Perianal pseudoverrucous papules and nodules in hirschprung’s disease: Rapid resolution with oral loperamide



While irritant napkin dermatitis is a common disorder, extreme variants may occur in unusual clinical circumstances. We report a case of a young boy with Hirschprung’s disease (HD) and Giardia infection who developed the rare clinical picture of perianal pseudoverrucous papules and nodules (PPN). The patient, now a 3 year old boy, was diagnosed with Hirschprung’s disease at 7 months of age and subsequently suffered napkin dermatitis with a marked deterioration at 23 months with Giardia infection. Clinically, he developed multiple, discrete, brightly erythematous, flat-topped papules, mostly between 2-5mm diameters, covering the perianal area. The papules were friable and bled on contact, resulting in iron deficiency anaemia requiring transfusion. The perianal area was extremely tender and constantly exposed to faecal ooze, making hygiene almost impossible.
The condition was poorly responsive to topical therapies over a period of 6 months and colostomy was considered. However, after the commencement of loperamide 2mg daily, stool leakage reduced within 24 hours, and over several weeks the PPN completely resolved. To the authors’ knowledge, this is the first case report of the use of loperamide in the management of PPN. We discuss the presentation and management of PPN, as well as its distinction from similar entities.


Dr. Francis Yap

Royal Perth Hospital