Introduction
Pruritus ani is a chronic perianal itching that may result in disruption in quality of life, irritability and depression. Itching may persist for weeks or even years. Two main types of pruritus ani are defined; primary (idiopathic) type in which there is no underlying cause or condition and the secondary type in which anorectal cause, dermatological or colonic disorder could be addressed. Primary(idiopathic) pruritus ani is responsible for 50–90% of all cases of pruritus ani and it is more common than secondary cases.Treatment options of pruritus ani(anal itching), includes following instructions about how to keep the perianal skin dry and clean and the use of topical treatment and barrier creams. It also involves treating the underlying condition in seconday cases.
General tips for treatment options of pruritus ani(anal itching)
- The main aims of treatment is to break the itch–scratch cycle and to restore intact, dry and clean perianal skin.
- You have to identify primary from secondary type pruritus ani. In case of secondary type, treatment is the treatment of the underlying cause.
- Psychiatric screening should be considered in the light of history taking because stress and anxiety may aggrevate itching.
- For affected children, pinworm should be excluded.
- Diabetic patients with perianal erythema should be investiagted for fungal infections.
- For resistant cases, punch biopsy and Rectosigmoidoscopy and/or colonoscopy should be considered.
- Patient should be advised to avoid any behaviors, foods or drinks that may aggrevate pruritus ani.
- Diet modification
- Avoidance or abstinence from agents including alcohol, tobacco, and caffeine should be advised.
- Avoidance of tomatoes, citrus, and spicy ingestions may help some patients.
- Probiotics, increased dietary fber and low-nickel diet may be helpful.
- Lactobacillus replacement therapy is recommended in patients receiving chronic antibiotic therapy who have loose stools.
- Mild cases often respond to sitz baths (e.g. with astringents such as black tea).
- Cleaning habits
- Avoidance of toilet paper may be helpful.
- Cleansing the area with a portable shower head is a practical alternative.
- The area is then dried with hair dryer or a fan, with avoidance of rubbing and alkaline soaps.
- An emollient should be applied after each wash.
- Overcleaning is bad as inadequate cleaning. It may be irrritating.
- Barrier creams such as zinc oxide can help to protect the skin from further irritation and friction.
- Nonporous tight Underwear clothing should be avoided. Cotton made clothes are preferable.
- Prolonged high-potency steroid use should be avoided.
- Consult a colo‐rectal specialist if required.
Medical treatment options of idiopathic pruritus ani(anal itching)
Topical treatment of pruritus ani
- A mild corticosteroid cream (class 6 or 7) is often effective in controlling symptoms.
- Hydrocortisone 1% in paraffn twice daily.
- If the skin is lichenified and the condition is severe, more potent topical corticosteroids may be required, but, be aware with the risk of skin atrophy.
- Topical calcineurin inhibitors
- For longer period of treatment, 0.1% tacrolimus can be used alternatively with topical corticosteroids.
- Some authors advise using combination of creams with steroid, antifungal, and antibacterial components .
- Topical capsaicin
- Topical capsaicin 0.006% three times a day for 4 weeks could be used. Capsaicin will cause perianal irritation in most patients during the therapy.
- Intralesional steroid injections to the perianal skin may be considered.
- For resistant cases, Intradermal methylene blue 1–2% methylene blue alone or in combination with 0.5% lidocaine are reported to damage dermal nerve endings and provide relief.
- Injection with phenol in almond oil has been reported to be beneficial.
- Cryotherapy.
Points to remember
Differentiate between idiopathic and socndary pruritus ani.
Most patients with pruritus ani have a nonspecific etiology.
Fecal contamination play a central role in idiopathic pruritus ani.
Detailed history with focus on the patient`s perineal hygiene, whether it was insufficient or aggressive.
Sources
- Idiopathic Pruritus Ani and Acute Perianal Dermatitis
- Dermatology , Edited by Jean L. Bolognia , Julie V. Schaffer , Lorenzo Cerroni Fourth edition: Elsevier, 2018, ISBN 978–0‐7020–6275–9.
- Griffiths, C., Barker, J., Bleiker, T. O., Chalmers, R., & Creamer, D. (Eds.). (2016). Rook’s textbook of dermatology. John Wiley & Sons.
- Lebwohl, M. G., Heymann, W. R., Berth-Jones, J., & Coulson, I. (2013). Treatment of skin disease E-Book: comprehensive therapeutic strategies. Elsevier Health Sciences.
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