pruritis ani

Pruritis AniPruritis Ani

Raymond G Buick FRCS

14 mins

Pruritis Ani

Pruritus ani • is the irritation of the peri-anal skin• causing the desire to scratch• mild to severe– can cause intolerable discomfort accompanied by

burning and soreness– if severe and persistent - depression

Pruritis Ani

affects 1 – 5%

M>F 4:1

typically age group 40 – 60 years

Pruritis Ani

Cause?

25% idiopathic

75% co-existing pathologyidentifiable ‘irritant’

Pruritis Ani

We will discuss –aetiology–investigation–treatment

Pruritis Ani

Cause?

idiopathic – a diagnosis of exclusion

Nearly 100 different ‘causes’ have been described

• co-existing pathology• identifiable ‘irritant’

Pruritis Ani - pathogenesisperineal faecal contamination– overt– occult• faeces; moist; prolonged

• Peri-anal skin reacts differently from skin elsewhere

• [Caplan – skin patch testing]• on perineum up to 50%• on arm 4%

Pruritis Ani - pathogenesisperineal faecal contamination

• 50% - loose stools• 41% - weekly faecal soiling

• alteration in recto-anal inhibitory reflexes

so any condition which so any condition which increases occult or overt increases occult or overt

soiling should be soiling should be identified and treatedidentified and treated

Pruritis Ani - aetiology• local/surgical conditions• peri-anal infection– bacterial, viral, fungal & parasite

• dermatological conditions• systemic disease• medication• allergic contact dermatitis• food• clothing

Pruritis Anico-existing pathology• Local/Surgical Pathology (about 50%)

• haemorrhoids• anal fisssure• anal fistula• rectal prolapse• rectal polyps• peri-rectal abscess• solitary rectal ulcer• anal papilloma• Crohn’s Disease• cancer

Pruritis Aniperi-anal infection – bacterial, viral, fungal & parasite

Candida albicans Threadworms (Enterobius) β-Haemolytic streptococci Corynebacterium minutissimum (Erythrasma) Tinea cruris, [crotch itch, crotch rot, Dhobie itch] Staphylococcus aureus Herpes Simplex Virus (HSV) Human Papillomavirus (HPV) Scabes Sexually transmitted diseases

Gonorrhoea Syphilis

Pruritis Aniperi-anal infection – bacterial, viral, fungal & parasite

Candida albicans Threadworms (Enterobius) β-Haemolytic streptococci Staphylococcus aureus Corynebacterium minutissimum (Erythrasma) Tinea cruris, [crotch itch, crotch rot, Dhobie itch] Herpes Simplex Virus (HSV) Human Papillomavirus (HPV) Scabes Sexually transmitted diseases

Gonorrhoea Syphilis

Pruritis Ani

dermatological conditions• Psoriasis• lichen sclerosis• Paget's disease • Bowen's disease• lichen planus• Seborrhoeic Dermatitis• Neurodermatitis• Atrophic Dermatitis

Pruritis Anisystemic disease• diabetes mellitus• liver disease• leukaemia• lymphoma• renal failure• iron-deficiency anaemia• hyperthyroidism.• Anxiety, stress • personality traits • a manifestation of depression or psychological disturbance

Pruritis Anisystemic disease• diabetes mellitus• liver disease• leukaemia• lymphoma• renal failure• iron-deficiency anaemia• hyperthyroidism.• Anxiety, stress • personality traits • a manifestation of depression or psychological disturbance

constipationconstipationdiarrhoeadiarrhoea

Pruritis Ani

medication• topical – steroids

• systemic– colchicine– quinidine– laxatives– colpermin– peppermint oil – some antibiotics

Pruritis Ani

allergic contact dermatitis– chemicals– cleansing and therapeutic – creams, soaps, wet wipes, deodorants or perfumes– Alcohol-based anal wipes– glyceryl trinitrate, local anaesthetic– toilet paper dye– Fabric softener intolerance

Ointments have fewer preservatives Ointments have fewer preservatives and constituents than creams. and constituents than creams. They are less likely to sensitise or be They are less likely to sensitise or be washed off.washed off.

Pruritis Ani

food– caffeinated drinks– alcohol– milk products– peanuts,– spices– citrus– grapes– tomato (histamine) – chocolate & milk products– beer

Pruritis Ani

food– caffeinated drinks– alcohol– milk products– peanuts,– spices– citrus– grapes– tomato (histamine) – chocolate

reduction in anal sphincter pressures, reduction in anal sphincter pressures, exaggerated anal reflexesexaggerated anal reflexeslooser stoolslooser stoolsquicker transit time quicker transit time greater stool frequency greater stool frequency increased faecal seepageincreased faecal seepageundigested foods sensitising the peri-anal skinundigested foods sensitising the peri-anal skinanal trauma from recurrent wipinganal trauma from recurrent wiping

Pruritis Ani

history– other skin diseases or symptoms– allergies– general health– bowel history– local applications– clothes– detergents– food

Pruritis Ani

examination

– other sites of skin diseases– other associated disease manifestations

Pruritis Aniexamination

lesion– distinct boundry

• tinea, psoriasis or neoplasia

– bright erythema • chronic topical steroid use • yeast infection

– Lichen sclerosis • labia or perineum

– itch with multiple lesions • herpes

– palpable groin nodes • neoplasia• sexually transmitted infections.

Pruritis Aniinvestigations

swab / culture

skin scrapings – fungal culture & microscopy

biopsies

skin-patch testing

Pruritis Anitreatment

refer to appropriate speciality

elimination of irritants and scratching

general control measures

active treatment measures


elimination of irritants and scratching

Eliminate irritants


general control measures wash the perineum

bidet or shower head no soap, hair dryer. wash in the squatting positionAqueous cream or emollients (not soap and barrier

creams inc zinc oxide)petroleum ointment


general control measures change daily keep dry cotton wool

ACUTE EXACERBATIONACUTE EXACERBATIONof pain burning itching of pain burning itching

best treatmentbest treatmentimmediate local hygineimmediate local hygine

gently clean and drygently clean and dry


active treatment measuressurgery if requiredtreat infectionbowel management


active treatment measuressurgery if requiredtreat infectionbowel managementsystemic antihistamines [NOT topical]weak topical steroid (1% hydrocortisone) [NOT systemic]NO topical anaesthetics



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