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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_538_Библиотеки_им_академика_М_И_Перельмана.pdf
314
and umbilicus will hint the physician to place the appropriate diagnosis. Furthermore, there are forms of paradoxical
psoriasis in the perianal area that can be caused by biologic therapy (anti TNFa agents) for the treatment of
patients with inammatory bowel disease [18]. For perianal psoriasis, the treatment is usually a low- to midpotency topical steroid. Tacrolimus and dapsone can also
be used for more severe cases [19].
Lichen simplex chronicus is a condition that can result
from chronic diarrhea. Inammation in the perianal area
results in thickened (lichenied) and cracked, excoriated
skin. Treatment is focused on controlling the frequency of
bowel movements. Psyllium husk, loperamide, and silver
sulfadiazine can be used with addition of low-dose hydrocortisone for more severe cases.
In a similar way, lichen sclerosus (atrophicus) presents
mainly in women with a thinning and wrinkling of the perianal skin, also known as a “cigarette-paper” appearance with
associated skin discoloration. This also classically affects the
labial skin and perineum. Lichen sclerosis may be associated
with squamous cell carcinoma. Thus, the affected area should
be examined at least annually, and a biopsy should be considered for any suspicious lesions. Treatment is a topical glucocorticoid like clobetasol propionate 0.05% for 6–8weeks
[20]. Tacrolimus has also been used for this condition.
Seborrheic dermatitis is a rare cause of anal itching. It is
caused by a fungus called Malassezia furfur, and it is treated
with an antidandruff shampoo or any other topical antifungal
agent.
Hidradenitis suppurativa is a chronic, suppurative process involving the skin and subcutaneous tissue. The usual
initial presentation is of recurrent, painful, and inamed nodules. The nodules may rupture, discharging purulent, sometimes malodorous material. Persistent disease leads to the
formation of sinus tracts, end-stage “tombstone” comedones,
and scarring [21]. There are three stages of the disease: stage
1 is abscess formation, single or multiple, without scarring or
sinus tracts; stage 2 is recurrent abscesses with tract formation and scarring, single or multiple, and widely separated
lesions (Fig. 17.2); and stage 3 is multiple interconnected
tracts and abscesses throughout an entire body area.
Treatment strategies can be categorized broadly into medical
and surgical. Antibiotics, retinoids, hormones, and immunosuppressive agents have been used. All have shown success
in reducing symptoms temporarily but none long term.
Antibiotics must be chosen to cover both aerobic and anaerobic bacteria. Topical clindamycin and oral clindamycin with
rifampin, in addition to tetracycline, erythromycin, and doxycycline, have shown efcacy at reducing symptoms. Longterm treatment up to 12 weeks is required to achieve
remission. Evidence is lacking that antibiotics change the
natural course of this disease. Isotretinoin, nasteride, prednisone, and cyclosporine have resulted in temporary remis-
K. Umanskiy and E. Messaris
Fig. 17.2 Mild form of hidradenitis suppurativa with several abscesses
and sinus tracts
sion. Iniximab and etanercept (TNF-α inhibitors) are
biologics that have shown promise in improving symptoms.
Radiation, cryosurgery, and laser therapy have been effective
in a small series of patients with early stages. Upon diagnosis
of HS, the extent and stage of disease should guide surgical
approach. For stages 2–3, surgery is regarded as the most
effective treatment.
Cutaneous squamous cell carcinoma in situ (Bowen’s dis-
ease) appears as a well-demarcated plaque with crusting and
scaling. Perianal intraepithelial adenocarcinoma (Paget disease, Fig.17.3) usually occurs in the seventh decade of life
and appears as a slowly expanding, sharply demarcated erythematous plaque that can be eczematous, crusting, scaling,
or ulcerated. If discovered, endoscopic evaluation of the
colon is needed to rule out an underlying carcinoma. Wide
local excision with frozen sections is performed in noninvasive Paget’s disease, while more radical surgery may be
required for invasive disease [22]. Cloacogenic carcinoma
and squamous cell carcinoma of the anal margin can present
with refractory pruritus ani (Fig.17.4) [23]. Thus, for any
lesions that do not respond to the rst line of treatment,
biopsy is mandatory in order to rule out neoplastic disease.
Other skin disorders that may be associated with anal pruritus include scleroderma, erythema multiforme, dermatitis
herpetiformis, lichen planus, radiation dermatitis, and Darier
disease.
