Background. Recurrent perianal inflammation has great etiologic diversity. A possible cause is cow’s milk allergy (CMA). The aim was to assess the magnitude of this cause. Subjects and Methods. This follow up clinical study was carried out on 63 infants with perianal dermatitis of more than 3 weeks with history of recurrence. Definitive diagnosis was made for each infant through medical history taking, clinical examination and investigations including stool analysis and culture, stool pH and reducing substances, perianal swab for different cultures and staining for Candida albicans. Complete blood count and quantitative determination of cow’s milk-specific serum IgE concentration were done for all patients. CMA was confirmed through an open withdrawal-rechallenge procedure. Serum immunoglobulins and CD markers as well as gastrointestinal endoscopies were done for some patients. Results. Causes of perianal dermatitis included CMA (47.6%), bacterial dermatitis (17.46%), moniliasis (15.87%), enterobiasis (9.52%) and lactose intolerance (9.5%). Predictors of CMA included presence of bloody and/or mucoid stool, other atopic manifestations, anal fissures, or recurrent vomiting. Conclusion. We can conclude that cow’s milk allergy is a common cause of recurrent perianal dermatitis. Mucoid or bloody stool, anal fissures or ulcers, vomiting and atopic manifestations can predict this etiology. 1. Introduction Perianal dermatitis is probably the most common cutaneous disorder of the genitoanal area [1]. Diaper dermatitis is observed most frequently in infants at 9–12 months of age [2]. It has a multifactorial etiology and high chronicity [3, 4]. Its prevalence is not greatly different between genders or among races [5]. Signs of diaper dermatitis including erosions have been noted as early as the first 4 days of life [6–8]. There have been only a few studies on the etiology and causative factors in anal eczema [9–11]. The patient’s diet may be a factor in the development of diaper dermatitis [12]. Breastfed infants are less likely to develop moderate to severe diaper dermatitis relative to formula-fed infants [2, 13]. Adverse reactions to cow’s milk are frequent (2–7%) in the first year of life and may include cutaneous (50–60%), gastrointestinal (50–60%), or respiratory (20–30%) affection [14]. Streptococcal perianal infections were reported as a frequent cause of such a recurrent condition [15]. The aim of this work was to find out the different causes of recurrent perianal dermatitis with focus on the magnitude of cow’s milk allergy and the possible clinical or
References
[1]
G. F. Hayden, “Skin diseases encountered in a pediatric clinic. A one-year prospective study,” American Journal of Diseases of Children, vol. 139, no. 1, pp. 36–38, 1985.
[2]
W. E. Jordan, K. D. Lawson, R. W. Berg, J. J. Franxman, and A. M. Marrer, “Diaper dermatitis: frequency and severity among a general infant population,” Pediatric Dermatology, vol. 3, no. 3, pp. 198–207, 1986.
[3]
D. P. Amren, A. S. Anderson, and L. W. Wannamaker, “Perianal cellulitis associated with group A streptococci,” American Journal of Diseases of Children, vol. 112, no. 6, pp. 546–552, 1966.
[4]
B. Kr？nke, M. Trummer, E. Brabek, P. Komericki, T. D. Turek, and W. Aberer, “Etiologic and causative factors in perianal dermatitis: results of a prospective study in 126 patients,” Wiener Klinische Wochenschrift, vol. 118, no. 3-4, pp. 90–94, 2006.
[5]
D. B. Ward, A. B. Fleischer Jr., S. R. Feldman, and D. P. Krowchuk, “Characterization of diaper dermatitis in the United States,” Archives of Pediatrics and Adolescent Medicine, vol. 154, no. 9, pp. 943–946, 2000.
[6]
A. T. Lane, P. A. Rehder, and K. Helm, “Evaluations of diapers containing absorbent gelling material with conventional disposable diapers in newborn infants,” American Journal of Diseases of Children, vol. 144, no. 3, pp. 315–318, 1990.
[7]
R. Philipp, A. Hughes, and J. Golding, “Getting to the bottom of nappy rash. ALSPAC Survey Team. Avon Longitudinal Study of Pregnancy and Childhood,” The British Journal of General Practice, vol. 47, pp. 493–497, 1997.
[8]
M. O. Visscher, R. Chatterjee, K. A. Munson, D. E. Bare, and S. B. Hoath, “Development of diaper rash in the newborn,” Pediatric Dermatology, vol. 17, no. 1, pp. 52–57, 2000.
[9]
P. C. Goldsmith, R. J. G. Rycroft, I. R. White, C. M. Ridley, S. M. Neill, and J. P. Mcfadden, “Contact sensitivity in women with anogenital dermatoses,” Contact Dermatitis, vol. 36, no. 3, pp. 174–175, 1997.
[10]
A. Bauer, J. Geier, and P. Elsner, “Allergic contact dermatitis in patients with anogenital complaints,” Journal of Reproductive Medicine, vol. 45, no. 8, pp. 649–654, 2000.
[11]
J. D. Wilkinson, E. M. Hambly, and D. S. Wilkinson, “Comparison of patch test results in two adjacent areas of England. II. Medicaments,” Acta Dermato-Venereologica, vol. 60, no. 3, pp. 245–249, 1980.
[12]
H. T. Shin, “Diaper dermatitis that does not quit,” Dermatologic Therapy, vol. 18, no. 2, pp. 124–135, 2005.
[13]
A. G. Pratt and W. T. Read Jr., “Influence of type of feeding on pH of stool, pH of skin, and incidence of perianal dermatitis in the newborn infant,” The Journal of Pediatrics, vol. 46, no. 5, pp. 539–543, 1955.
