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Therapeutic Strategies

Pruritus Ani

Timothy Berger Bruce Wintroub

Thursday, September 18, 2008

Overview

In the absence of a primary cutaneous disorder, pruritus ani is thought to have two probable causes. One is irritation from rectal mucus and fecal material. The other is nerve impingement in the sacral region, causing neuropathic itch. Rarely, pinworms, contact dermatitis, extramammary Paget's disease, and streptococcal proctitis can cause perianal itching with minimal changes evident on physical examination.

Initial Steps

  1. Perianal and anal hygiene after defecation is critical. After defecation, the patient should clean by washing with a mild soap and water, and dry by patting (not wiping) the perianal area with soft toilet paper. Use of pads premoistened with witch hazel may be substituted for washing.
  2. The perianal area should be kept dry with applications of absorbent powder as needed.
  3. Treat perianal area with iodochlorhydroxyquin 3% and hydrocortisone 1% cream or hydrocortisone and pramoxine 1-2.5% cream after perianal cleansing twice daily.
  4. Soft, loose-fitting, natural-fiber underclothing should be worn; men should wear loose trousers and cotton boxer undershorts.
  5. If there is a history of lumbosacral disc disease, the possibility of a neuropathic cause should be considered.

Subsequent Steps

The patient should expect symptomatic relief within 10-14 days and then:

  1. Continue perianal hygiene.
  2. Apply Zeasorb powder as needed.
  3. Decrease applications of iodochlorhydroxyquin 3% and hydrocortisone 1% cream or hydrocortisone and pramoxine 1-2.5% cream to as infrequently as needed to control symptoms.
  4. Continue wearing soft, loose-fitting, natural-fiber undergarments and, when possible, loose clothing.

Alternative Steps

  1. For severe cases with accompanying dermatitis, applications of a fluorinated steroid in a cream base twice daily may be necessary. Treat for no longer than 7-10 days. Under no circumstances should patients use fluorinated steroids in the perianal region on a regular basis.
  2. Application of an imidazole cream twice daily may be useful as empiric treatment for symptoms owing to suspected candidiasis.
  3. Topical capasicin 0.006% may be useful in cases with a neuropathic cause. This agent will cause severe burning in up to one-third of patients and therefore may not be tolerated. In those able to use it, about two-thirds will be 50% improved.
  4. Dietary alterations may be useful.
    a. Avoidance of milk, pork, corn, nuts, coffee, tea, cola, chocolate, alcohol, citrus fruits, and spices has been advocated.
    b. If necessary, dietary habits should be modified to encourage "regular" stool habits in order to avoid the irritation of constipation or frequent loose stools.
  5. Oral nystatin tablets (500,000 U 3 times daily) may alleviate symptoms in difficult cases in which pruritus caused by yeast is suspected.

Pitfalls

Failure to detect a primary disease responsible for pruritus is the principal pitfall. Pinworms, tinea, candidiasis, erythrasma, extramammary Paget's disease, occult allergic contact dermatitis, hemorrhoids, and psoriasis must be sought prior to therapy or in difficult cases.

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