Visual Diagnosis in Pediatrics
1st Edition
© 2006 Lippincott Williams & Wilkins
←↑→
57
Perianal and Buttock Redness
Robert L. Zarr
Approach to the Problem
Friction and exposure to excessive moisture are often the predisposing factors in many diseases that cause redness in the buttock and perianal area. The specific location of redness, whether found over convex surfaces, in the gluteal fold, in the perianal area, or in other intertriginous areas, will help to determine the specific etiology of the problem. Redness over convex surfaces may result from primary irritant diaper dermatitis or folliculitis. Perianal redness may result from several problems, including streptococcal dermatitis, pinworm infestation, candidiasis, psoriasis, and seborrheic dermatitis. Redness in intertriginous areas is often caused by candidiasis, seborrheic dermatitis, and, more rarely, psoriasis. The presence or absence of rash in other areas of the body will also assist in making an accurate diagnosis.
Key Points in the History
  • Fifty percent of infants develop primary irritant diaper dermatitis usually between 9 and 12 months of age.
  • Perianal streptococcal dermatitis may present with perianal itching and rash. Rectal pain may occur with defecation, and there may be a history of bloody stools.
  • Perianal streptococcal colonization may occur concomitantly with streptococcal pharyngitis.
  • Streptococcal dermatitis typically is seen between the ages of 7 months to 12 years. It is more common in males.
  • Pinworm infestation may present with severe nocturnal and early morning itching, enuresis, changes in bowel habits, insomnia, restlessness, anorexia, weight loss, and abdominal cramping.
P.380

Key Points in the Physical Examination
  • Shiny erythematous macules and papules over convex surfaces with sparing of the creases suggest primary irritant diaper dermatitis.
  • Erythema in the inguinal and other creases is suggestive of candidal diaper dermatitis.
  • The presence of satellite lesions is a hallmark of candidal diaper dermatitis.
  • Streptococcal dermatitis often presents as a bright red, well-demarcated, superficial, confluent redness, sometimes with associated swelling, exudate, pustules, and bleeding.
  • There may be a paucity of physical findings with pinworm infestation, but excoriation may be present because of intense itching.
  • Perianal erythema and desquamation may be seen in toxin-mediated disease resulting from staphylococcal or streptococcal infection, and these may be seen in Kawasaki disease.
  • Psoriasis in the diaper area of an infant or toddler may not have the classic thick-silvery scale that is seen in psoriatic lesions in drier areas of the skin.
P.381

DIAGNOSIS ICD-9 DISTINGUISHING CHARACTERISTICS DISTRIBUTION ASSOCIATED FINDINGS COMPLICATIONS
Primary Irritant Diaper Dermatitis 691.0 Erythematous shiny or glazed-appearing areas with possible areas of erosion Convex surfaces of the perineum that are maximally exposed to moisture, stool, and friction Skin erosion with bleeding if untreated Persistence after 48–72 hours of treatment may suggest secondary candidal or bacterial infection
Candidiasis 691.0 Confluent papular erythema with erythematous satellite papules in intertriginous areas Groin and diaper area Adverse effect of oral antibiotic treatment
Persistently moist perirectal area
Thrush in infants		 Focal areas of skin erosion with possible bleeding if left untreated
Streptococcal Dermatitis 041.0 No itching
Bright red, well-defined erythema		 Perianal Streptococcal pharyngitis None
Folliculitis 704.8 Erythema surrounding the hair follicle with a small, central, yellow pustule
Multiple lesions may occur		 Buttocks in infants and toddlers wearing diapers May also occur in other areas where hair follicles are present May progress to a furuncle, a deeper infection with a larger area of erythema with a central cavity of pus
May persist or spread if left untreated
Pinworm 127.4 Intense nocturnal itching
Excoriations		 Perianal Restlessness
Insomnia
Urinary tract infection in girls		 Perianal abscess
Appendicitis
Salpingitis
P.382

Figure 57-1 Primary irritant diaper dermatitis. Confluent areas of shiny erythema over labia majora and buttocks. (Courtesy of Jan E. Drutz, MD.)
Figure 57-2 Candidal diaper dermatitis. Infant with erythematous rash with satellite lesions in the groin. (Courtesy of Jan E. Drutz, MD.)
Figure 57-3 Perianal group A beta-hemolytic streptococcus (GABHS). Intense erythema is noted in the immediate perianal area of this toddler. (Courtesy of Jan E. Drutz, MD.)
Figure 57-4 Perianal group A beta-hemolytic streptococcal infection (GABHS). Perianal streptococcal disease in an African American child. (Courtesy of George A. Datto, III, MD.)
Figure 57-5 Buttock folliculitis. A child with erythematous papules over the posterior buttocks consistent with folliculitis. (Courtesy of Jan E. Drutz, MD.)
Figure 57-6 Perianal erythema and desquamation in a patient with Kawasaki disease. (Courtesy of Esther K. Chung, MD.)
P.383

Other Diagnoses to Consider
  • Acrodermatitis enteropathica (zinc deficiency)
  • Histicytosis X
  • Seborrheic dermatitis
  • Granuloma gluteale infantum
  • Inflammatory bowel disease (IBD)
  • Sexual abuse
Suggested Readings
Brilliant LC. Perianal streptococcal dermatitis. Am Fam Physician. 2000;61:391–397.
Bugatti L. Filosa G. Ciattaglia G. Perianal dermatitis in a child. Perianal streptococcal dermatitis (PSD). Arch Dermatol. 1998;134(9):1147–1150.
Elston DM. What’s eating you? Enterobius vermicularis (pinworms, threadworms). Cutis 2003;7(4):268–270
Friedlander SF. Contact dermatitis. Pediatr Rev. 1998;(19):166–171.
Jones JE. Pinworms. Am Fam Physician. 1998;38(3):159–164.
Shwayder T. Five common skin problems—and a string of pearls for managing them. Contemp Pediatr. 2003;20(7)34–54.
←↑→