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Pruritis Ani

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Pruritis Ani

  1. 1. Pruritis AniPruritis Ani Raymond G Buick FRCS 14 mins
  2. 2. 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
  3. 3. Pruritis Ani affects 1 – 5% M>F 4:1 typically age group 40 – 60 years
  4. 4. Pruritis Ani Cause? 25% idiopathic 75% co-existing pathology identifiable ‘irritant’
  5. 5. Pruritis Ani We will discuss –aetiology –investigation –treatment
  6. 6. Pruritis Ani Cause? idiopathic – a diagnosis of exclusion Nearly 100 different ‘causes’ have been described • co-existing pathology • identifiable ‘irritant’
  7. 7. Pruritis Ani - pathogenesis perineal 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%
  8. 8. Pruritis Ani - pathogenesis perineal faecal contamination • 50% - loose stools • 41% - weekly faecal soiling • alteration in recto-anal inhibitory reflexes so any condition whichso any condition which increases occult or overtincreases occult or overt soiling should besoiling should be identified and treatedidentified and treated
  9. 9. Pruritis Ani - aetiology • local/surgical conditions • peri-anal infection – bacterial, viral, fungal & parasite • dermatological conditions • systemic disease • medication • allergic contact dermatitis • food • clothing
  10. 10. Pruritis Ani co-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
  11. 11. Pruritis Ani peri-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
  12. 12. Pruritis Ani peri-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
  13. 13. Pruritis Ani peri-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
  14. 14. Pruritis Ani peri-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
  15. 15. Pruritis Ani peri-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
  16. 16. Pruritis Ani peri-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
  17. 17. Pruritis Ani peri-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
  18. 18. Pruritis Ani dermatological conditions • Psoriasis • lichen sclerosis • Paget's disease • Bowen's disease • lichen planus • Seborrhoeic Dermatitis • Neurodermatitis • Atrophic Dermatitis
  19. 19. Pruritis Ani systemic disease • diabetes mellitus • liver disease • leukaemia • lymphoma • renal failure • iron-deficiency anaemia • hyperthyroidism. • Anxiety, stress • personality traits • a manifestation of depression or psychological disturbance
  20. 20. Pruritis Ani systemic disease • diabetes mellitus • liver disease • leukaemia • lymphoma • renal failure • iron-deficiency anaemia • hyperthyroidism. • Anxiety, stress • personality traits • a manifestation of depression or psychological disturbance constipationconstipation diarrhoeadiarrhoea
  21. 21. Pruritis Ani medication • topical – steroids • systemic – colchicine – quinidine – laxatives – colpermin – peppermint oil – some antibiotics
  22. 22. 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 preservativesOintments have fewer preservatives and constituents than creams.and constituents than creams. They are less likely to sensitise or beThey are less likely to sensitise or be washed off.washed off.
  23. 23. Pruritis Ani food – caffeinated drinks – alcohol – milk products – peanuts, – spices – citrus – grapes – tomato (histamine) – chocolate & milk products – beer
  24. 24. 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 reflexes looser stoolslooser stools quicker transit timequicker transit time greater stool frequencygreater stool frequency increased faecal seepageincreased faecal seepage undigested foods sensitising the peri-anal skinundigested foods sensitising the peri-anal skin anal trauma from recurrent wipinganal trauma from recurrent wiping
  25. 25. Pruritis Ani history – other skin diseases or symptoms – allergies – general health – bowel history – local applications – clothes – detergents – food
  26. 26. Pruritis Ani examination – other sites of skin diseases – other associated disease manifestations
  27. 27. Pruritis Ani examination 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.
  28. 28. Pruritis Ani investigations swab / culture skin scrapings – fungal culture & microscopy biopsies skin-patch testing
  29. 29. Pruritis Ani treatment refer to appropriate speciality elimination of irritants and scratching general control measures active treatment measures
  30. 30. Pruritis Ani treatment elimination of irritants and scratching Eliminate irritants
  31. 31. Pruritis Ani treatment general control measures  wash the perineum bidet or shower head no soap, hair dryer. wash in the squatting position Aqueous cream or emollients (not soap and barrier creams inc zinc oxide) petroleum ointment
  32. 32. Pruritis Ani treatment general control measures  change daily  keep dry  cotton wool ACUTE EXACERBATIONACUTE EXACERBATION of pain burning itchingof pain burning itching best treatmentbest treatment immediate local hygineimmediate local hygine gently clean and drygently clean and dry
  33. 33. Pruritis Ani treatment  active treatment measures surgery if required treat infection bowel management
  34. 34. Pruritis Ani treatment  active treatment measures surgery if required treat infection bowel management systemic antihistamines [NOT topical] weak topical steroid (1% hydrocortisone) [NOT systemic] NO topical anaesthetics
  35. 35. Pruritis Ani treatment  active treatment measures surgery if required treat infection bowel management systemic antihistamines [NOT topical] weak topical steroid (1% hydrocortisone) [NOT systemic] NO topical anaesthetics capsaicin
  36. 36. Pruritis Ani treatment  active treatment measures surgery if required treat infection bowel management systemic antihistamines [NOT topical] weak topical steroid (1% hydrocortisone) [NOT systemic] NO topical anaesthetics capsaicin anal tatooing
  37. 37. The EndThe End A narrated tutorial on this subject will be available soon on Meducation Premium

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