Pruritus ani: etiology and management

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.

Causes and Management of Pruritus Ani

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.

Assessment of the anxiety and depression among patients with idiopathic pruritus ani

Introduction

Pruritus ani is an unpleasant sensation that leads to scratching of the skin around the anus. It is a common symptom due to many systemic, dermatological, and proctological conditions. In the absence of evident organic origin of a disease, pruritus may be related to mental disorders as well as personality disorders.

Aim

To assess the influence of pruritus on anxiety and depression in these patients.

Material and methods

The study involved 60 patients complaining of persistent pruritus ani. The study included people in which pruritus for organic reasons was ruled out. Tests were carried out to assess the level of depression and anxiety disorders. In addition, patients were asked to fill in the Questionnaire for the Descriptive Assessment of Pruritus and the 4-Item Itch Questionnaire by prof. Jacek Szepietowski.

Results

The cause of pruritus ani in the study groups has been shown to have a significant influence on the level of depressive symptoms. There was no such relationship for anxiety disorders. In the study group, there was no correlation of depressive-anxiety symptoms with the level of pruritus intensity and the frequency of pruritus.

Conclusions

The presented data reveal the negative effect of pruritus ani on the psychological functioning of patients. Pruritus ani is characterized by moderate intensity of pruritus, but has a significant influence on the aggravation of depressive symptoms. It is important to look for the causes of this symptom, which can help to eliminate its intensity, improve the patients’ mood, and thus improve their quality of life.

Recalcitrant anal and genital pruritus treated with dupilumab

Chronic anogenital pruritus can significantly impair affected patients’ quality of life by disrupting their sleep, mood, sexual function, and personal relationships. Although a significant portion of these patients can be managed with hygiene measures, topical therapy, oral anti-pruritics, and allergen avoidance after patch testing, guidelines to treat patients who do not respond to standard therapy have yet to be established. We describe the therapeutic response of a case of anogenital pruritus recalcitrant to multiple topical and systemic therapies. Treatment of this patient with dupilumab, an interleukin-4 receptor alpha blocker, resulted in clinical remission at 1 year from the initiation of the therapy, without significant adverse effects.

Pruritus Ani

Pruritus ani is a common condition with many different potential causes. Because of this, it can be difficult to treat. It is important to identify and eliminate any inciting factors, which are often unintentional consequences of the patient's attempts to alleviate symptoms. If no reversible cause is found, simple measures with diet modification and perianal hygiene are tried before using topical medications or procedures.

Therapeutic management of anal eczema: an evidence-based review

AIM

To conduct a systematic review of treatments for anal eczema (AE).

METHODS

We conducted a Medline search for clinical trial data for the treatment of perianal diseases including AE, including papers not published in the English language. We assessed the study reports using the system recommended by the Oxford Centre for Evidence-based Medicine. No meta-analysis was attempted.

RESULTS

The evidence base for topical treatments used to treat AE is very poor: there are very few studies and many of those that exist are of poor quality. The best evidence was found for medications that are yet to be licensed for AE. Among products with existing licences for the treatment of eczema, our assessment found some evidence to support the continued use of mild-to-moderate corticosteroids first line in most patients.

DISCUSSION

Features of the perianal region, and the fact that it is almost always occluded, mean that not all medications recommended in the general treatment guidelines for eczema are appropriate for AE. However, there are no specific treatment guidelines for these patients. This may in part be because of the lack of high-quality evidence-based medicine in this therapy area. Many frequently prescribed medications were developed and licensed many years ago, in an era when clinical trial design was not expected to be as rigorous as it is today.

CONCLUSION

This review highlights the need to conduct more high-quality clinical trials in patients with AE in order that specific guidelines for the management of this difficult proctological condition can be prepared.

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: diagnosis and treatment

Pruritus ani is a common condition with multiple causes. Primary causes are thought to be fecal soiling or food irritants. Secondary causes include malignancy, infections including sexually transmitted diseases, benign anorectal diseases, systemic diseases, and inflammatory conditions. A broad differential diagnosis must be considered. A reassessment of the diagnosis is required if symptoms or findings are not responsive to therapy. The pathophysiology of itching, an overview of primary and secondary causes, and various treatment options are reviewed.

Perianal infections: a primer for nonsurgeons

The topic of perianal infections covers a broad range of illnesses that can be difficult to differentiate from each other. As a result, patients may suffer from unnecessary examinations and ineffective or delayed therapeutic interventions. This article reviews common and unusual infectious pathology and inflammatory or malignant conditions that should be considered in the differential diagnosis. Presentations of infectious pathology specific to HIV are discussed. New treatment strategies, where available, are noted.