The management of perianal disease (PD) in children with Crohn's disease was reviewed. Of 325 patients (184 boys), 200 (62%) developed PD. The mean age at diagnosis of Crohn's disease was 11.2 years (range, 5 to 17 years). Skin tags were present in 114 (35%) patients, fissures in 165 (51%), fistulas in 41 (15%), and perirectal abscesses in 47 (13%). One hundred fifty-three patients had PD as one of the first symptoms; 71 of these had complete remission of PD and the remaining 82 had chronic symptoms. Forty-two patients were initially free of PD, only to develop it later. PD occurred in 50% of patients with gastroduodenal Crohn's disease, 57% with jejunal, 68% with ileal, 64% with ileocecal, 60% with ileocolic, and 51% with colonic. Local minor operation was necessary in 38 (12%) patients, fistulotomy in 12, and abscess drainage in 26. Four patients required either intestinal resection and/or enterostomy for progressive PD. Fifty-three patients received metronidazole, with amelioration in 38. It is concluded that PD is a common complication of Crohn's disease in children and adolescents. Its presentation may antedate that of the primary disease. Most PD follows a benign course. There is a limited role for operation, but a need for meticulous perineal care and a potential benefit with metronidazole therapy. We advocate conservatism in the management of perianal complications of Crohn's disease in pediatric patients.