Causes and Management of Pruritus Ani.

CASE SUMMARY: A 48-year-old healthy man presented to the office reporting a long-standing history of anal pruritus. He had tried various over-the-counter creams without much success. Besides an anal fissure in the past, which responded to nitroglycerin ointment, his medical history was unremarkable. On physical examination, he was found to have grade I hemorrhoids and mild fecal smearing on perianal skin. Recent colonoscopy and laboratory work ordered by the primary care provider were normal. He was counseled on common inciting agents and local irritants and was advised on hygiene, diet modification, and stool-bulking agents. The colorectal surgeon recommended that the patient keep a journal about his symptoms, foods, and household chemicals used. He was seen twice more over the course of 6 months to pinpoint the cause of his pruritus. A short-course trial of topical steroid, barrier cream, and topical tacrolimus was not helpful. A biopsy of perianal skin was performed and was unrevealing. Eventually, given the persistence of symptoms, it was decided that he would undergo methylene blue injection to address his pruritus (Fig. 1). The procedure consisted of several intradermal and subcutaneous injections of 10 mL of 1% methylene blue combined with 7.5 mL of 0.25% bupivacaine with adrenaline (1/100,000) and 7.5 mL 0.5% lidocaine. After the methylene blue injection, the severity of his symptoms improved, but pruritus still persisted. A methylene blue injection of the same concentration was repeated in 3 months with complete resolution of symptoms.

[Differential diagnosis of anal eczema]. / Differenzialdiagnose des Analekzems.

Dermatologic disorders often show involvement of the (peri)anal skin. However, diagnosis of (peri)anal dermatoses is often difficult even for experienced dermatologists due to delayed clinical presentation or prior treatment with over-the-counter medications. The distinct anatomical conditions of the (peri)anal region results in atypical clinical presentation of common dermatoses. Typical symptoms include pruritus, burning, bleeding and pain. Careful history of symptoms, stool, hygiene, sexual practice as well as thorough inspection of the entire body and proctological examination are crucial to make the correct diagnosis. In case of atypical presentation or uncertainty a biopsy needs to be obtained to ensure correct diagnosis and treatment.

[Pruritus ani]. / Pruritus ani.

INTRODUCTION: Pruritus ani is defined as a dermatologic disease characterized by itching and/or burning in the perianal area. It occurs in 15% of the population. Men are affected more frequently than women, in the ratio 4:1. It is accompanied by an irresistible desire to scratch in the perianal area. Pruritus ani is divided into two subtypes: primary (idiopathic) and secondary. In idiopathic (primary) pruritus it is not possible to detect any other cause of itching. Secondary pruritus has an obvious causal origin.The aim of this paper is to offer a complex overview of possible causes, diagnostic procedures and treatment possibilities of this unpleasant and annoying disease. METHODS: We have researched available publications using PubMed and MEDLINE databases, focusing on articles on anal pruritus. At first the key word "Pruritus ani" was put in without any restrictions. Subsequently, we limited the selection by the time period of 5 years and 10 years; then we looked up articles in English, German and Czech languages, and finally review articles, clinical trials and others. RESULTS: 574 articles were found without entering any restrictions; 45 of them were review articles and 25 clinical trials. 437 articles were in the English language and 40 of them were review articles. 44 were in the German language and 1 of them was a review article. A total of 33 articles were found with a 5-year time limit. 6 of them were review articles and 4 were clinical trials. 66 articles from the last 10 years were found. 14 of them were review articles and 10 were clinical trials. In most of the other articles among the total number of articles found, pruritus ani was mentioned only marginally in articles focused on different topics. We have not found any summary articles on this topic in Czech publications. CONCLUSION: Pruritus ani is a common disease with a number of causes; therefore, effective treatment may be insufficient in the initial stages. The therapy is focused on the primary cause, if found. Broad differential diagnosis options need to be taken into consideration, and reevaluation of the therapy is a priority. When no obvious secondary cause is found, the empiric treatment is focused on an improvement of hygiene and change in the life style, removal of common irritators, and protection of perianal skin.

