From the Department of Pediatrics, Sri Ramachandra Medical College and Research Institute (Deemed University), Porur, Chennai 600 116, India.
Reprint requests: Dr. S. Balasubramanian, Associate Professor of Pediatrics, Sri Ramachandra Medical College and Research Institute (Deemed University), Porur, Chennai 600 116, India.

Manuscript Received: May 7, 1999;
Initial review completed: June 15, 1999;
Revision Accepted: September 24, 1999

Perianal dermatitis is a common dermatological condition in infants and children. It can be caused by a variety of conditions like pin worm infestation, candidiasis, diaper dermatitis, seborrehic dermatitis and eczema(1). Bacterial infections by Group A beta hemolytic Streptococci and Staph. aureus have also been reported to cause this condition rarely(1,2). We report three cases of perianal streptococcal dermatitis in children.

Case I : A 13-month-old male child presented with fever, pain during defecation, perianal redness and pruritus for a duration of 2 days. His stools were normal. On examination, the child was febrile (38.8°C) and toxic. There was a superficial, erythematous, well-marginated, non-confluent, perianal rash that was moist and tender to touch without any signs of cellulitis (Fig. 1). Rest of the physical examination did not reveal any abnormalities.

Fig. 1. Perianal erythema with whitish pseudomembrane.

His total and differential leukocyte counts and peripheral blood smear were normal. A perianal swab culture was done which revealed a pure and heavy growth of Group A beta hemolytic streptoccocci but the blood culture was sterile. Perianal swab culture for fungi was negative. The child was treated with oral Penicillin-V in a dose of 50 mg/kg/day for a total duration of 10 days.

Fever subsided within 24 hours of initiation of Penicillin therapy and the rash and painful defecation regressed in 72 hours.

Case II & III : Two more children, one 11-month-old male infant and another, a female child aged 13 months presented with fever and a similar perianal erythema with pain during defecation. These two children were also treated with oral Penicillin for 10 days after taking a perianal swab culture which again grew Group A beta hemolytic streptococci. Hemograms and blood cultures were not done in these 2 cases. Both of them recovered completely within 3 days of starting Penicillin therapy.

There was no history of streptococcal throat or skin infection in any of the other family members in all the three cases.

Perianal streptococcal dermatitis was first described in 1966(3). The occurrence of this dermatosis characterized by well defined erythema in the perianal region has certainly been underestimated(4) and the diagnosis is often delayed and tends to be uniformly missed(2-5). Any erythema in the perianal region that is associated with perianal tender-ness, irritation or pruritus, pain on defecation, tissue loss and exudation, rectal bleeding and secondary constipation, should make one suspect streptococcal infection(5). In the acute stage, a white pseudomembrane may be present. As the rash becomes more chronic, the perianal eruption may consist of painful fissures, a dry mucoid discharge or of psoriaform plaques(1). Perianal dermatitis can also be caused by Staph. aureus or Candida(1).

The signs and symptoms observed in peri-anal streptococcal dermatitis have included perianal dermatitis (90%), itching (78%), rectal pain (52%), blood streaked stools (35%) and cellulitis(6). In our series of 3 cases, perianal dermatitis and rectal pain were present in all the 3 patients while blood streaked stools was not a feature in any of them. Perianal streptococcal dermatitis has been reported at ages ranging from 7 months to 8 years (mean 4.25 ± 1.8 years)(6). All the three children in our series were aged between 11 to 13 months (2 male and 1 female).

Fever and other constituitional symptoms like arthritis, arthralgia and headache have been conspicuously absent in earlier reports of peri-anal streptococcal dermatitis(4,6). However, fever was a significant presenting symptom in all our 3 cases. Intrafamily spread only to siblings has been reported to occur in up to 50% of possible situations(6). However, such intrafamily spread was not a feature in any of our 3 cases.

Confirmation of the diagnosis is accomp-lished by culturing a moderate to heavy growth of Group A beta hemolytic streptococci on 5% sheep blood agar. This organism is not normally present in the perianal region and children with asymptomatic perianal coloniza-tion have only light growth on blood agar(1). In all the 3 cases, we observed a pure and heavy growth and all the 3 children were symptomatic thus confirm-ing the diagnosis. Direct perianal antigen studies for streptococci have also been reported to be very sensitive(6) but acute and convalescent sera for Antistreptolysin O or Anti DNAse do not help in diagnosis. Treatment with oral Penicillin for 10 days produces resolution of the dermatitis and other symptoms in most patients but a relapse rate as high as 39% has been reported(6).

In conclusion streptococcal dermatitis should be considered in the differential diagnosis of any perianal dermatitis.

1. Darmstadt D, Lane AT. Cutaneous bacterial infections. Eds. Behrman RE, Kleigman RM, Arvin AM. In: Nelson’s Textbook of Pediatrics, 15th edn. Philadelphia, W.B. Saunders Co, 1996; pp 1892-1893.

2. Teillac-Hamel D, de Prost Y. Perianal streptoco-ccal dermatitis in children. Eur J Dermatol 1992; 2: 71-74.

3. Amren DE, Anderson AS, Wannamaker LW. Perianal cellulitis associated with Group A streptococci. Am J Dis Child 1966; 112: 546.

4. Paradisi M, Cianchini G, Angelo C, Conti G, Puddu P. Perianal streptococcal dermatitis. Minerva Pediatr 1994; 46: 303-306.

5. Stockman JA. Perianal streptococcal dermatitis in children. In: Year Book of Pediatrics, Ed. A Stockman JA. St Louis Mosby Co., 1994; pp 117-119.

6. Kokx NP, Comstock JA, Facklam RR. Streptococcal perianal disease in children. Pediatrics 1987; 80: 659-663.