Pruritus ani

Pruritus ani
Classification and external resources
Specialty	dermatology
ICD-10	L29.0
ICD-9-CM	698.0
DiseasesDB	30154
MeSH	D011538

Pruritus ani (also known as anusitis) is the irritation of the skin at the exit of the rectum, known as the anus, causing the desire to scratch.^[1] The intensity of anal itching increases from moisture,^[2] pressure, and rubbing caused by clothing and sitting. At worst, anal itching causes intolerable discomfort that often is accompanied by burning and soreness. It is estimated that up to 5% of the population of the United States experiences this type of discomfort daily.

Causes

If a specific cause for pruritus ani is found it is classified as "secondary pruritus ani". If a specific cause is NOT found it is classified as "idiopathic pruritus ani".^[3] The irritation can be caused by intestinal parasites, anal perspiration, frequent liquid stools, diarrhea, residual stool deposits, or the escape of small amounts of stool as a result of incontinence or flatulence. Another cause is yeast infection or candidiasis. Some diseases increase the possibility of yeast infections, such as diabetes mellitus or HIV infection. Treatment with antibiotics can bring about a disturbance of the natural balance of intestinal flora, and lead to perianal thrush, a yeast infection affecting the anus. Psoriasis also can be present in the anal area and cause irritation. Abnormal passageways (fistulas) from the small intestine or colon to the skin surrounding the anus can form as a result of disease (such as Crohn's disease), acting as channels which may allow leakage of irritating fluids to the anal area. Other problems that can contribute to anal itching include pinworms, hemorrhoids, tears of the anal skin near the mucocutaneous junction (fissures), and skin tags (abnormal local growth of anal skin). Aside from diseases relative to the condition, a common view suggests that the initial cause of the itch may have passed, and that the illness is in fact prolonged by what is known as an itch-scratch-itch cycle.^[4][5] It states that scratching the itch encourages the release of inflammatory chemicals, which worsen redness, intensifies itchiness and increases the area covered by dry skin, thereby causing a snowball effect.

Some authorities describe “psychogenic pruritus” or "functional itch disorder",^[6] where psychological factors may contribute to awareness of itching.

Ingestion of helminth (worm) Enterobius vermicularis (pinworm, or threadworm) eggs leads to enterobiasis, indicative of severe itching around the anus from migration of gravid females from the bowel. Severe cases of enterobiasis result in hemorrhage and eczema.

Treatment

The goal of treatment is asymptomatic, intact, dry, clean perianal skin with reversal of morphological changes. For pruritus ani of unknown cause (idiopathic pruritus ani)^[7] treatment typically begins with measures to reduce irritation and trauma to the perianal area.^[8] Stool softeners can help prevent constipation.^[8] If this is not effective topical steroids or injected methylene blue may be tried. Another treatment option that has been met with success in small-scale trials is the application of a very mild (.006) topical capsaicin cream.^[9] This strength cream is not typically commercially available and therefore must be diluted by a pharmacist or end-user. If the itchiness is secondary to another condition such as infection or psoriasis these are typically treated.^[8]

A successful treatment option for chronic idiopathic pruritus ani has been documented using a clean, dry and apply (if necessary) methodology. The person is instructed to follow this procedure every time the urge to scratch occurs. The treatment makes the assumption that there is an unidentified bacteria in the feces that causes irritation and itching when the feces makes contact with the anal and perianal skin during defecation, flatulation or anal leakage (particularly during sleep). Cleaning the area with a disposable moist towel (baby wipe) is required to remove all traces of fecal matter. Water alone, even with a sprayer or shower is not adequate and water with soaps can cause additional irritation. The next step is to pat the area dry (wiping is too rough) with toilet tissue. If persons with pruritus ani do not need to scratch after these steps they are instructed to do nothing else. If the urge to scratch is still present they are instructed to apply Pranicure ointment and to rub it in until the itch is satisfied. The goal of the treatment is to reduce the use of ointment until it is either no longer needed or until use of the ointment is minimized.

See also

• Pruritus scroti
• Pruritus vulvae
• Perianal candidiasis

References

1. James, William; Berger, Timothy; Elston, Dirk (2005). Andrews' Diseases of the Skin: Clinical Dermatology. (10th ed.). Saunders. ISBN 0-7216-2921-0.
2. American Society of Colon & Rectal Surgeons (2012). Pruritus Ani. http://www.fascrs.org/patients/conditions/pruritus_ani/
3. J Korean Soc Coloproctolv.27(2); 2011 AprPMC3092075
4. http://www.nhs.uk/Conditions/Itching/Pages/Treatment.aspx
5. Pfenninger JL, Zainea GG (June 2001). "Common anorectal conditions: Part I. Symptoms and complaints". American Family Physician 63 (12): 2391–8. PMID 11430454.
6. Misery L, Alexandre S, Dutray S, et al. (2007). "Functional itch disorder or psychogenic pruritus: suggested diagnosis criteria from the French psychodermatology group". Acta Dermato-venereologica 87 (4): 341–4. doi:10.2340/00015555-0266. PMID 17598038.
7. J Korean Soc Coloproctolv.27(2); 2011 AprPMC3092075
8. Markell KW, Billingham RP (February 2010). "Pruritus ani: etiology and management". The Surgical Clinics of North America 90 (1): 125–35, Table of Contents. doi:10.1016/j.suc.2009.09.007. PMID 20109637.
9. Lysy J, Sistiery-Ittah M, Israelit Y, et al. (September 2003). "Topical capsaicin--a novel and effective treatment for idiopathic intractable pruritus ani: a randomised, placebo controlled, crossover study". Gut 52 (9): 1323–6. doi:10.1136/gut.52.9.1323. PMC 1773800. PMID 12912865.