Anorectal diseases associated with anal pruritus include
prolapsed internal hemorrhoids, abscesses, ssures, and stulas. Details about the diagnosis and treatment of these diseases are given in a different chapter.
17 Dermatology andPruritus Ani
315
Fig. 17.3 Paget’s disease of the perianal skin. (Courtesy of Dr. Dana
Fugelso)
Pruritus ani can have an infectious inciting factor. Risk
factors for developing an infection that can cause anal
symptomatology include diabetes, immunocompromised
state, obesity, hyperhidrosis, and living in tropical climates.
Fungal infections are the most common perianal infections
[16]. These include Candida albicans and dermatophytes.
Candida albicans, a saprophytic yeast, is normally present in
the gut. The yeast can cause a perianal fungal infection in
patients with compromised immune defenses such as patients
with uncontrolled diabetes mellitus, on chemotherapy, prolonged antibiotic use, prolonged use of steroids, or other
immunosuppressive medications. The infected skin appears
moist, red, and macerated. Under microscopic scrutiny,
mycelium forms and spores can be identied from scrapings
of the lesion, after preparing the scapings with 20% potassium hydroxide. Treatment consists of applying nystatin
powder or ointment or imidazole compound several times
daily, along with controlling or eliminating the precipitating
cause. Epidermophyton occosum, Trichophyton mentagro-
phytes, and Trichophyton rubrum are fungal infections that
can occur in the perineum. The presence of dermatophytes is
always associated with pruritus. Topical and systemic antifungal agents have been successfully used for the eradication
of the fungal infections.
Fig. 17.4 Anal carcinoma presenting as an ulcer. (Courtesy of Dr.
Dana Fugelso)
Bacterial infections such as Streptococcus, Staphylococcus
aureus, and Corynebacterium minutissimum (erythrasma)
have all been implicated [24]. Corynebacterium minutissimum causes erythrasma which affects the perianal area,
axilla, thighs, and toe web spaces. A classic, large pinkreddish patch is seen initially which eventually turns brown.
Under an ultraviolet lamp (Wood’s lamp), the lesions appear
with a coral to salmon uorescence from the porphyrin production made from the bacteria. It is best diagnosed by a
Wood’s lamp, which reveals the coral-red uorescence [25].
Corynebacterium minutissimum is susceptible to erythromycin 250mg q6 hours or tetracycline.
Pruritus ani can also be caused by parasitic infections,
especially in tropic climates and younger ages. Pinworms
(Enterobius vermicularis) are often implicated in the pediatric population but can occur in adults. The worms emerge at
night, and consequently pruritus worsens in the nighttime.
Scratching tends to scatter the eggs in the bed and wherever
the patient gets dressed. The diagnosis is made using a cellophane tape test. The adult worms and eggs can be identied
on the tape. Lactophenol is used to enhance the slide.
Mebendazole is the treatment of choice. Perianal topical
application of albendazole as well as a single oral dose
100mg has been demonstrated to provide immediate relief
316
K. Umanskiy and E. Messaris
[26]. Pediculosis pubis is a parasite, visible macroscopically,
that can lay its eggs in the pubic and perianal hair. Treatment
consists of malathion 0.5% lotion applied to the hair. All
sexual partners must be treated, and clothing and bedding
need to be sterilized by washing in very hot water. Scabies is
a mite, Sarcoptes scabiei, that creates dark punctate lesions,
which are readily identied on the trunk and particularly
between the ngers and ventral surface of the wrists. Scabies
can infect the perianal area. The diagnosis is established
using potassium hydroxide preparation to stain the parasite.
Treatment includes topical permethrin with cure rates in randomized trials approximating or exceeding 90%.
Alternatively, oral ivermectin is advantageous because of
ease of administration and lower cost. Detailed cleansing of
all clothing and bedding by washing in hot water is necessary
to avoid re-infestation. Individuals with classic scabies can
return to work, child care, or school the day after the rst
treatment.
Sexually transmitted diseases like herpes simplex, gonorrhea, and condyloma acuminata can also present with itching.
A detailed sexual history is usually the rst clue that a sexually transmitted disease needs to be addressed. Patients who
present with tenesmus, purulence, and proctitis, in addition to
pruritus, should be tested for gonococcal infection. A swab
should be done and placed on Thayer-Martin media. Anal
gonorrhea is treated with ceftriaxone 250mg IM plus azithromycin 1g PO.Syphilis often presents as a painless chancre,
starting as a papule that eventually ulcerates. In contrast to
syphilis, painful ulcers in the perianal region are usually associated with herpes and chancroid. Syphilis is caused by the
spiral-shaped bacterium Treponema pallidum. These spiro-
chetes can be seen on dark-eld microscopy from scrapings
obtained at the base of the lesion. Alternatively, serologic
screening can be done with a nontreponemal test. Treatment
is a one-time dose of penicillin G 2.4 million units IM.
