Approach to anal itching – Laurence Lever

‘Approach to
Anal Itching’
Dr Laurence Lever
Consultant Dermatologist
Northwick Park Hospital
Anal Itching-Pruritus Ani


Symptoms:
 Itching of anal and genital areas
 Worsening at night
 May awaken the patient from sleep
 Embarrassing during the day
 Male>Female
Chronic itching can lead to hypertrophic skin,
with associated nodularity and scarring
Causes of Pruritus Ani
Jones, DJ: Pruritus ani. ABC of Colorectal disease 1992, BMJ
Common causes of anal itch










Constipation/diarrhoea (faecal contact as irritant)
Anal fissure
Haemorrhoids
GI infections (threadworm)
Food?
Infections
Psoriasis
Lichen sclerosus et atrophicus
Other skin diseases
Malignancy
 Dermatitis/Eczema
Rectal disease in cake
Common causes of anal itch










Constipation/diarrhoea (faecal contact as irritant)
Anal fissure
Haemorrhoids
GI infections (threadworm)
Food?
Infections
Psoriasis
Lichen sclerosus et atrophicus
Other skin diseases
Malignancy
 Dermatitis
Foods associated with pruritus ani
Most common
Coffee (caffeinated and decaffeinated)
Tea
Cola
Other caffeinated drinks
Alcohol, especially beer and wine
Chocolate
Tomato including ketchup (histamine)
Others Milk products
Peanuts and nuts
Spices
Citrus fruits
Grapes
Popcorn
Spicy foods
Prunes
Figs
Pruritus Ani. Siddiqi S, Vijay V, Ward M, Mahendran R, Warren S.
Ann R Coll Surg Engl. 2008 Sep; 90(6): 457–463.
Viral
Fungal
Bacterial: Perianal streptococcal dermatitis
Not bacterial
LSA
LSA & SCC
Benign familial pemphigus
Bowenoid papulosis
Chronic erosion
Extramammary Paget’s
MM
BCC
Dermatitis or Eczema
Mechanism of dermatitis
Atopic Dermatitis
Perianal dermatitis in babies
‘Idiopathic pruritus’?
Perianal dermatitis in adults







Itch
Red skin, dry or weeping
History of eczema or atopy
Too much washing
Use of wet wipes
Use of local anaesthetic preparations
Clinical evidence of scratching
Lichenification
lichenification, pigmentation
Irritant or allergy?
Wet Wipes/Moist toilet paper
Methylisothiazolinone (MI)
Contact allergy






Perfumes
Parabens preservatives
Lanolin
Neomycin
Local anaesthetics
Methylisothiazolinone
Pediatrics: February 2014, VOLUME 133 / ISSUE 2
Six Children With Allergic Contact Dermatitis to Methylisothiazolinone in Wet Wipes (Baby
Wipes)
Mary Wu Chang, Radhika Nakrani
Management of perianal dermatitis







Consider differential diagnosis
Patch Testing?
Stop soap, gel, wet wipes
Emollient for washing, applying twice daily
Short course of potent topical steroid ointment
with or without antibacterial
Must review after 2 weeks
Plan for maintenance therapy
Ointment (not cream)
Emulsifying Ointment
Emulsifying Wax 30%
White Soft Paraffin 50%
Liquid Paraffin 20%
Softer Brands: Epaderm Ointment,
Hydromol Ointment
Steroid ointment (not cream)
Detailed instructions for patient





No soap
Wash with emulsifying ointment
Apply ointment after washing, at least twice
daily, before and after toilet
Apply steroid ointment at night
Come back after 2 weeks
Why review?
Thank you