[14]
A. H？st, “Frequency of cow's milk allergy in childhood,” Annals of Allergy, Asthma and Immunology, vol. 89, no. 6, supplement 1, pp. 33–37, 2002.
[15]
J. E. Wright and H. L. Butt, “Perianal infection with β haemolytic streptococcus,” Archives of Disease in Childhood, vol. 70, no. 2, pp. 145–146, 1994.
[16]
J. Hyams, R. Colletti, C. Faure, E. Gabriel-Martinez, and M. Verna, “Functional gastrointestinal disorders. Working group report of the first World Congress of Pediatric Gastroenterology, Hepatology, and Nutrition,” Journal of Pediatric Gastroenterology and Nutrition, vol. 35, supplement 2, pp. S110–S117, 2002.
[17]
F. K. Gishan, “Chronic diarrhea,” in Nelson Textbook of Pediatrics, R. E. Behrman, R. M. Kliegman, and H. B. Jenson, Eds., pp. 1276–1281, WB Saunders, Philadelphia, Pa, USA, 17th edition, 2004.
[18]
S. Ahlstedt, I. Holmquist, A. Kober, and H. Perborn, “Accuracy of specific IgE antibody assays for diagnosis of cow's milk allergy,” Annals of Allergy, Asthma and Immunology, vol. 89, no. 6, supplement 1, pp. 21–25, 2002.
[19]
S. L. Taylor, S. L. Hefle, C. Bindslev-Jensen et al., “Factors affecting the determination of threshold doses for allergenic foods: how much is too much?” Journal of Allergy and Clinical Immunology, vol. 109, no. 1, pp. 24–30, 2002.
[20]
R. S. Zeiger, S. Heller, M. H. Mellon et al., “Effect of combined maternal and infant food-allergen avoidance on development of atopy in early infancy: a randomized study,” Journal of Allergy and Clinical Immunology, vol. 84, no. 1, pp. 72–89, 1989.
[21]
P. N. Dixon, R. P. Warin, and M. P. English, “Role of Candida albicans infection in napkin rashes,” British Medical Journal, vol. 2, no. 648, pp. 23–27, 1969.
[22]
C. L. Taschdjian, J. J. Burchall, and P. J. Kozinn, “Rapid identification of Candida albicans by filamentation on serum and serum substitutes,” A.M.A. Journal of Diseases of Children, vol. 99, pp. 212–215, 1960.
[23]
U. C. Ghoshal, U. Ghoshal, K. Das, and A. Misra, “Utility of hydrogen breath tests in diagnosis of small intestinal bacterial overgrowth in malabsorption syndrome, and its relationship with orocecal transit time,” Indian Journal of Gastroenterology, vol. 25, no. 1, pp. 6–10, 2006.
[24]
M. B. Heyman and Committee on Nutrition, “Lactose intolerance in infants, children, and adolescents,” Pediatrics, vol. 118, no. 3, pp. 1279–1286, 2006.
[25]
N. Radlovi？, M. Mladenovi？, and Z. Lekovi？, “Lactose intolerance in infants with gluten-sensitive enteropathy: frequency and clinical characteristics,” Srpski Arhiv Za Celokupno Lekarstvo, vol. 137, no. 1-2, pp. 33–37, 2009.
[26]
T. Doganci and R. Cengizlier, “Role of cow's milk allergy in children with chronic constipation,” The Turkish Journal of Pediatrics, vol. 16, pp. 8–12, 2007.
[27]
G. Iacono, F. Cavataio, G. Montalto et al., “Intolerance of cow's milk and chronic constipation in children,” The New England Journal of Medicine, vol. 339, no. 16, pp. 1100–1104, 1998.
[28]
R. W. Berg, K. W. Buckingham, and R. L. Stewart, “Etiologic factors in diaper dermatitis: the role of urine,” Pediatric Dermatology, vol. 3, no. 2, pp. 102–106, 1986.
[29]
G. Ferrazzini, R. R. Kaiser, S. K. Hirsig Cheng et al., “Microbiological aspects of diaper dermatitis,” Dermatology, vol. 206, no. 2, pp. 136–141, 2003.
[30]
P. J. Honig, B. Gribetz, J. J. Leyden, K. J. McGinley, and L. A. Burke, “Amoxicillin and diaper dermatitis,” Journal of the American Academy of Dermatology, vol. 19, no. 2, pp. 275–279, 1988.
[31]
S. Singalavanija and I. J. Frieden, “Diaper dermatitis,” Pediatrics in Review, vol. 16, no. 4, pp. 142–147, 1995.
[32]
J. E. Rasmussen, “Classification of diaper dermatitis: an overview,” Pediatrician, vol. 14, supplement 1, pp. 6–10, 1987.
[33]
A. S. Paller, “Immunodeficiency syndromes,” in Textbook of Pediatric Dermatology, J. Harper, A. Oranje, and N. Prose, Eds., pp. 1678–1699, Blackwell Science, Oxford, UK, 2000.
[34]
W. Z. Mostafa, H. H. Arnaout, M. I. El-Lawindi, and Y. M. Zein El-Abidin, “An epidemiologic study of perianal dermatitis among children in Egypt,” Pediatric Dermatology, vol. 14, no. 5, pp. 351–354, 1997.
[35]
E. Isolauri, A. Tahvanainen, T. Peltola, and T. Arvola, “Breast-feeding of allergic infants,” Journal of Pediatrics, vol. 134, no. 1, pp. 27–32, 1999.
[36]
J. Zhao, M. Fox, Y. Cong et al., “Lactose intolerance in patients with chronic functional diarrhoea: the role of small intestinal bacterial overgrowth,” Alimentary Pharmacology and Therapeutics, vol. 31, no. 8, pp. 892–900, 2010.