Viral etiologies of pruritus ani include herpes (HSV) and
condyloma (human papilloma virus). HSV infection often
presents as painful, scattered lesions including ulcers and
vesicles. Perianal presentation of herpes simplex virus (HSV-
2) is rare, compared to its frequent presentation as genital
infection and even less frequently when compared to herpes
simplex virus (HSV-1), which presents as the familiar “cold
sore” and “fever blister.” The mode of infection is usually
sexual, but the virus may be spread by direct contact. A viral
culture taken from the base of the ulcer or from vesicular
uid is usually diagnostic. The disease is usually self- limiting
in 1–3 weeks if there is no secondary bacterial infection.
Supportive treatment is recommended, and medication can
limit the symptoms and duration of the attacks. The treatment of an acute episode is acyclovir 800mg three times a
day for 2 days or valacyclovir 500mg PO three times a day.
For patients with frequent recurrences, acyclovir 400 mg
twice daily or valacyclovir 500mg daily have been advocated. Large anal condylomata can cause pruritus and usually requires excision and/or fulguration in the operating
room (Fig.17.5).
Anal pruritus has been associated with several systemic
diseases such as diabetes, cholestasis, lymphoma, leukemia,
pellagra, renal failure, thyrotoxicosis, hypothyroidism,
human immunodeciency virus (HIV) disease, and deciencies in vitamins A and D and iron. Frequently the patients
with systemic diseases have generalized pruritus that indicates the diagnoses and the cause of the itching. Treatment of
the systemic disease resolves the perianal symptoms.
Several psychiatric disorders, such as stress, anxiety, and
depression, have been associated with pruritus ani. Despite
these associations, scientic evidence is lacking. There is a
study that attempted to link emotional disorders with pruritus ani, but it did not reach statistical signicance. If any psychiatric condition is present, it should be treated concurrently
Fig. 17.5 Perianal condylomas either small or large can exacerbate skin irritation and moisture and cause anal pruritus
17 Dermatology andPruritus Ani
317
with the anal disease. Anxiolytic medications may benet
some patients especially at bedtime [14].
Diagnostic Approach
The clinical assessment of a patient with anal pruritus begins
with a history, physical examination, and anoscopy. The
decision to perform laboratory testing and endoscopic evaluation should be guided by the clinical assessment and/or
response to initial therapy.
History History taking in patients with anal pruritus is criti-
cal because it can help identifying the causative factor and
guide appropriate treatment. Symptoms, which usually start
insidiously, are characterized by the occasional awareness of
an uncomfortable perianal sensation. Some patients feel an
itch, whereas others sense burning. With time, the condition
may progress to an unrelenting, intolerably tormenting burning sensation in addition to the urge to scratch and otherwise
irritate the area in a futile effort to obtain relief. These feelings will usually lead the patient to self-treatment with overthe- counter medications or with self-made remedies. The
patient will usually overtreat the condition that will exacerbate the problem. The history of present illness should
include questions related to all known risk factors for anal
pruritus (Table 17.1). Thus, the physciscian should collect
information on the duration of anal pruritus and the presence
or not of associated symptos such as: generalized pruritus,
fecal seepage, diarrhea, constipation, or a change in bowel
habits, systemic symptoms including fever, night sweats,
fatigue, change in appetite or weight, heat/cold intolerance,
decrease in urine output, change in the color of stool or urine,
and jaundice. A personal history of diabetes; dermatological,
gastrointestinal, thyroid, renal, or sexually transmitted diseases; radiation; and food allergies is very important to
assess. Changes in diet to include foods associated with anal
pruritus or use of topical or systemic medications should be
reported. Anal hygiene practices including the use of soaps,
detergents, perfumes, and the frequency of cleansing or use
of tight-tting undergarments need to be described in detail.
Coexisting skin and perianal conditions should be questioned. Atopy, urticaria, hay fever, allergies, and family history are key components as are the use of over-the-counter
medication.
Physical Examination
body for any skin abnormalities or lesions should be performed before the focused exam. Dermatologic diseases
are usually not limited to just one site of the body. Inguinal
An examination of the whole
lymph nodes should be palpated before the patient is
placed on prone jack knife position for focused examination. The presence of palpable inguinal lymph nodes is
suggestive of a neoplasia or sexually transmitted diseases.
