​Kembara Xtra - Medicine - Pruritus Ani

​Kembara Xtra - Medicine - Pruritus Ani 
Intense anal/perianal itching and/or burning that is classified as either primary (idiopathic) or secondary (occurs in 25–75% of cases) to anorectal disease.

1-5% of the general population are affected by  incidence. Although present in all age groups, the 30 to 50 year age group predominates. Male is more prevalent than female (4:1) (1) Prevalence
Affects 1-5% of the population; difficult to assess because many people fail to report symptoms 

Pathophysiology and Etiology 
Inflammatory, infectious, systemic, neoplastic, neuropathic, neurogenic, and psychogenic causes among the several etiologies The majority of cases (25–90%) are idiopathic, and these are probably caused by trauma from wiping or scratching as well as perianal fecal contamination.
A self-sustaining "itch-scratch-itch" cycle may result from pruritus, which makes a person feel the urge to scratch incessantly.
 The itch pathway may be histamine- or nonhistamine-mediated depending on the underlying etiology.
The patient often experiences pruritus ani quite strongly because of extensive innervation.
When no other observable causes can be identified, take primary pruritus ani into consideration, including: - Poor anal hygiene - Loose or leaking feces that make it difficult to maintain hygiene.
Most patients with abdominal ostomy bags don't have pruritus.
Laxity of the internal sphincters
Secondary pruritus causes include: - Inflammatory dermatologic disorders
 Allergic contact dermatitis (toilet paper colours, soaps with fragrances, topical anesthetics) Lichen simplex chronicus and atopic dermatitis (Patients also suffer from eczema and/or asthma.) Psoriasis (Lesions typically lack a clear border, are pale, and do not scale.) Dermatitis seborrhoeica
• Scleroderma
Lichen planus (which may be present in people with myasthenia gravis and ulcerative colitis) Hidradenitis purpura
 Dermatitis from radiation - Colorectal/anorectal diseases: polyps, persistent diarrhea, fissures or fistulas, proctitis, and rectal prolapse - Infectious etiologies may be sexually transmitted: bacteria (gonorrhea, chlamydia, syphilis), viruses (herpes simplex virus [HSV], condyloma acuminate from human papillomavirus [HPV], molluscum), parasites (pinworms, lice, scabies, or bed bugs), fungal (Candida, or dermatophytes like tinea); other bacteria (Staphylococcus aureus, β-hemolytic Streptococcus, Corynebacterium minutissimum [erythrasma]).
- Malignancies: leukemia, lymphoma, colorectal cancer, melanoma, basal cell/squamous cell carcinoma, or (rarely) the presenting sign of Bowen or Paget disease - Mechanical elements: abrasive scrubbing, tightly-fitting clothing, and synthetic undergarments - Systemic disorders (which frequently manifest as generalized pruritus): lumbosacral radiculopathy (especially in the elderly), hyperthyroidism, anemia, HIV, cholestasis, chronic liver disease, renal failure, and hyperthyroidism.
- Chemical irritants: chemotherapy, local anesthetics, and diarrhea (frequently caused by antibiotic use). - Dietary components (fruits and vegetables, dairy products, coffee, tea, cola, chocolate, beers, wines, tomatoes, and nuts) - Psychogenic factors: the cycle of itchiness and anxiety

Risk factors include: obesity; excessive perianal hair growth; excessive sweating; underlying anorectal pathology; atopic disease; underlying anxiety condition; and a correlation between symptoms and caffeine usage.

Prevention 

 Maintain good personal hygiene; abstain from excessive care.
Avoid mechanical skin irritation (abrasive soaps or perfumed products, rigorous washing or rubbing with dry toilet paper or baby wipes, excessive fingernail scratching, or tight/synthetic undergarments).
Reduce the amount of moisture in the perianal area (drying absorbent cotton in the anal cleft may assist).
 Refrain from using laxatives (loose stools irritate).

Accompanying Conditions 

In 5–55% of patients with pruritus ani, psoriasis is present (1).
Up to 52% of patients with pruritus ani may also have coexisting anorectal illness, such as hemorrhoids.