Management and outcome of perianal Paget's disease: a 6-decade institutional experience.

BACKGROUND: Perianal Paget's disease (intraepithelial adenocarcinoma) is rare and sometimes difficult to diagnose because symptoms are nonspecific. It is often noninvasive but frequently recurs locally. Invasive disease can metastasize to distant sites. OBJECTIVE: The purpose of this work was to review the diagnosis, management, and outcomes of patients with perianal Paget's disease. DESIGN: Institutional databases were queried for all of the cases of perianal Paget's disease at Memorial Sloan-Kettering Cancer Center between 1950 and 2011. Clinicopathologic factors were investigated for association with recurrence and survival. SETTINGS: The study was conducted at a tertiary care center. PATIENTS: Sixty-five patients with perianal Paget's disease were included in the study (35 women [54%]; median age at diagnosis, 66 years [range, 60-72 years]; and 41 with invasive disease/24 with noninvasive disease). A total of 56% with invasive disease were men. MAIN OUTCOME MEASURES: Measures included median follow-up, disease status, local and distant recurrence, sites of recurrence, disease-specific survival, overall survival, and treatment modality. RESULTS: A total of 95% with invasive disease and 87% with noninvasive disease were symptomatic at presentation. The most common symptoms were pruritus and perianal bleeding. The duration of symptoms was longer in patients with invasive (12.0 months; range, 4.0-18.0 months) versus noninvasive (3.5 months; range, 1.0-10.0 months) disease. Synchronous malignancies unrelated to the primary disease were noted in 5 patients with invasive disease and 3 with noninvasive disease. Noninvasive disease was treated with a wide local excision and invasive disease with a wide local excision (n = 32, 78%) or abdominoperineal resection (n = 9, 22%). Forty-one patients (27 invasive and 14 noninvasive) required multiple operations for tumor clearance. In those with invasive disease, the median time to recurrence was 5 years, and the median tumor-specific survival rate was 10 years. LIMITATIONS: This was a retrospective study, limited by selection bias. CONCLUSIONS: Perianal Paget's disease is associated with nonspecific symptoms, frequently delaying diagnosis. Wide local excision is the treatment of choice if negative margins can be obtained. Abdominoperineal resection should be considered for invasive disease. Local recurrence is common; follow-up includes periodic proctoscopy and digital examination. Invasive disease can metastasize to distant sites; follow-up should include the examination of inguinal lymph nodes and the imaging of liver and lungs.

Perianal pruritus in dogs with skin disease.

BACKGROUND: Perianal pruritus has been reported in dogs with anal sac disease but not in healthy dogs. Some authors describe it as typical of allergy, but there is little evidence in support of this. HYPOTHESIS/OBJECTIVES: The aim was to investigate the association between perianal pruritus and canine atopic dermatitis (CAD), adverse food reaction (ARF) and other skin diseases in dogs. ANIMALS: Two hundred and fifty privately owned dogs with skin disease and without anal sac disease. METHODS: The presence or absence of perianal pruritus, macroscopic and cytological evaluation of the perianal skin surface and the macroscopic appearance of anal sac contents were assessed. Chi-square and Fisher's exact tests were performed to compare the frequency of perianal pruritus with the clinical diagnoses and with clinical and cytological parameters. RESULTS: Perianal pruritus was seen in 39 of 75 dogs with CAD, in 29 of 57 dogs with ARF and in only 24 of 118 dogs with other conditions. The frequency of perianal pruritus in dogs with CAD and/or ARF was significantly higher than that in dogs with other diagnoses (P < 0.0001). No other disease was significantly associated with perianal pruritus. Perianal pruritus was significantly associated with signs of perianal alopecia, erythema, excoriations, lichenification and hyperpigmentation; it was not associated with the presence of bacteria or yeasts or with anal sac impaction. CONCLUSIONS AND CLINICAL IMPORTANCE: Perianal pruritus was seen more frequently in dogs with AFR/CAD than with other dermatological diseases. This is the first study to evaluate perianal pruritus in dogs with skin disease and without anal sac disease.