The perianal exam should include a detailed inspection of
the perianal area looking for skin color changes, nodules,
stula opening, skin lesions, hemorrhoids, ssures, skin
rash, or ulcers. Perianal plaques with a distinct boundary
are suggestive of psoriasis, erythrasma, or neoplasia.
Perianal erythema may be seen in patients with chronic
steroid use and candidiasis. Hyperpigmentation of the
skin may result from chronic inammation due to an
infection or chronic discharge. The skin around the genitalia should also be thoroughly inspected. If sexually
transmitted diseases are suspected, appropriate swabs
should be obtained before the rectal examination is performed. Valsalva maneuver can exclude mucosal prolapse.
A digital examination of the anorectum should be performed to identify anorectal lesions, sphincter, or pelvic
oor issues. If any lesion is identied that is suspicious
for malignancy, a biopsy of the lesion should be performed either in clinic under local anesthesia (punch/fullthickness biopsy) or in the operating room under general
anesthetic. Every patient with pruritus ani needs to
undergo an anoscopy to evaluate the anal canal and the
distal rectum. Anoscopy is a quick, relatively painless,
inexpensive procedure that can be performed in an
unprepped patient to exclude distal anorectal disorders.
Hemorrhoids, ssures, polyps, masses, and inammatory
changes can be clearly visualized with an anoscope.
Based on the physical exam, there is a clinical staging
system for patients with pruritus ani. The stages represent the
severity and the chronicity of the skin ndings [27].
• Stage 1. No lesion is seen at inspection of anal verge, but
patient nds palpation and anoscopy painful. Other anal
lesions have been excluded.
• Stage 2. Red dry skin only, at times weeping skin with
supercial round splits and longitudinal supercial
ssures.
• Stage 3. Reddened weeping skin, with supercial ulcers
and excoriations disrupted by pale, whitish areas with no
more hairs.
• Stage 4. Pale, whitened, thickened, dry leathery, scaly,
skin with no hairs and no supercial ulcers or excoriations
(chronic condition) (Fig.17.6).
The staging system is rarely used, but it can simplify the
communication between physicians or provide structured
results for research done on anal pruritus.
318
Fig. 17.6 Chronic perianal skin changes from fecal soilage and persistent anal pruritus
K. Umanskiy and E. Messaris
phatase to evaluate for evidence of liver disease, thyroidstimulating hormone to evaluate for evidence of a thyroid
disorder, blood urea nitrogen (BUN) and creatinine to evaluate for renal disease and human immunodeciency virus
(HIV) antibody test in patients with risk factors for HIV
infection can assist in diagnosing the primary cause of the
pruritus.
Endoscopic evaluation in the form of colonoscopy is indicated in patients with systemic or refractory symptoms or a
change in bowel habits, diarrhea, abdominal pain, or
hematochezia.
Tissue biopsies are usually not needed in the rst evaluation, unless a clear lesion suspicious for malignancy is present. If the rst line of treatment fails and the causative factor
has not been identied, then at the second visit, tissue biopsy
should be performed either in clinic under local anesthesia
(punch/full-thickness biopsy) or in the operating room under
general anesthetic. Tissue samples should be sent to both the
microbiology and the pathology laboratories. Histopathology
will demonstrate epithelial intercellular edema and vesiculation. In more chronic cases, hyperkeratosis and acanthosis
will be present.
Rarely, patients with persistent or recurrent anal pruritus
could benet from anal manometry. Patients with pruritus
ani have an abnormal transient internal sphincter relaxation,
one that is greater and prolonged compared to controls. Thus,
occult fecal leakage occurs and causes perianal itching [13].
Laboratory Testing
Anal culture swabs for virology and microbiology are inexpensive and can be performed at the rst evaluation of the
patient that carries high risk for an infectious etiology. Viral
cultures should be kept on ice. Fluid from vesicular lesions
should be aspirated or taken with a swab from the base of an
unroofed lesion and placed on a cell culture media or a
microscopic slide for Tzanck smears if herpes zoster is suspected. Skin scrapings may be submitted for fungus culture
or examined for hyphae with KOH prep. In patients with
diarrhea, bacterial stool cultures as well as ova and parasites
on three different stool samples can be useful. In patients
with suspected streptococcal or staphylococcal perianal
infections, nasal or throat swabs rarely detect the offending
bacteria and therefore are unnecessary.
