1. Pruritis AniPruritis Ani
Raymond G Buick FRCS
14 mins

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. Pruritis Ani
affects 1 – 5%
M>F 4:1
typically age group 40 – 60 years

4. Pruritis Ani
Cause?
25% idiopathic
75% co-existing pathology
identifiable ‘irritant’

5. Pruritis Ani
We will discuss
–aetiology
–investigation
–treatment

6. Pruritis Ani
Cause?
idiopathic – a diagnosis of exclusion
Nearly 100 different ‘causes’ have been
described
• co-existing pathology
• identifiable ‘irritant’

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. 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. Pruritis Ani - aetiology
• local/surgical conditions
• peri-anal infection
– bacterial, viral, fungal & parasite
• dermatological conditions
• systemic disease
• medication
• allergic contact dermatitis
• food
• clothing

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

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. 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. Pruritis Ani
medication
• topical
– steroids
• systemic
– colchicine
– quinidine
– laxatives
– colpermin
– peppermint oil
– some antibiotics

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

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

26. Pruritis Ani
examination
– other sites of skin diseases
– other associated disease manifestations

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. Pruritis Ani
investigations
swab / culture
skin scrapings – fungal culture & microscopy
biopsies
skin-patch testing

29. Pruritis Ani
treatment
refer to appropriate speciality
elimination of irritants and scratching
general control measures
active treatment measures

30. Pruritis Ani
treatment
elimination of irritants and scratching
Eliminate irritants

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. 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. Pruritis Ani
treatment
 active treatment measures
surgery if required
treat infection
bowel management

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. 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. 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

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