Pruritus ani: more than a decade of personal experience in Lebanon.

INTRODUCTION: Pruritus ani is a common medical condition that is difficult to treat in the absence of obvious predisposing factors. Hereby, we report more than a ten-year experience in the management of pruritus ani stressing the importance of early detection, identification of the etiology, and management. METHODOLOGY: A total of 124 patients were managed in the surgical clinic. The follow-up was between 11 to 17 months. All patients had the symptoms for a period of time ranging between 6 and 40 months. Patients were treated according to their respective etiology. Medical cases like contact dermatitis and psoriasis were treated by applying proper topical ointments, while other cases like anal fissure and fistula were treated surgically. Idiopathic patients were treated by tattooing (injection to perianal skin with methylene blue). RESULTS & DISCUSSION: The majority of patients with known medical etiology responded favorably to conservative treatment (≈ 92%). In addition, surgical management for anorectal disorders like hemorrhoids and fistula showed a consistent improvement (94%). However, patients who had their symptoms neglected for longtime or had used over the counter medication without a proper medical follow-up, experienced a lower success rate of cure (76%). CONCLUSION: Patients who were diagnosed and treated at first hand, showed better results than those who sought late medical advice and management (i.e. > 18 months). In light of the above, a multidisciplinary team approach consisting of a proctologist, a gastroenterologist and a dermatologist is recommended.

Diagnosis and treatment of perianal Crohn disease: NASPGHAN clinical report and consensus statement.

Inflammatory bowel disease is a chronic inflammatory disorder of the gastrointestinal tract that includes both Crohn disease (CD) and ulcerative colitis. Abdominal pain, rectal bleeding, diarrhea, and weight loss characterize both CD and ulcerative colitis. The incidence of IBD in the United States is 70 to 150 cases per 100,000 individuals and, as with other autoimmune diseases, is on the rise. CD can affect any part of the gastrointestinal tract from the mouth to the anus and frequently will include perianal disease. The first description connecting regional enteritis with perianal disease was by Bissell et al in 1934, and since that time perianal disease has become a recognized entity and an important consideration in the diagnosis and treatment of CD. Perianal Crohn disease (PCD) is defined as inflammation at or near the anus, including tags, fissures, fistulae, abscesses, or stenosis. The symptoms of PCD include pain, itching, bleeding, purulent discharge, and incontinence of stool. In this report, we review and discuss the etiology, diagnosis, evaluation, and treatment of PCD.

Evaluation, management and future perspectives of anal pruritus: a narrative review.

PURPOSE: The without a time limitation. Most recent search was performed on 1st June 2022. RESULTS: Thorough history and physical examination are very important in view of multiple possible causes of anal pruritus. Most of the focus during examination is drawn on to the perianal region. A digital rectal examination and an anoscopy are essential. It is necessary aim of this narrative review is to overview the classification, diagnostics, possible treatment options and future perspective of anal pruritus. METHODS: The search was performed by two authors (AD and MJ) independently in the following electronic databases: PubMed, EMBASE, Web of Science, Cochrane Library, CENTRAL and the Allied and Complementary Medicine Databases (AMED). Search was restricted to English language only to avoid moisture and the use of soaps in the perianal region. Furthermore, the patient should avoid certain foods and increase the intake of fiber. If the symptoms do not resolve, topical steroids, capsaicin (0.006%) and tacrolimus (0.1%) ointments may be used. For intractable cases, intradermal methylene blue injection might give a long-lasting symptom relief. CONCLUSION: Anal pruritus is a long-term deteriorating quality of life issue. Most of the time it is a symptom with a difficult diagnosis. Thorough history and examination should be performed for the best possible treatment.

Outcome of repeated stapler haemorrhoidopexy for recurrent prolapsing haemorrhoids.