Blood testing is usually not needed during the rst evaluation of the patient unless systemic symptoms are reported.
Furthermore, if the patient has failed the rst line of treatment, as part of the escalating diagnostic pathway, several
blood tests are recommended. The physcician should obtain
a complete blood count with differential to evaluate for evidence of hematologic malignancy, myeloproliferative disease, or iron deciency anemia. Furthermore, obtaining
levels of serum bilirubin, transaminases, and alkaline phos-
Treatment
The care of patients with anal pruritus can be challenging.
The patient should be informed about the chronic nature of
the condition, not just to reduce the expectation of immediate
cure but also to improve compliance with advice given. It is
common for both patients and physicians to get frustrated
and discouraged when initial therapy is not successful, and
despite extensive testing, no denitive diagnosis can be
made. The aims of treatment for any form of anal dermatitis
are rapid relief of symptoms and prevention of recurrence.
Successful management depends on accurate diagnosis and
ruling out coexisting disorders. For patients that have an
obvious factor causing the anal pruritus, the sole intervention
needed is the treatment of the inciting factor, and the symptoms should resolve. Thus, all anorectal conditions should be
sought and treated, as even small skin tags may hide fecal
residue or trap moisture perpetuating the condition. Anal
dermatophyte infections should be treated with a topical
imidazole. Fungal infections should be treated with a topical
imidazole if thought to be pathogenic. In rare cases per os,
antifungals can be used such as uconazole. β-Hemolytic
streptococci, S. aureus, and C. minutissimum should be elim-
inated with topical antibiotics such as fusidic acid or mupiro-
17 Dermatology andPruritus Ani
Secondary
pruritis ani (D)
A. Presentation
Evaluation
History and physical
examination
Anoscopy (B)
Biopsy and endoscopy (C)
Idiopathic
pruritis ani (J)
319
Systemic disease (G)
Diabetes
Malignancy
Cholestasis
Psychiatric
Illnesses
Thyrotoxicosis
Medications
Treatment (G)
Disease-specific
Symptoms
resolve?
Local irritants (H)
Treatment (H)
Romove offending
Refractory pruritis
evaluation
Treatment
Caspsaicin (M)
Anal tattooing (N)
Tacrolimus (O)
Infectious (E)
Bacterial
Viral
Fungal
Parasites
Treatment (E)
Antibiotic
Antiviral
Antifungal
Antihelminthic
Dermatologic (F)
Psoriasis
Lichen planus
Lichen simplex
Chronicus
Lichen sclerosis
Contact dermatitis
Atopic dermatitis
Treatment (F)
Low-to-mid potency
topical steroid
YesNo
Observation
Fig. 17.7 Diagnostic and treatment algorithm for patients with anal pruritus
Stool
Soaps
Wiping
Clothing
Topicals
agent
ani (L)
Repeat
Colorectal and
Anal disorders (J)
Hemorrhoids
Fissure
Fistula in ano
Dysplasia
Malignancy
Treatment (J)
Disease-specific
General Principles (K)
Improve hygiene
Remove inciting agents
Food education
Improve bowel habit
+/– low potency
topical steroid
cin, and oral antibiotics may be necessary in more chronic
and advanced cases.
For the patients that do not have an obvious risk factor
causing the anal pruritus, a stepwise approach of escalating
treatment and diagnostic tests is recommended. Reassurance
and education are key for the success of the treatment. We
have constructed an algorithm that delineates the diagnostic
and therapeutic recommendations for patients with anal pruritus (Fig.17.7).
First Encounter
The majority of patients with either secondary or primary
pruritus ani will benet from simple, general principles
including improving anal hygiene, removing any potential
inciting agents, food education, and improving bowel habit.
These interventions can be effective in up to 90% of idio-
pathic cases. Key goals for treatment are the reestablishment
of ideal anal hygiene and the reassurance that there is no
underlying condition causing the symptoms. The ultimate
goal is to restore clean, dry, and intact skin.
Inciting Agents
Any inciting factors, mechanical or chemi-
cal irritants, trauma, and scratching should be avoided.
Hygiene Sitz baths without additives, taken after defeca-
tion, often help keep the perianal skin clean. Bidets are
becoming more popular as an alternative. Patients should be
counseled to avoid soaps, scrubbing, and aggressive wiping.
