Infectious Diseases (Except Sexually Transmitted Diseases)

Vulvo-Vaginitis
The prepubertal vulva is thin, delicate, and susceptible to trauma, infection and irritation as it lacks labial fat pads and pubic hair. The anus is anatomically closer to the introitus, allowing contamination with feces and fecal pathogens.

The unestrogenized vaginal mucosa is thin and atrophic, has a neutral pH, and is an excellent medium for bacterial growth. In addition, hygiene in prepubertal children is frequently substandard as maternal supervision diminishes with age. The distinction (by history and clinical examination) between vulvitis and vaginitis has to be made. In vulvitis, dermatologic lesions involve exclusively the vulva and there is no vaginal discharge; often symptomatic treatment and advice will be enough. In cases of vaginitis, there are both clinical vulvo-vaginal manifestations and a vaginal discharge and a sexually transmitted disease has to be excluded.

Vulvitis without vaginal involvement is very common in young girls.

Symptoms include pruritus and urinary and/or anal signs. Clinical examination often shows an isolated erythema, without other dermatologic lesions. In these cases, there is no need for bacteriologic swabs as they are related to poor hygiene, irritants, and sometimes pinworms. Recommendations for improved hygiene and avoidance of irritation, in association with treatment of pinworms, are sufficient measures.

Vulvo-vaginitis with a discharge is most likely due to an infection or a retained foreign body. In this case, it is very important to clarify whether there is sexual contamination (sexually active teenagers or children who are being abused): a pertinent history and a clinical examination have to be very carefully conducted.

Any discharge must be fully investigated and samples taken for wet smears to screen for Trichomonas and Candida as well as for Gram staining and bacterial cultures. In prepubertal girls, pathogenic organisms include Streptococcus pyogenes (group A hemolytic streptococci), Haemophilus influenzae, Streptococcus pneumoniae, Staphylococcus aureus, Neisseria meningitidis, Shigella, Yersinia. Candida vulvo-vaginitis may occur in post-pubertal girls but is very rare in early infancy. Sexually transmitted disorders of bacterial origin include Trichomonas, gonorrhea and Chlamydia infections. In case of persistent vulvo-vaginitis with negative bacterial cultures, a vaginoscopic examination should be performed under anesthesia to rule out a retained foreign body.

Perineal Dermatitis
Bullous impetigo is characterized by the formation of large flaccid bullae arising from normal skin. The bullae rupture leaving red denuded round areas with honey-colored crusts. Those lesions spread rapidly and can quickly involve the thighs, buttocks, and abdomen. The causative agent is often S. aureus phage type II, which produces an epidermolytic toxin. Treatment is topical and general antibiotherapy.