AIM: Stapled haemorrhoidopexy (SH) is associated with minor postoperative pain and high overall satisfaction rates. Some patients will have persistent or recurrent symptoms requiring re-intervention. METHOD: All patients who underwent SH for grade III internal haemorrhoids and required a second SH (2005-2008) were studied. Grade IV patients were excluded. Data on surgical technique, postoperative pain, complications, time to first bowel movement, functional recovery and suspected reason for first SH failure were retrieved from medical records. Similar data were collected for the second procedure at four postoperative follow-up visits. RESULTS: Twelve patients were enrolled. The mean time to recurrent symptoms was 15 months. The indications for repeated surgery were bleeding, prolapse, and pruritus w/wo discharge. Recurrence was attributed to a too high staple line in the first procedure (n = 4) and an incomplete resected ring (n = 1). The median operative time of the second procedure was 24 min (17-29) and the median follow up was 20 ± 4.3 months (15-30). Repeat SH was associated with higher pain scores, more analgesic requirements, and longer recovery period compared to the first procedure. There were no early or late postoperative complications. Histological examination of the 12 tissue doughnuts resected during the second SH showed no smooth muscle fibres in any of the patients. After 12 months of follow up, 10 patients with repeated SH remained asymptomatic, while 2 had recurrent bleeding. CONCLUSION: Repeat SH can be performed safely and reliably without risk of complications, but the second SH is associated with more pain and longer recovery time.

Pruritus ani.

BACKGROUND: Anal pruritus affects up to 5% of the population. It is often persistent and the constant urge to scratch the area can cause great distress. Although usually caused by a combination of irritants, particularly faecal soiling and dietary factors, it can be a symptom of serious dermatosis, skin or generalised malignancy or systemic illness. OBJECTIVE: This article discusses the assessment and management of pruritus ani. DISCUSSION: It is important not to trivialise the symptom of anal pruritus and to enquire about patient concerns regarding diagnosis. Once serious pathology has been excluded, management involves education about the condition; elimination of irritants contributing to the itch-scratch cycle including faecal soiling, dietary factors, soaps and other causes of contact dermatitis; and use of emollients and topical corticosteroid ointments. Compounded 0.006% capsaicin appears to be a safe and valid option for pruritus not responding despite adherence to these conservative measures.

Pruritus ani: an approach to an itching condition.

Pruritus ani is frequently encountered in children by the primary care physician and the pediatrician. It is mainly due to an infection with pinworms, but fecal soiling, poor hygiene, local irritation, and dietary agents should also be considered. Treatment should be directed at the underlying etiology. Once these have been excluded, both general and specific measures must be initiated. There is almost no experience for local treatment modalities in children, and they cannot currently be recommended.

Consumption of red-hot chili pepper increases symptoms in patients with acute anal fissures. A prospective, randomized, placebo-controlled, double blind, crossover trial.

BACKGROUND: Red-hot chili pepper and other spices have been blamed for causing or exacerbating symptoms of anal pathologies like anal fissure and hemorrhoids. AIM: To determine if consumption of chilies increases symptoms of acute anal fissures. METHODS: Individual patients were randomized to receive capsules containing chili or placebo for one week in addition to analgesics and fiber supplement. Patients were asked to note score for symptoms like pain, anal burning, and pruritus during the study period. After 1 week, cross over treatment was administered to the same group of patients with the same methodology and results were noted at the end of 2 weeks. RESULTS: Fifty subjects were recruited for this study. Forty three of them completed the trial (22 in the chili group and 21 in the placebo group). The daily mean pain score was significantly lower in the placebo group in the study period. Score 2.05 in chili group and 0.97 in placebo group. There was a significant burning sensation experienced by the patients in the chili group (score 1.85 for the chili group vs 0.71 for the placebo group). Patients mean recorded improvement score was significantly higher after taking placebo. Eighty one point three percent patients preferred placebo while 13.9% preferred chilies. Two patients had no preference. CONCLUSION: Consumption of chili does increase the symptoms of acute anal fissure and reduces patient compliance.