Excessive moisture can cause hygiene problems. Blotting
with damp toilet paper should be used instead of a moist
wipe. Using a hair dryer on the lowest setting or dabbing
with a towel is also benecial. Apply corn starch powder or
talc to ensure the intergluteal fold remains dry. Avoid corn-
320
K. Umanskiy and E. Messaris
starch powder if there is suspicion of a fungal infection as
fungus is known to thrive very well in cornstarch. Soaps,
perfumes, dyes in tissue or clothing, and baby wipes containing deodorants should be avoided because they can act
as irritants. Handheld detachable shower heads and bidets
are very effective in cleaning and washing away any remaining soap or stool residue. There are commercially available
mineral oil-based preparations that can be used at home or
taken along in a pocket or a purse for use in public facilities.
A homemade solution for a cleaning agent is the use of
diluted white vinegar. One tablespoon in an 8 ounce glass of
water can be kept in the bathroom and applied with a cotton
ball.
Light cotton as undergarments should be used instead of
tight tting, synthetic underwear. Clothes should be washed
in non-perfumed detergent. A dry cotton ball or gauze placed
at the anus can be used to limit moisture in the area. As a
general rule, topical creams should be avoided initially as
they may trap moisture. For cases with signicant skin
changes, a cream with zinc oxide or, alternatively, petroleum
ointment can be applied after washing. Additional topical
agents such as numbing medications, menthol, phenol, camphor, or a combination of them may be helpful. There are
commercial or compound creams which are a combination
of zinc oxide and menthol and can be very benecial at
relieving patients’ symptoms. In specic cases, if there is any
concern that there may be an infection, topical antibiotics
(gentamicin, clindamycin, or bacitracin) or antifungals
(clotrimazole, nystatin) may be added in conjunction with
other therapies. Most creams can be applied at nighttime
before bed and again in the morning after bathing.
In cases with severe skin irritation in the ofce, the surgeon can apply Berwick’s solution (crystal violet 1%, brilliant green 1%, 95% ethanol 50%, distilled water 100%)
followed by cool air drying or hair dryer. This is covered
with tincture of benzoin and dried once more, and the sealant
may remain on the skin for up to a week, which is enough
time for skin to regenerate or re-epithelialize.
Acute itch is a marker of fecal seepage, and immediate
cleansing is the most effective remedy, especially for nocturnal itch. Patients should be given advice on how to cleanse
when outside their homes. If the barrier creams do not work,
the patient can use ostomy powder in the perianal area three
times a day. Ostomy powder is designed to protect the skin
from irritation related to moisture. Although it was designed
to be used around the stoma or under the ostomy barrier, it
absorbs moisture in the perianal area and keeps the skin dry.
Food Education
Patients should receive a list of foods
(Table17.1) that they should avoid: coffee, cola, beer, tomatoes, chocolate, tea, citrus, and lactose-containing foods. An
elimination diet may be attempted. Encourage patients to
keep a diary and then reintroduce the foods one at a time in
an attempt to determine the offending foods.
Bowel Habits
High-ber diet and an addition of ber sup-
plements are highly encouraged. The ber serves to absorb
the moisture from the stool, adding bulk and allowing for
complete evacuation of stool during bowel movements.
High-ber diet and bulking agents are helpful in absorbing
water from stool, in turn decreasing fecal seepage. High dose
of psyllium husk 2 tablespoons every am with 8–10 8oz
glasses of liquids over the day is highly recommended. If
stools still remain loose, additional medications may be
helpful. Antidiarrheals such as loperamide or atropine/
diphenoxylate can enhance the action of the ber and thicken
or rm the stool and help decrease seepage.
Second Encounter (3–6Weeks After First
Encounter)
Clinicians should be prepared to manage refractory pruritus
ani if there is no resolution of symptoms despite previous
treatment. Repeating a thorough history may identify an
inciting event that may have not been identied initially.
Journals with foods and/or timing of symptoms should be
reviewed since they can demonstrate a temporal relation to
onset of symptoms. A biopsy and endoscopy should be performed if they were not done at the initial evaluation. Similar
to initial evaluation, the focus should be on nding an underlying cause. These patients will need to be counseled that
refractory pruritus ani may be a chronic condition requiring
a long-term treatment plan and their expectations need to be
set that treatments are aimed at improving symptoms rather
than complete resolution. After the rst line of treatment
fails, a short-course trial of a low-potency topical steroid
(1% hydrocortisone) can be tried twice a day for 2 weeks.