Diagnosis 
Patients complain of itching, burning, or excoriation in the anals and/or perianals.
● Ask about the following: - Timing (when it began, when it is worse)
- Perianal hygiene, including how often you clean and the items you use.
- Alteration of bowel habits
- Bleeding (hematochezia, melena, and toilet paper spotting)
- Recent antibiotic use - Skin conditions (eczema, psoriasis)
- Vaginal or rectal odor, menstrual cycle
Focus on the "C"s: caffeine, coffee, cola, chocolate, citrus, and calcium (dairy) in your diet history (3).
- Medical history (particularly hepatitis, iron deficiency anemia, and diabetes); - A history of colorectal cancer in the family
- Anal receptive interaction - A change in personal care items
- Itchy family members, especially children, who may have pinworms - Preference for tight, synthetic clothing - Pets

Perianal visual examination for erythema, hemorrhoids, anal fissures, maceration, lichenification, warts, polyps, excoriations, neoplasia, and stool seepage is part of the clinical examination.  Stage 1: Erythema, inflamed look; Stage 2: Lichenification; Stage 3: Lichenification, coarse skin, possible cracks or ulcerations A noscopy to check for hemorrhoids, fissures, and other internal lesions. A digital rectal exam to check for masses, internal sphincter tone, and pain. 

Differential Diagnosis abbreviation "ITCHeS" 
Infections include Candida, gram-positive bacteria, gonorrhea, chlamydia, pinworms, parasites (scabies, pinworms), HPV, HSV, and syphilis. Topical irritants include clothing, deodorants, perfumes, soaps/detergents, and stool leaks. Eczema, psoriasis, lichen planus, lichen sclerosus, seborrhea, skin cancer, extramammary Paget disease, Bowen disease, fistula, fissure, prolapse, hemorrhoids, and colorectal cancer are examples of cutaneous/cancer/colorectal conditions. Food and drug hypersensitivity (colchicine, quinidine, mineral oil) eSystemic hypersensitivity (diabetes, iron deficiency anemia, uremia, cholestasis)

Laboratory Results 

Initial examinations (lab, imaging)
Utilize the past and the examination to direct tests and indicate a certain cause: To detect underlying systemic disease, use the pinworm tape test, stool examination for parasites and ova, CBC, full metabolic panel, A1c, and thyroid investigations. Examining a wood lamp will reveal coral-red fluorescence in the erythrasma.
 Mineral oil preparation for scabies and potassium hydroxide (KOH) preparation for dermatophytes or candidiasis (as etiology or as superinfection)  Hemoccult stool tests; perianal skin culture (bacterial superinfection)
Child Safety Considerations
Common in childhood are pinworms. Think about perianal Crohn's disease.

Tests in the Future & Special Considerations

A gonorrhea and chlamydia DNA polymerase chain reaction (PCR) probe. When having receptive anal contact, test for anal HPV. HIV testing for people who have risk factors for HIV.


Other/Diagnostic Procedures
Biopsy suspicious lesions (such as lichenification, ulcerated epithelium, and cases that are resistant to treatment) to rule out neoplasia and determine the cause.
If your history, examination, or testing point to colorectal pathology (family history of the condition, especially if you're older than 40, weight loss, rectal bleeding, or a change in bowel habits), you should think about getting a colonoscopy.
Aspects of Geriatrics
Stool incontinence could operate as a risk factor.
Consider systemic illness. Increased possibility of colorectal pathology 

Management 
Adequate anal and perianal hygiene. Avoid touching your skin vigorously after a bowel movement. Instead of tissue paper, use cotton swabs that have been dampened with warm water. Wear appropriate underwear, stay away from mechanical and chemical irritants.
 A high-fiber diet and/or bowel routine to keep bowel motions regular Steer clear of restrictive apparel. Wear cotton underwear.
 Preventing moisture; in the event of excess moisture, absorbent cotton, talcum powder, or cornstarch. To dry the anal area, use a hair dryer set to the cool setting.To prevent nocturnal scratching, wear cotton gloves at night.

