Sixty-four full-text articles reporting on pediatric cases a result, patients are submitted to unnecessary investi- of PID were included, being available from either the gations, sometimes invasive and costly (i.e., upper and mentioned databases or (for older papers) by personally lower digestive endoscopies under general anesthesia, and contacting their authors (email and/or phone). Only magnetic resonance enterography), as well as to various one reported on a RCT[12] (including 35 children); the re- therapies. Delays in diagnosis and treatment increase maining represented descriptive observational prospective patient discomfort and stress, which can also affect the studies/case series [6 articles, comprising a total of 351 [2,6,11,14-16] patient’s family. patients (between 10 and 150/study)] , descriptive The aim of this narrative review, therefore, is to sum- observational retrospective studies/case series [16 articles, marize the currently available scientific literature regarding comprising a total of 549 patients (between 6 and 157/ [4,5,8,10,17-28] pediatric PID-as an alert to the medical community-to study)] , and case reports [41, comprising a total [3,7,9,13,29-65] help ensure more instances of correct management. of 75 patients (between 1 and 4 cases/report)] . The author provides updated knowledge of essential Three cases diagnosed by this author were also added, aspects of PID (epidemiology, etiology, pathogenesis, as giving a total of 78 case reports that were analyzed in this well as clinical characteristics, investigations required and review. Ultimately, the analysis in this review involved the therapeutic options) and of diagnostic pitfalls. 78 patients from the case reports, 35 from RCTs, 549 from retrospective studies and 351 from prospective studies, giving a total number of PID pediatric cases of 1013. LITERATURE SEARCH The main characteristics of the included studies/case Published full manuscripts and abstracts
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