This should be tapered off using a barrier cream containing
zinc oxide to prevent skin atrophy [28]. In a randomized
trial, patients with primary pruritus ani received 1% hydrocortisone or placebo for 2weeks. Treatment with 1% hydrocortisone resulted in a 68% reduction of itch, and 75% of the
patients had improvement in their quality of life [29].
Steroids can be used up to 8weeks at most. Long-term use of
topical steroids has been associated with atrophy of the skin.
While it is unlikely that low-potency steroids (hydrocortisone 1%) have a curative effect over time, they can work as a
“bridge” therapy that can alleviate symptoms long enough
for the patient to stop the itch-scratch-itch cycle and allow
for healing of excoriated skin. In more chronic or severe
cases, the use of high-potency steroids (clobetasol propionate 0.05%) can increase the chances for symptom relief.
While commonly prescribed by referring physicians, it may
17 Dermatology andPruritus Ani
321
be necessary to stop use of topical steroids while a causative
agent is sought. Oral steroids are not indicated.
Systemic antihistamines may reduce nocturnal scratching; however, as this is probably a marker of anal seepage,
the patient should be advised to wash the area immediately
and apply a barrier cream. There have been no randomized
trials exploring the usefulness of antihistamines in pruritus
ani, but some series have reported some effect against
peri- anal itch [30]. Sedative antihistamines like diphenhydramine (25–50mg) or hydroxyzine (12.5–25mg) are given to
break the itch-scratch-itch cycle and to prevent the patient
from night scratching. Sedating antihistamines may be effective by aiding sleep rather than local inhibition. Topical antihistamines are not potent enough and can sensitize or irritate
the skin.
In patients who do not respond to these drugs, agents
which have anti-depressive effects like doxepin (10–25mg up
to 75mg) or amitriptyline (25mg up to 100mg) can be used.
Doxepin, a tricyclic antidepressant, possesses both anti-H1
and anti-H2 activity. Amitriptyline is particularly useful in
anogenital itch having neuropathic qualities such as stinging
or burning. Gabapentin (a structural analogue of gamma-aminobutyric acid) and selective serotonin reuptake inhibitors
(SSRIs) such as uoxetine, paroxetine, sertraline, uvoxamine, mirtazapine, and citalopram may be useful for patients
with intractable pruritus resistant to routine therapy [31–33].
Local anesthetics such as lidocaine gel 2–5% can provide
temporary relief but have no treatment effect or long-term
result. There is no place for the topical use of anesthetics as
they do not alter the disease and sensitize and moisturize the
skin.
Hypnosis has been used, but there is insufcient evidence
available for its recommendation.
The use of capsaicin is indicated in refractory cases.
Topical capsaicin produces a short burning sensation that in
consequence provides an inhibitory feedback, which may
eliminate the need to scratch. Furthermore, as a component
of chili peppers, it has been reported that it has the ability to
suppress histamine release, deplete substance P, and damage
C ber terminals, the bers that mediate itch signaling. A
randomized, crossover study showed topical 0.006% capsaicin cream applied three times a day to be superior to placebo
(1% methanol) in those who had pruritus ani for greater than
3months. Overall, 31 of 44 (70%) patients had a response to
capsaicin, 8 had no response, 1 had response equally with
capsaicin and methanol, and 4 withdrew because of side
effects [34].
Tacrolimus is a non-corticosteroid, macrolide antiinammatory drug. There are some studies reporting that
topical application of tacrolimus ointment for 4weeks may
decrease itch intensity and frequency in pruritus ani and
improve the Dermatology Life Quality Index (DLQI), a
quality of life questionnaire. The studies have small sample
sizes and potential carryover effect. In general, local tacrolimus in a 0.1% concentration is well tolerated and appears to
be most effective in patients with atopic dermatitis [35]. Two
randomized controlled trials comparing topical tacrolimus
0.1% to placebo in a total of 53 patients with chronic idiopathic pruritus ani showed signicant symptomatic improvement up to 6weeks follow-up [35, 36]. This agent may be a
good alternative to topical steroids or as a replacement when
tapering off steroids to help avoid skin atrophy.
Anal tattooing with methylene blue is an intervention of
last resort with good results. The exact mechanism of action
is not clear, but it appears that methylene blue may be directly
toxic to the nerves supplying the perianal skin, thus suppressing the desire to scratch and disrupting the vicious itchscratch- itch cycle. The procedure is consisted of several
intradermal and subcutaneous injections of 10ml 1% methylene blue + 5ml normal saline + 7.5ml 0.25% bupivacaine
with adrenaline (1/100,000)+7.5ml 0.5% lidocaine in prone
jackknife under sedation or general anesthesia in the perianal
region and the entrance of the anal canal. The tattoo disappears in about 3–4 weeks. The initial study [37] demonstrated a more than 80% complete or partial response, and
then other reports have conrmed the initial trial [38–40].