Perianal psoriasis as the first manifestation of the disease

Introduction: Inverse psoriasis affects the skin of flexural areas, such as the groin, axillae, umbilicus, intergluteal fold, and external genitalia. Clinical Case: We herein report the case of a man who presented with anal pruritus and, upon physical examination, a perianal dermatosis was found, which was characterized by erythematous plaques, with fine scaling. The case was initially managed with zinc oxide, and when no improvement was observed, we decided to take an incisional biopsy, which indicated histological changes suggestive of psoriasiform dermatitis. Discussion: Inverse psoriasis affects 3% to 7% of patients with psoriasis, and it manifests with erythematous plaques without the classic scaling appearance. The skin in these areas is susceptible to maceration, irritation, and ulceration, which alter the classic clinical picture. It may present with typical lesions or, less frequently, in isolation in the anogenital region. In the anogenital presentation only, the diagnosis should be made by biopsy, looking for the classic histopathological features of psoriasis. As for the first-line treatment, low- or medium-potency topical steroids are used for short periods of time; the second-line treatment is with emollients and tar-based products; and the third-line treatment uses an immunomodulator. Conclusion: This presentation is infrequent, and it requires a high index of suspicion for the diagnosis, always supported by biopsies, in search of the classic histopathological features of psoriasis. (AU)

Etiologic and causative factors in perianal dermatitis: results of a prospective study in 126 patients.

BACKGROUND: Perianal dermatitis is probably the most common cutaneous disorder of the genitoanal area. Studies on the epidemiology of causative factors are rare. METHODS: Over a 4-year period we prospectively studied 126 patients with a presumptive diagnosis of anal eczema. The diagnostic algorithm comprised medical history, inspection, microbiology, laboratory chemistry, patch tests, proctoscopy, and biopsy if appropriate. RESULTS: The age range was 7-82 years and the majority of patients were male (57.1%). Periods of anal symptomatology ranged from 6 days to 120 months and most of the patients (51.6%) had complaints for more than 12 months. The clinical diagnosis in 68 patients (54%) was: intertrigo/candidiasis (42.9%), atopic dermatitis (6.3%), pruritus ani (5.6%), psoriasis (3.2%), skin atrophy from steroid use (2.4%), lichen sclerosus et atrophicus (n = 2), herpes simplex (n = 1), and condylomata acuminata (n = 1). Contact eczema was suspected in 58 patients (46%), but 25 of these (43.1%) showed no contact sensitization. CONCLUSION: The majority of patients with symptoms of anal eczema suffer from intertrigo/candidiasis, and relevant, causative contact sensitization may be found in only some of them. Patch-testing is a valuable investigative tool only when the patients' own products are included in the test series. Most patients suffer from their perianal complaints for more than 12 months, therefore diligent evaluation is warranted.

[Enterobiasis during 2002-2003 in Perugia province: beyond diagnostics]. / Enterobiasi nel biennio 2002-2003 nel perugino: considerazioni non soltanto diagnostiche.

Between 2002 and 2003 we examined cellophane tapes of 119 children, both symptomatic and apparently asymptomatic. Eggs of Enterobius vermicularis were observed in 13.4% of children. This helminth is the most frequent in Italy, but it is as yet unrecognized, probably due to parasitological laboratories not being consulted, resulting in incomplete epidemiological data. We recall the biological aspects of this nematode and suggest the need for sound diagnosis to ensure proper surveillance of this exclusively human infection.

Itch in Special Skin Locations Management.

Itch management can be particularly complicated in some small areas like the scalp or the anogenital region for many reasons: the frequently poor diagnosis of the causes of itch in these areas, the dense innervation of these areas, and the symbolic value of these areas for the human psyche. The diagnosis of itchy scalp is easier than that of anogenital pruritus. Clinical examination and a careful inventory of all diseases of the patient and of the local environment are necessary. Localized treatments are frequently used at both sites, whereas specific pharmaceutical formulations are necessary for the pilose or the mucous environment. Nonetheless, systemic treatments or psychological interventions can be very useful.