First Line of Medicine
Treat underlying infections by applying topical antibacterials to treat bacterial infections and topical imidazoles to treat fungal or dermatophyte infections.
 Treat any underlying anorectal anatomic abnormalities, such as fistulas or fissures, or band prolapsing internal hemorrhoids.
Break the cycle of itching and scratching by using a low-potency steroid cream, such as hydrocortisone 1% ointment, sparingly up to 4 times a day. When the itching stops, stop. Avoid using for longer than two weeks to prevent skin atrophy.
If low-potency steroids don't work, think about high-potency steroid cream.
Until local remedies take effect, antihistamines, especially sedating antihistamines, may be helpful in relieving overnight itching. Due of anticholinergic effects, avoid with geriatric individuals.
Tricyclic antidepressants could lessen itchiness at night. In cases of resistance, gabapentin or SSRIs may be utilized.
After a course of steroids, zinc oxide can be used as a barrier; petroleum jelly is another barrier. Mineral oil ought to be avoided as it aggravates itch.
For pinworm, use albendazole.


Next Line
If symptoms aren't improving, use a topical steroid cream and low-dose capsaicin cream.In situations where high potency steroids are ineffective, 0.03% tacrolimus ointment can be explored.
In circumstances where medicinal therapy is ineffective, intradermal methylene blue injections, also referred to as anal tattooing, may be used to kill nerve endings and produce permanent numbness.
Though there is currently little information, biologics, such as the IL-4 inhibitor dupilumab, offer promise for recalcitrant instances.
Though there is currently little information, biologics, such as the IL-4 inhibitor dupilumab, offer promise for recalcitrant instances.

Referral 
Consider referring someone with intractable pruritus to gastroenterology for a colonoscopy or dermatology for extra therapy, maybe including injections or biopsies. Because long-lasting pruritus is linked to a higher chance of colorectal disease, refractory or persistent symptoms should raise the potential of underlying neoplasia.
If you are at risk for colon cancer, have a colonoscopy.

Surgery as described above, especially if there is a suspicion of malignancy

Take Action 

If the patient is not improving, schedule a visit every two weeks.
 Be sure to practice good hygiene and stay away from irritants.
Check for chronic lichenification and perform a systemic illness workup. Consider a malignancy if persistent pruritus or lichenification do not go away.

Diet 

Eliminate foods and drinks that are known or suspected of exacerbating symptoms, such as coffee, tea, chocolate, beer, cola, excessively high dosages of vitamin C supplements, citrus fruits, tomatoes, and spices.
Eliminate substances or meals that cause rashes or loose stools.
To bulk stools and stop fecal leakage in patients with fecal incontinence or incomplete stools, use fiber supplements.

Modification of Lifestyle 
Review proper anal hygiene by refraining from excessive soap usage and rubbing, and by avoiding items containing irritants such perfumes and colors.
- Steer clear of mineral oil and ointments.
Wear loose, light cotton clothing, and use cotton, unscented talcum powder, or cornstarch to keep the region dry if moisture is an issue.
- Use cotton soaked in water to clean the perianal area after a bowel movement.
- After showering, wipe the region dry with a soft cloth or use a cool setting on your hair dryer.
 Steer clear of drugs that make you bloated or constipated.
Avoid drinking alcohol, using caffeine, cola, chocolate, tomatoes, citrus, tea, nuts, and dairy goods.
Use barrier protection when having anal contact.
Use a brief plain-water enema (baby bulb syringe) after each bowel movement to prevent soiling and irritation if you are unable to completely empty your rectum with feces. If this problem persists, you should explore an underlying medical condition.

90% of patients with conservative treatment have successful outcomes. Idiopathic pruritus ani frequently lasts a lifetime and waxes and wanes.

Lichenification, bacterial superinfection at the site of excoriations, the possibility of abscess development, or penetrating infection through self-inoculation with colonic pathogens are complications.

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