The surgeon should be aware that there can be complications
after the procedure such as decreased perianal sensation,
transient fecal incontinence, and local inammatory reactions in the injection area. A recent systematic review demonstrated that methylene blue injection can successfully treat
anal pruritus; however, the evidence to support the ndings
was graded as weak, due to the limited number of patients
participating in the studies [41].
Conclusions
Pruritus ani is a common condition that all primary care,
general surgeons, and colorectal surgeons will encounter in
their career. There are several etiologies for the disease,
some of which are easy to diagnose and some are not. Once
underlying dermatologic, food, infectious, neoplastic, and
anorectal pathology has been treated, the therapy must be
directed toward proper anal hygiene, avoidance of irritants,
and minimizing skin trauma. If the rst line of therapy is not
successful, then more diagnostic and therapeutic interventions are needed to cure the disease. Managing patient expectations at the rst visit is of paramount importance, as the
resolution of symptoms often takes time.
322
K. Umanskiy and E. Messaris
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Sexually Transmitted Infections
oftheColon andRectum
MichelleCowan andAndrewT.Schlussel
18
Key Concepts
• Recognize at-risk populations who are susceptible to sexually transmitted infections and to understand the growing public health concern in transmission of these
organisms.
• Develop a basic understanding of anorectal immunology
and how it relates to the inoculation and systematic infection by viral and bacterial organisms.
• Recognize pathology in patients with sexually transmitted infections that require operative intervention.
• Provide an overview of diagnostic and treatment recommendations for sexually transmitted infections.
• Provide prevention strategies for sexually transmitted
infections.
Introduction
The term sexually transmitted disease (STD) refers to a variety of clinical syndromes and infections as a result of pathogens acquired and transmitted through sexual activity,
whether it be vaginal, anal, or oral sex. The term STD has
recently been replaced with sexually transmitted infection
(STI), a less stigmatizing and more accurate phrase as acquiring an infection does not necessarily correlate with symptoms
or disease, such as in the case of human papillomavirus
(HPV). In the United States, the incidence of STIs has been
on a steady climb over the last several years with an estimated
2.4 million reported cases of chlamydia, gonorrhea, and
syphilis alone in 2018 [1]. Specically, anorectal STIs are
also thought to be on the rise due to the increased practice of
anal receptive intercourse; however, accurate numbers are
M. Cowan
University of Washington, Department of Surgery,
Seattle, WA, USA
A. T. Schlussel (
Madigan Army Medical Center, Department of Surgery,
Tacoma, WA, USA
*)
hard to quantify. In addition to anal intercourse, additional
risk factors for anorectal STIs include oral-anal sex and contiguous spread from genital infections with reports demonstrating that approximately 50–60% of cases of chlamydia
and gonorrhea occur at non-urethral sites [2]. Anorectal STIs
are often asymptomatic; however, when present, symptoms
are often similar to other common anorectal conditions.
Initially, anorectal STIs may be inappropriately attributed to
hemorrhoids, and thus colorectal surgeons play a critical role
in the diagnosis and treatment of these pathogens, and a high
level of suspicion is required to ensure an accurate diagnosis
is achieved in a timely fashion. This chapter reviews sexually
transmitted infections of the anus and rectum and current
approaches to their presentation, diagnosis, and
management.
Anorectal Immunology
The mucosal integrity of the anorectum plays a critical role
in the transmission of both viral and bacterial organisms.
This physical barrier protects the host from pathogens and is
composed of an immune system that functions autonomously
from the rest of the body. Infection ensues when a virus or
bacteria diffuses through this layer and gains access to the
circulatory system. Appropriate maintenance of this mucosal
defense mechanism is necessary for optimal protection from
disease.
Viral entry into the systemic circulation may occur
through direct penetration of damaged mucosa. In the setting
of human immunodeciency virus (HIV), this organism has
the distinct ability to bind secretions, facilitating its transport
across the epithelial barrier to infect target cells. The abundant quantity of T cells in the gastrointestinal (GI) tract
makes it a preferential target for viral replication and nal
introduction into the blood stream [3–6]. The ability to resist
and recover from a primary infection requires an intimate
balance between the innate and antigen-specic immune
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